Associations of Cancer Patients' Demographic and Clinical Characteristics With Cannabis-Related Interest and Behaviors

Background: Cannabis interest and use is increasing in the United States, yet research on its use among cancer patients is limited. Methods: Individuals with cancer completed an anonymous cross-sectional questionnaire. Multivariable logistic regressions estimated odds ratios (OR) between patients' demographic and clinical characteristics with cannabis-related interest, current use, and provider recommendation. Results: Participants (n = 943) were, on average, 61.7 years old. Older patients were less likely to use cannabis products (OR = 0.42, confidence interval [95% CI]: 0.26-0.69) and less likely to be interested in cannabis (OR = 0.60, 95% CI: 0.44-0.84) than younger patients. Those with higher education were less likely to be using cannabis (OR = 0.41, 95% CI: 0.25-0.67) and less likely to have received a provider recommendation of cannabis use than the least educated (OR = 0.38, 95% CI: 0.19-0.76). Cancer spread and type were significant correlates of provider recommendation of cannabis use. Conclusions: Additional research is warranted to better understand cancer patients' motivations for cannabis use and interest.

Current cannabis use and pain management among US cancer patients

BACKGROUND

National studies reporting the prevalence of cannabis use have focused on individuals with a history of cancer without distinction by their treatment status, which can impact symptom burden. While pain is a primary motivation to use cannabis in cancer, the magnitude of its association with cannabis use remains understudied.

METHODS

We examined cannabis use and pain management among 5523 respondents of the Behavioral Risk Factor Surveillance System with a cancer history. Survey-weighted prevalence proportions of respondents' cannabis use are reported, stratified on cancer treatment status. Regression models estimated odds ratios (ORs) and 95% confidence intervals (CIs) of cancer-related pain and cannabis use.

RESULTS

Cannabis use was slightly more prevalent in those undergoing active treatment relative to those who were not undergoing active treatment (9.3% vs. 6.2%; P=0.05). Those under active treatment were more likely to use cannabis medicinally (71.6% vs. 50.0%; P=0.03). Relative to those without cancer-related pain, persons with pain under medical control (OR 2.1, 95% CI, 1.4-3.2) or uncontrolled pain were twice as likely to use cannabis (OR 2.0, 95% CI, 1.1-3.5).

CONCLUSIONS

Use of cannabis among cancer patients may be related to their treatment and is positively associated with cancer-related pain. Future research should investigate the associations of cannabis use, symptom burden, and treatment regimens across the treatment spectrum to facilitate interventions.

Alpelisib-Induced Diabetic Ketoacidosis: A Pharmacovigilance Analysis of the FDA Adverse Event Reporting System and Review of the Literature

BACKGROUND

Alpelisib is a PI3K inhibitor indicated with fulvestrant for treatment of advanced or metastatic hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative, PIK3CA-mutated breast cancer. In the phase III SOLAR-1 trial, grade 3/4 hyperglycemic events were reported in 36.6% of patients receiving alpelisib-fulvestrant compared to 0.7% receiving placebo-fulvestrant. As case reports of diabetic ketoacidosis (DKA) have been associated with alpelisib use, the goal of this study was to characterize the FAERS reported cases of this severe adverse effect.

METHODS

A retrospective disproportionality analysis was performed using the FAERS database by calculating the reporting odds ratio (ROR) of DKA events with alpelisib from 2019 to 2022. A PubMed literature review of case reports characterizing alpelisib-induced DKA was performed.

RESULTS

Pharmacovigilance database analysis revealed significance in reporting among 87 DKA cases with alpelisib (ROR 9.84, 95% confidence interval 7.3-13.2), including hospitalization and death as reported outcomes. Review of 11 published case reports reveals median onset of DKA at 14 days with successful rechallenge possible.

CONCLUSION

Significant association with reporting exists between DKA and alpelisib exposure. We observed similar median time to onset of hyperglycemia between our analysis compared to that reported in SOLAR-1. Considering early onset of this toxicity, it is imperative that patients be closely monitored when initiating alpelisib. Addition of a preemptive antihyperglycemic or escalation in those previously on antihyperglycemic medications is beneficial in decreasing the severity of hyperglycemia with alpelisib. Further study investigating risk factors is warranted to better elucidate which patients require preemptive therapy.

