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Lele AV, Moreton EO, Mejia-Mantilla J, Blacker SN. The Implementation of Enhanced Recovery After Spine Surgery in High and Low/Middle-income Countries: A Systematic Review and Meta-Analysis. J Neurosurg Anesthesiol 2024:00008506-990000000-00128. [PMID: 39298547 DOI: 10.1097/ana.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 08/24/2024] [Indexed: 09/22/2024]
Abstract
In this review article, we explore the implementation and outcomes of enhanced recovery after spine surgery (spine ERAS) across different World Bank country-income levels. A systematic literature search was conducted through PubMed, Embase, Scopus, and CINAHL databases for articles on the implementation of spine ERAS in both adult and pediatric populations. Study characteristics, ERAS elements, and outcomes were analyzed and meta-analyses were performed for length of stay (LOS) and cost outcomes. The number of spine ERAS studies from low-middle-income countries (LMICs) increased since 2017, when the first spine ERAS implementation study was published. LMICs were more likely than high-income countries (HICs) to conduct studies on patients aged ≥18 years (odds ratio [OR], 6.00; 95% CI, 1.58-42.80), with sample sizes 51 to 100 (OR, 4.50; 95% CI, 1.21-22.90), and randomized controlled trials (OR, 7.25; 95% CI, 1.77-53.50). Preoperative optimization was more frequently implemented in LMICs than in HICs (OR, 2.14; 95% CI, 1.06-4.41), and operation time was more often studied in LMICs (OR 3.78; 95% CI, 1.77-8.35). Implementation of spine ERAS resulted in reductions in LOS in both LMIC (-2.06; 95% CI, -2.47 to -1.64 d) and HIC (-0.99; 95% CI, -1.28 to -0.70 d) hospitals. However, spine ERAS implementation did result in a significant reduction in costs. This review highlights the global landscape of ERAS implementation in spine surgery, demonstrating its effectiveness in reducing LOS across diverse settings. Further research with standardized reporting of ERAS elements and outcomes is warranted to explore the impact of spine ERAS on cost-effectiveness and other patient-centered outcomes.
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Affiliation(s)
- Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | | | | | - Samuel N Blacker
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC
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McIntosh A, Lachmann E, Datcu A, McLeod C. Posterior spinal fusion for adolescent idiopathic scoliosis and the impact of postoperative intravenous dexamethasone supplementation. PAEDIATRIC & NEONATAL PAIN 2024; 6:19-26. [PMID: 38863457 PMCID: PMC11163225 DOI: 10.1002/pne2.12117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/05/2023] [Accepted: 10/24/2023] [Indexed: 06/13/2024]
Abstract
Postoperative care pathways for adolescent idiopathic scoliosis patients undergoing posterior spinal fusion have demonstrated decreases in postoperative opioid consumption, improved pain control, and lead to decreased lengths of stay. Our objective was to implement postoperative steroids to reduce acute postoperative opioid consumption, pain scores, and length of stay. Dosing consisted of intravenous dexamethasone 0.1 mg/kg up to 4 mg per dose for a total of three doses at 8, 16, and 24 h postoperatively. As part of a quality initiative, we compared three cohorts of patients. The initial retrospective epidural cohort (EPI) (n = 59) had surgeon placed epidural catheters with infusion of ropivacaine 0.1% postoperatively for 18-24 h. Following an institutional change in postoperative care, epidural use was discontinued. A second cohort (n = 149), with prospectively collected data, received a surgeon placed erector spinae plane block and wound infiltration with a combination of liposomal and plain bupivacaine (LB). A third cohort (n = 168) was evaluated prospectively. This cohort received a surgeon placed erector spinae plane block and wound infiltration with liposomal and plain bupivacaine and additionally received postoperative dexamethasone for three doses (LB + D). Compared to the LB cohort, the LB + D cohort demonstrated statistically significant decreases in oral milligram morphine equivalents per kilogram at 0-24, 24-48, and 48-72 h. There was a statistically significant difference in median pain scores at 24-48 and 48-72 h in LB + D versus LB. The LB + D cohort's median length of stay in hours was significantly less compared to the LB cohort (52 h vs. 70 h, p < 0.0001). Postoperative intravenous dexamethasone was added to an established postoperative care pathway for patients undergoing posterior spinal fusion for idiopathic scoliosis resulting in decreased VAS pain scores, opioid consumption, and shorter length of stay.
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Affiliation(s)
- Amy McIntosh
- Department of Orthopedic Surgery, Scottish Rite for ChildrenUT Southwestern Medical CenterDallasTexasUSA
| | - Emily Lachmann
- Department of Orthopedic SurgeryScottish Rite for ChildrenDallasTexasUSA
| | - Anne‐Marie Datcu
- Department of Orthopedic SurgeryScottish Rite for ChildrenDallasTexasUSA
| | - Christopher McLeod
- Department of Anesthesiology, Scottish Rite for ChildrenUT Southwestern Medical CenterDallasTexasUSA
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Marziali ME, Giordano M, Gleit Z, Prigoff J, Landau R, Martins SS. Development and design of a mobile application for prescription opioid clinical decision-making: a feasibility study in New York City, USA. BMJ Open 2023; 13:e066427. [PMID: 36854603 PMCID: PMC9980329 DOI: 10.1136/bmjopen-2022-066427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 02/19/2023] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVES Excessive opioid prescribing is a contributing factor to the opioid epidemic in the USA. We aimed to develop, implement and evaluate the usability of a clinical decision-making mobile application (app) for opioid prescription after surgery. METHODS We developed two clinical decision trees, one for opioid prescription after adult laparoscopic cholecystectomy and one for posterior spinal fusion surgery in adolescents. We developed a mobile app incorporating the two algorithms with embedded clinical decision-making, which was tested by opioid prescribers. A survey collected prescription intention prior to app use and participants' evaluation. Participants included opioid prescribers for patients undergoing (1) laparoscopic cholecystectomy in adults or (2) posterior spinal fusion in adolescents with idiopathic scoliosis. RESULTS Eighteen healthcare providers were included in this study (General Surgery: 8, Paediatrics: 10). Intended opioid prescription before app use varied between departments (General Surgery: 0-10 pills (mean=5.9); Paediatrics: 6-30 pills (mean=20.8)). Intention to continue using the app after using the app multiple times varied between departments (General Surgery: N=3/8; Paediatrics: N=7/10). The most reported reason for not using the app is lack of time. CONCLUSIONS In this project evaluating the development and implementation of an app for opioid prescription after two common surgeries with different prescription patterns, the surgical procedure with higher intended and variable opioid prescription (adolescent posterior spinal fusion surgery) was associated with participants more willing to use the app. Future iterations of this opioid prescribing intervention should target surgical procedures with high variability in both patients' opioid use and providers' prescription patterns.
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Affiliation(s)
- Megan E Marziali
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Mirna Giordano
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Zachary Gleit
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jake Prigoff
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Silvia S Martins
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
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Contartese D, Salamanna F, Brogini S, Martikos K, Griffoni C, Ricci A, Visani A, Fini M, Gasbarrini A. Fast-track protocols for patients undergoing spine surgery: a systematic review. BMC Musculoskelet Disord 2023; 24:57. [PMID: 36683022 PMCID: PMC9869597 DOI: 10.1186/s12891-022-06123-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 12/29/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND CONTEXT Fast-track is an evidence-based multidisciplinary strategy for pre-, intra-, and postoperative management of patients during major surgery. To date, fast-track has not been recognized or accepted in all surgical areas, particularly in orthopedic spine surgery where it still represents a relatively new paradigm. PURPOSE The aim of this review was provided an evidenced-based assessment of specific interventions, measurement, and associated outcomes linked to enhanced recovery pathways in spine surgery field. METHODS We conducted a systematic review in three databases from February 2012 to August 2022 to assess the pre-, intra-, and postoperative key elements and the clinical evidence of fast-track protocols as well as specific interventions and associated outcomes, in patients undergoing to spine surgery. RESULTS We included 57 full-text articles of which most were retrospective. Most common fast-track elements included patient's education, multimodal analgesia, thrombo- and antibiotic prophylaxis, tranexamic acid use, urinary catheter and drainage removal within 24 hours after surgery, and early mobilization and nutrition. All studies demonstrated that these interventions were able to reduce patients' length of stay (LOS) and opioid use. Comparative studies between fast-track and non-fast-track protocols also showed improved pain scores without increasing complication or readmission rates, thus improving patient's satisfaction and functional recovery. CONCLUSIONS According to the review results, fast-track seems to be a successful tool to reduce LOS, accelerate return of function, minimize postoperative pain, and save costs in spine surgery. However, current studies are mainly on degenerative spine diseases and largely restricted to retrospective studies with non-randomized data, thus multicenter randomized trials comparing fast-track outcomes and implementation are mandatory to confirm its benefit in spine surgery.