Hepatitis B reactivation in patients with multiple myeloma treated with anti-CD38 monoclonal antibody-based therapies: a pharmacovigilance analysis

BACKGROUND

Daratumumab and isatuximab are anti-CD38 monoclonal antibodies indicated for the treatment of multiple myeloma. These agents can increase the risk of infectious complications, including viral infections. Cases of hepatitis B virus (HBV) reactivation have been reported in the literature in patients receiving anti-CD38 monoclonal antibody-based therapies.

AIM

The objective of this analysis was to determine if the association between anti-CD38 monoclonal antibody exposure and the development of hepatitis B reactivation had a detectable reporting signal in the United States Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS).

METHOD

We conducted a post marketing pharmacovigilance analysis by querying the FAERS for reports of HBV reactivation with daratumumab or isatuximab exposure reported between 2015 and 2022. Disproportionality signal analysis was conducted by calculating reporting odds ratios (RORs).

RESULTS

Sixteen cases of hepatitis B virus reactivation were reported in the FAERS database among patients receiving daratumumab or isatuximab reported between 2015 and 2022. The ROR for HBV reactivation was statistically significant for both daratumumab (ROR 4.76, 95% CI 2.76-8.22) and isatuximab (ROR 9.31, 95% CI 3.00-28.92).

CONCLUSION

Overall, our analysis demonstrates a significant reporting signal for HBV reactivation with daratumumab and isatuximab.

Use of patient-reported outcome measures for oncology drugs receiving accelerated approval

Patient-reported outcomes (PROs) represent an important evaluation of health-related quality of life that has become more commonly incorporated into oncology drug clinical trials. The frequency of PRO inclusion as an endpoint in oncology drug clinical trials leading to the initial accelerated approval of a new therapy is not yet known. We conducted a cross-sectional study evaluating all new drug applications submitted to the FDA over the past 10 years (2013-2022) that led to the initial approval of an oncology drug through the accelerated approval process. The objective was to assess whether the trials leading to such an approval included PROs. Between 2013 and 2022, the FDA approved 59 unique drugs for an oncology indication via the accelerated approval pathway, and 35 (59%) included a PRO assessment in the clinical trial. A median of 1 PRO measurement was used in each trial, with 23 different types of PRO assessment tools were used across the 59 new drug applications. In summary, we found that PRO measurements are inconsistently utilized in trials leading to initial accelerated approval of oncology drugs, and there seems to be a lack of harmonization of different PRO measurement tools used across trials.

Marijuana and Cannabidiol Use Prevalence and Symptom Management Among Patients with Cancer

Symptoms such as pain, nausea, and anxiety are common in individuals with cancer. Treatment of these issues is often challenging. Cannabis products may be helpful in reducing the severity of these symptoms. While some studies include data on the prevalence of cannabis use among patients with cancer, detailed data remain limited, and none have reported the prevalence of cannabidiol (CBD) use in this population. Adult patients with cancer attending eight clinics at a large, NCI-designated Comprehensive Cancer Center completed a detailed, cannabis-focused questionnaire between 2021 and 2022. Eligible participants were diagnosed with invasive cancer and treated in the past 12 months. Summary statistics were calculated to describe the sample regarding cannabis use. Approximately 15% (n = 142) of consented patients (n = 934) reported current cannabis use (defined as use within the past 12 months). Among which, 75% reported cannabis use in the past week. Among current cannabis users, 39% (n = 56; 6% overall) used CBD products. Current users reported using cannabis a median of 4.5 (interquartile range: 0.6–7.0) days/week, 2.0 (1.0–3.0) times per use/day, and for 3 years (0.8–30.0). Use patterns varied by route of administration. Patients reported moderate to high relief of symptoms with cannabis use. This study is the most detailed to date in terms of cannabis measurement and provides information about the current state of cannabis use in active cancer. Future studies should include complete assessments of cannabis product use, multiple recruitment sites, and diverse patient populations.

SIGNIFICANCE

Clinicians should be aware that patients are using cannabis products and perceive symptom relief with its use.

Ventral hernia repair: an increasing burden affecting abdominal core health

PURPOSE

To estimate the annual volume and cost of ventral hernia repair (VHR) performed in the United States.

METHODS

A retrospective cohort study was performed using the National Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) for 2016-2019. Patients over the age of 18 who underwent open (OVHR) or minimally invasive ventral hernia repair (MISVHR) were identified. NIS procedural costs were estimated using cost-to-charge ratios; NASS costs were estimated using the NIS cost-to-charge ratios stratified by payer status. Costs were adjusted for inflation to 2021 dollars using US Bureau of Labor Statistics Consumer Price Index.

RESULTS

On average 610,998 VHRs were performed per year. Most were outpatient (67.3% per year), and open (70.7%). MIS procedures increased from 25.8% to 32.8% of all VHRs. Inpatient OVHR had significantly higher associated cost than MISVHR [$35,511 (34,100-36,921) vs. $21,165 (19,664-22,665 in 2019]. Outpatient MISVHR was more expensive than OVHR [$11,558 (11,174-11,942 MIS vs. $6807 (6620-6994) OVHR in 2019]. The estimated cost of an inpatient MISVHR remained similar between 2016 and 2019, from $20,076 (13,374-20,777) to $21,165 (19,664-22,665) and increased slightly from $9975 (9639-10,312) to $11,558 (11,174-11,942) in the outpatient setting. The estimated cost of an inpatient OVHR increased from $31,383 (30,338-32,428) to $35,511 (34,100-36,921), while outpatient costs increased from $6018 (5860-6175) to $6807 (6620-6994). VHR costs decreased slightly over the study period to a mean cost of $9.7 billion dollars in 2019.

CONCLUSION

Compared to 2006 national data, VHRs in the United States have almost doubled to 611,000 per year with an estimated annual cost of $9.7 billion. A 1% decrease in VHR achieved through recurrence reduction or hernia prophylaxis could save the US healthcare system at least $139.9 million annually.

Ventral hernia repair: an increasing burden affecting abdominal core health

PURPOSE

To estimate the annual volume and cost of ventral hernia repair (VHR) performed in the United States.

METHODS

A retrospective cohort study was performed using the National Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) for 2016-2019. Patients over the age of 18 who underwent open (OVHR) or minimally invasive ventral hernia repair (MISVHR) were identified. NIS procedural costs were estimated using cost-to-charge ratios; NASS costs were estimated using the NIS cost-to-charge ratios stratified by payer status. Costs were adjusted for inflation to 2021 dollars using US Bureau of Labor Statistics Consumer Price Index.

RESULTS

On average 610,998 VHRs were performed per year. Most were outpatient (67.3% per year), and open (70.7%). MIS procedures increased from 25.8% to 32.8% of all VHRs. Inpatient OVHR had significantly higher associated cost than MISVHR [$35,511 (34,100-36,921) vs. $21,165 (19,664-22,665 in 2019]. Outpatient MISVHR was more expensive than OVHR [$11,558 (11,174-11,942 MIS vs. $6807 (6620-6994) OVHR in 2019]. The estimated cost of an inpatient MISVHR remained similar between 2016 and 2019, from $20,076 (13,374-20,777) to $21,165 (19,664-22,665) and increased slightly from $9975 (9639-10,312) to $11,558 (11,174-11,942) in the outpatient setting. The estimated cost of an inpatient OVHR increased from $31,383 (30,338-32,428) to $35,511 (34,100-36,921), while outpatient costs increased from $6018 (5860-6175) to $6807 (6620-6994). VHR costs decreased slightly over the study period to a mean cost of $9.7 billion dollars in 2019.

CONCLUSION

Compared to 2006 national data, VHRs in the United States have almost doubled to 611,000 per year with an estimated annual cost of $9.7 billion. A 1% decrease in VHR achieved through recurrence reduction or hernia prophylaxis could save the US healthcare system at least $139.9 million annually.

Acquired thrombotic thrombocytopenic purpura associated with immune checkpoint inhibitors: A real-world study of the FDA adverse event reporting system

INTRODUCTION

Immune checkpoint inhibitors (ICIs) are used for a variety of cancers and are associated with a risk of developing immune-related adverse events, most commonly colitis, dermatitis, hepatitis, and thyroiditis. Rare autoimmune hematologic toxicities have been reported but are less well-described in the literature. Acquired thrombotic thrombocytopenic purpura (TTP) is a life-threatening autoimmune condition that has been reported with ICIs but has been limited to case reports.

METHODS

We performed a retrospective observational analysis of the United States Food and Drug Administration Adverse Event Reporting System (FAERS) data. We searched for cases of TTP reported with exposure to ICIs from initial FDA approval for each agent to December 31, 2021. Disproportionality signal analysis was done by calculating the reporting odds ratio (ROR).