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Affiliation(s)
- Deyanira Contartese
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Francesca Salamanna
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Silvia Brogini
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Konstantinos Martikos
- grid.419038.70000 0001 2154 6641Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Cristiana Griffoni
- grid.419038.70000 0001 2154 6641Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Ricci
- grid.419038.70000 0001 2154 6641Anesthesia-resuscitation and Intensive care, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Andrea Visani
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Milena Fini
- grid.419038.70000 0001 2154 6641Scientific Direction, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Gasbarrini
- grid.419038.70000 0001 2154 6641Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Salamanna F, Contartese D, Brogini S, Visani A, Martikos K, Griffoni C, Ricci A, Gasbarrini A, Fini M. Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review. J Clin Med 2022; 11:4222. [PMID: 35887986 PMCID: PMC9322698 DOI: 10.3390/jcm11144222] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.
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Affiliation(s)
- Francesca Salamanna
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Deyanira Contartese
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Silvia Brogini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Andrea Visani
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Konstantinos Martikos
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Cristiana Griffoni
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Alessandro Ricci
- Anesthesia-Resuscitation and Intensive Care, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Alessandro Gasbarrini
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Milena Fini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
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Blood loss estimation during posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform 2022; 10:581-588. [PMID: 34784000 DOI: 10.1007/s43390-021-00440-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Blood loss (BL) during posterior spinal fusion for adolescent idiopathic scoliosis (AIS) may be estimated using a variety of unproven techniques. Patient care and research on BL are likely impacted by a lack of standardization. A novel FDA-approved blood volume (BV) analysis system (BVA-100 Blood Volume Analyzer) allows rapid processing with > 97% accuracy. The purpose of this study was to investigate common methods for BL estimation. METHODS BV assessment was performed with the BVA-100. After obtaining a baseline sample of 5 mL of blood, 1 mL of I-131-labeled albumin was injected intravenously over 1 min. Five milliliter blood samples were then collected at 12, 18, 24, 30, and 36 min post-injection. Intravenous fluid was minimized to maintain euvolemia. Salvaged blood was not administered during surgery. BL was estimated using several common techniques and compared to the BV measurements provided by the BVA-100 (BVABL). RESULTS Thirty AIS patients were prospectively enrolled with major curves of 54° and underwent fusions of 10 levels. BL based on the BVA-100 (BVABL) was 519.2 [IQR 322.9, 886.2] mL. Previously published formulas all failed to approximate BVABL. Multiplying the cell saver volume return by 3 (CS3) approximates BVABL well with a Spearman correlation coefficient and ICC of 0.80 and 0.72, respectively. An extrapolated cell salvage-based estimator also showed high intraclass correlation coefficient (ICC) and Spearman coefficients with less bias than CS3. CONCLUSION Published formulaic approaches do not approximate true blood loss. Multiplying the cell saver volume by 3 or using the cell salvage-based estimator had the highest correlation coefficient and ICC. LEVEL OF EVIDENCE Prospective cohort Level 2.
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Sundar SJ, Enders JJ, Bailey KA, Gurd DP, Goodwin RC, Kuivila TE, Ballock RT, Young EY. Use of a Standardized Perioperative Care Path for Adolescent Idiopathic Scoliosis Leads to Decreased Complications and Readmissions. Clin Spine Surg 2022; 35:E41-E46. [PMID: 34261869 DOI: 10.1097/bsd.0000000000001236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/01/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective review of patients ages 10-18 who underwent posterior fusion for adolescent idiopathic scoliosis (AIS) at a single institution from 2014 to 2019. OBJECTIVE The aim was to evaluate a standardized Care Path to determine its effects on perioperative outcomes in patients undergoing spinal fusion for AIS. SUMMARY OF BACKGROUND DATA AIS is the most common pediatric spinal deformity and thousands of posterior fusions are performed annually. Surgery presents several postoperative challenges, such as pain control, delayed mobilization, and opioid-related morbidity. Optimizing perioperative care of AIS is a high priority to reduce morbidity and improving health care efficiency. MATERIALS AND METHODS A total of 336 patients ages 10-18 were included in this study; 117 in the pre-Care Path cohort (2014-2015) and 219 in the post-Care Path cohort (2016-2019). Data compared included intraoperative details, length of stay, timing of mobilization, inpatient complications, emergency room (ER) visits, readmissions after discharge, postoperative complications, and reoperations. RESULTS The post-Care Path cohort had improved mobilization on postoperative day 0 (pre 16.7%, post 53.3%, P<0.00001), reduced length of stay (pre 4.14 days, post 3.36 days, P=0.00006), fewer total inpatient complications (pre 17.1%, post 8.1%, P=0.0469), and fewer instances of postoperative ileus (pre 8.5%, post 1.9%, P=0.0102). Within 60 days of surgery, the post-Care Path cohort had fewer ER visits (pre 12.8%, post 7.2%, P=0.0413), decreased postoperative infections (pre 5.1%, post 0.48%, P=0.00547), decreased readmissions (pre 6.0%, post 0.48%, P=0.0021), and decreased reoperations (pre 5.1%, post 0.96%, P=0.0195). There was a decrease in inpatient oral morphine equivalents in the Care Path cohort (pre 118.7, post 84.7, P=0.0003). CONCLUSIONS Our Care Path for AIS patients demonstrated significant improvements in postoperative mobilization and decreases in length of stay, complications, infections, ER visits, readmissions, and reoperations.
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Affiliation(s)
| | | | - Kevin A Bailey
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - David P Gurd
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Ryan C Goodwin
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Thomas E Kuivila
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Robert T Ballock
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Ernest Y Young
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
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Temby SE, Palmer GM, Penrose SP, Peachey DM, Johnson MB. Implementation of an enhanced recovery pathway in Australia after posterior spinal fusion for adolescent idiopathic scoliosis delivers improved outcomes. Spine Deform 2021; 9:1371-1377. [PMID: 33822322 DOI: 10.1007/s43390-021-00340-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/25/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Traditionally, spinal surgery for Adolescent Idiopathic Scoliosis (AIS) has seen long hospital length of stay (LOS) and slow mobility progression. Postoperative enhanced recovery pathways (ERP) for this population in North America and Asia have successfully reduced LOS and hospital costs without increasing complications. This study assessed if ERP introduced in an Australian center achieves similar results. METHODS A pre-post intervention study compared a historical AIS cohort having a posterior spinal fusion (PSF) who received conventional care (CC) (2013-2014) with prospectively assessed ERP recipients (2016-2018) separated by 1-year implementation period. Patient characteristics, surgical details, postoperative analgesia, mobilization, LOS and complication outcomes were collected. RESULTS The 32 CC and 61 ERP recipients had similar demographics. ERP recipients had 44% decreased LOS (mean LOS 3.5 ± 0.9 days vs. CC 6.3 ± 0.9 days, p < 0.001) as all ERP milestones were achieved sooner including transition to oral analgesia (MD - 2 days, 95% CI 1.8-2.3), oral intake (MD - 2.3 days, 95% CI 2.0-2.6) and mobilization, with fewer physiotherapy sessions (5.2 vs 8, p < 0.001). Postoperative in-hospital costs were 50.2% less for ERP vs CC (AUD $8234 vs $16,545). Due to small sample size, no differences between the groups were detectable for complications (4.9% vs 6.3%) or readmission (1.6% vs 3.1%). CONCLUSION An ERP for AIS after PSF in this Australian center improved functional recovery reducing LOS and by associated postoperative inpatient costs. Other Australian hospitals should consider an ERP for this population with larger-scale audit to assess impact upon complications. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Sarah E Temby
- Physiotherapy Department, The Royal Children's Hospital, Melbourne, VIC, Australia.