RESULTS

There were 35 reports of TTP with ICIs in the FAERS database, including atezolizumab (n = 7), durvalumab (n = 2), nivolumab (n = 18), and pembrolizumab (n = 8). The ROR was significant for atezolizumab (ROR 6.22, 95% CI 2.96-13.09), nivolumab (ROR 3.16, 95% CI 1.99-5.03), and pembrolizumab (ROR 2.56, 95% CI 1.28-5.12).

CONCLUSIONS

There is a significant reporting signal of TTP with several ICI agents. Clinicians should be aware of and monitor for signs of this potentially serious adverse event.

Prevalence, symptom management, and reporting of cannabis use among invasive cancer patients

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Background: Interest in the use of cannabis-based products, including marijuana (products containing ≥0.3% tetrahydrocannabinol [THC]) and cannabidiol (CBD; containing < 0.3% THC) for cancer symptom management, is increasing. Preliminary studies suggest that marijuana and CBD products are effective in alleviating common cancer- or treatment-related symptoms. Few studies have reported on the magnitude of cannabis use among cancer patients, but data remain limited to states with legalized non-medical (i.e., recreational) use. Further, none have assessed the prevalence of CBD use in cancer patients. The reasons for cannabis-based product use and patient attitudes towards discussing use with their physicians are not well understood. Methods: We report preliminary results from an ongoing anonymous cross-sectional study of cannabis use among patients attending 8 clinics at the Ohio State University Comprehensive Cancer Center. Eligible patients were diagnosed with invasive cancer and treated in the past 12 months. Between July 2021 and January 2022, 771 patients were contacted and 639 (82.9%) agreed to participate. Participants answered a validated, extensive cannabis-focused questionnaire and were remunerated with a gift card. We report here frequencies and prevalence proportions of cannabis-based product use, and cannabis-related behaviors and attitudes on reporting use with cancer providers. Missing values were included in the denominator of prevalence calculations, thereby making estimates conservative. Results: Participants were equally distributed by sex, White (86.4%), and resided within Ohio (90.3%). Among 433 patients who reported age, the median was 47 years (IQR 38-53). The prevalence of current cannabis-based product use was 15.2% (97/639), with overall prevalence of 6.9% for exclusive marijuana use, 1.7% exclusive CBD use, and 5.2% poly-use. Among current users, patients primarily reported inhaling or ingesting cannabis products; fewer reported topical or other applications. The top 5 reported reasons for cannabis use were to treat stress, improve sleep, reduce pain, improve appetite, and to treat depression. Among current users, 66% reported that their cancer care team was aware of their cannabis use, 17.5% reported none of their healthcare providers were aware, and 15.4% reported a medical professional unaffiliated with their cancer care was aware. A large proportion (86.6%) felt comfortable discussing cannabis with their treating physician. Conclusions: Our results indicate current cannabis-based product use for symptom relief among a sizeable minority of adults with cancer in a state where only medicinal marijuana is legalized. Further research is needed to characterize provider perspectives and communication about reported cannabis use among their patients.

Opioid Taper Practices Among Clinicians

Introduction

Opioid dose tapers are used frequently when cross-titrating from one or more opioids to another or when discontinuing therapy. Currently, there is no universally accepted evidence-based standard of care for this procedure which can leave patients at risk for withdrawal symptoms, inadequate pain control, or elevated suicide risk.

Objective

The objective of this study was to examine practices and rationale among clinicians, to determine if there is a difference among respondents in their comfort level, method and rationale for tapering opioids at various morphine milligram equivalents (MME) and to assess the need for the development of a standard of care.

Methods

Data were derived from an electronic survey developed using SurveyMonkey^®. The survey was disseminated via e-mail listservs, social media, and professional organizations. Data were collected regarding profession, confidence tapering opioids at varying total MME, method and rationale for tapering, and pharmacologic management of withdrawal symptoms. Pearson's Chi squared and Fisher's exact tests were used to assess statistical significance of results.

Results

A total of 149 clinicians completed the survey, physicians, NPs, pharmacists, and PAs accounted for 51%, 20%, 19%, and 10% of participants, respectively. Overall, 55% of the respondents self-identified as pain specialists. There were no statistically significant differences in reported comfort level among the different types of providers. Nearly 50% of participants indicated their rationale for tapering or discontinuing opioids was the 2016 CDC guidelines.