| | - Greta M Palmer
- Department of Anaesthesia and Pain Management Service, The Royal Children's Hospital, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,University of Melbourne, Melbourne, VIC, Australia
| | - Sueann P Penrose
- Department of Anaesthesia and Pain Management Service, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Donna M Peachey
- Department of Orthopaedics, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Michael B Johnson
- Department of Orthopaedics, The Royal Children's Hospital, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia
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Van de Velde SK, Cola K, Bompadre V, Steinman SE. Seasonal Variation in Parental Satisfaction With Pediatric Orthopaedics. J Pediatr Orthop 2021; 41:e296-e300. [PMID: 33417390 DOI: 10.1097/bpo.0000000000001747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The degree of parental satisfaction with health care is determined by the family's characteristics and expectations. Many aspects of human physiology and behavior have seasonal rhythms. The purpose of the present study was to determine whether parental satisfaction scores vary across the year in a pediatric orthopaedic outpatient population. METHODS We retrospectively reviewed a total of 22,951 parental satisfaction scores related to outpatient pediatric orthopaedic encounters between October 2015 and April 2019. Parental satisfaction was measured using the provider subdomain of the shortened version of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Families were stratified according to various pediatric orthopaedic subspecialty services. RESULTS The satisfaction scores of all pediatric orthopaedic encounters combined did not vary significantly across the year (P=0.8745). When the families were stratified into groups by pediatric orthopaedic subspecialty clinic, variation in seasons was not associated with statistically significant variation in satisfaction scores for the elective surgery, sports medicine, trauma/fracture care, and hand/upper extremity services. However, satisfaction with the spine service was significantly lower in the winter compared with the summer and fall (73.9±3.8 vs. 83.5±5.3 and 82.6±3.6, respectively; P=0.0147). CONCLUSIONS The provision of pediatric spine care in a region with 4 distinct seasons received lower parental satisfaction scores during the winter than during the summer and fall. This seasonal variation is an additional source of bias in the measurement of satisfaction with health care. LEVEL OF EVIDENCE Level II-retrospective study.
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Affiliation(s)
| | - Kristin Cola
- Pediatric Orthopedics of Southwest Florida, Fort Myers, FL
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McIntosh AL. Dexamethasone Administration Decreases Opioid Usage After Posterior Spinal Fusion in Patients with Adolescent Idiopathic Scoliosis: Commentary on article by Nicholas D. Fletcher, MD, et al.: "Postoperative Dexamethasone Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis". J Bone Joint Surg Am 2020; 102:e120. [PMID: 33086358 DOI: 10.2106/jbjs.20.01488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Fletcher ND, Ruska T, Austin TM, Guisse NF, Murphy JS, Bruce RW. Postoperative Dexamethasone Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. J Bone Joint Surg Am 2020; 102:1807-1813. [PMID: 33086348 DOI: 10.2106/jbjs.20.00259] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgeons have hesitated to use steroids in patients undergoing posterior spinal fusion because of the risk of wound complications. The literature has supported the use of postoperative steroids in other areas of orthopaedics on the basis of more rapid recovery and improved postoperative pain control. We hypothesized that a short course of postoperative dexamethasone following posterior spinal fusion for the treatment of adolescent idiopathic scoliosis (AIS) would decrease opioid usage without increasing wound-healing problems. METHODS Consecutive patients undergoing posterior spinal fusion for the treatment of AIS from 2015 to 2018 at a single hospital were included. A review of demographic characteristics, curve characteristics, surgical data, and postoperative clinic notes was performed. Opioid usage was determined by converting all postoperative opioids given into morphine milligram equivalents (MME). RESULTS Sixty-five patients underwent posterior spinal fusion for the treatment of AIS without postoperative steroids (the NS group), and 48 patients were managed with 3 doses of postoperative steroids (the WS group) (median, 8.0 mg/dose). There was no difference between the groups in terms of curve magnitude, number of vertebrae fused, or estimated blood loss. There was a 39.6% decrease in total MME used and a 29.5% decrease in weight-based MME used in the group receiving postoperative steroids (82.0 mg [1.29 mg/kg] in the NS group versus 49.5 mg [0.91 mg/kg] in the WS group]; p < 0.001). This difference persisted after accounting for gabapentin, ketorolac, and diazepam usage; surgical time; curve size; levels fused; and number of osteotomies (median decrease, 0.756 mg/kg [95% CI, 0.307 to 1.205 mg/kg]; p = 0.001). Three patients in the NS group (4.6%) and 4 patients in the WS group (8.3%) developed wound dehiscence requiring wound care (p = 0.53). One patient in the NS group required surgical debridement for the treatment of an infection. Patients in the WS group were more likely to walk at the time of the initial physical therapy evaluation (60.4% versus 35.4%; p = 0.013). CONCLUSIONS A short course of postoperative steroids after posterior spinal fusion was associated with a 40% decrease in the use of opioids, with no increase in wound complications. Surgeons may consider the use of perioperative steroids in an effort to decrease the use of postoperative opioids following posterior spinal fusion for the treatment of AIS. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Tracy Ruska
- Children's Healthcare of Atlanta, Atlanta, Georgia
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