Conclusion

Despite that the majority of providers surveyed self-identified as pain specialists, over 50% were not comfortable tapering opioids at doses greater than 120 MME/day. This observation suggests a need for further education and establishment of consensus guidelines on method and rationale for opioid tapering. Provider motivation for tapering was largely influenced by CDC guidelines based on low quality evidence. This strengthens the argument for the creation of guidelines based on high quality evidence.

In-house intensivist presence does not affect mortality in select emergency general surgery patients

BACKGROUND

This study aimed to assess the relationship between availability of round-the-clock (RTC) in-house intensivists and patient outcomes in people who underwent surgery for a life-threatening emergency general surgery (LT-EGS) disease such as necrotizing soft-tissue infection, ischemic enteritis, perforated viscus, and toxic colitis.

METHODS

Data on hospital-level critical care structures and processes from a 2015 survey of 2,811 US hospitals were linked to patient-level data from 17 State Inpatient Databases. Patients who were admitted with a primary diagnosis code for an LT-EGS disease of interest and underwent surgery on date of admission were included in analyses.

RESULTS

We identified 3,620 unique LT-EGS admissions at 368 hospitals. At 66% (n = 243) of hospitals, 83.5% (n = 3,021) of patients were treated at hospitals with RTC intensivist-led care. These facilities were more likely to have in-house respiratory therapists and protocols to ensure availability of blood products or adherence to Surviving Sepsis Guidelines. When accounting for other key factors including overnight surgeon availability, perioperative staffing, and annual emergency general surgery case volume, not having a protocol to ensure adherence to Surviving Sepsis Guidelines (adjusted odds ratio, 2.10; 95% confidence interval, 1.12-3.94) was associated with increased odds of mortality.

CONCLUSION

Our results suggest that focused treatment of sepsis along with surgical source control, rather than RTC intensivist presence, is key feature of optimizing EGS patient outcomes.

LEVEL OF EVIDENCE

Therapeutic, level III.

Hospital Admissions Associated With Cancer Pain in Older Adults With and Without Dementia

BACKGROUND

Neoplasm-related pain is often suboptimally treated, contributing to avoidable suffering and increased medical resource use and costs. We hypothesized that dementia may contribute to increased resource use and costs in patients hospitalized for neoplasm-related pain in the United States.

AIMS

To examine how persons with cancer and dementia use medical resources and expenditures in US hospitals compared to ondividuals without dementia.

DESIGN

This study examined a retrospective cohort.

SETTING

Admissions to US hospitals for neoplasm-related pain from 2012-2016 PARTICIPANTS/SUBJECTS: METHODS: Data were obtained from the 2012-2016 National Inpatient Sample (NIS). The sample included hospital admissions of individuals aged 60 or older with a primary diagnosis of neoplasm-related pain. Dementia was defined using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), and ICD-10-CM diagnosis codes. Primary outcomes were number of admissions, costs, and length of stay (LOS). Descriptive statistics and multivariable regression models were used to examine the relationships among dementia, costs, and LOS.

RESULTS

Of 12,034 admissions for neoplasm-related pain, 136 (1.1%) included a diagnosis of dementia and 11,898 (98.9%) did not. Constipation was present in 13.2% and 24.5% of dementia and nondementia admissions, respectively. The median LOS was 4 days in persons with dementia and three in those without. Mean costs per admission were higher in persons without dementia ($10,736 vs. $9,022, p = .0304). In adjusted regression results, increased costs were associated with nonelective admissions and longer LOS, and decreased costs with age above the mean. In contrast, decreased LOS was associated with age above the mean and nonelective admissions. Dementia was associated with neither endpoint.

CONCLUSION

This study provides nurses and other health care professionals with data to further explore opportunities for improvement in cancer pain management in patients with and without dementia that may optimize use of medical resources.

Opioid use by cancer status and time since diagnosis among older adults enrolled in the Prostate, Lung, Colorectal, and Ovarian screening trial in the United States

BACKGROUND

Dosing limits in opioid clinical practice guidelines in the United States are likely misapplied to cancer patients, however, opioid use may be difficult to ascertain as they are largely excluded from opioid use studies.

METHODS

The primary objective was to determine whether cancer patients were more likely to be chronic opioid users after diagnosis. We described prescription opioid use among U.S. older adult cancer patients during two time periods, within 2 years of diagnosis (short-term) and at least 2 years beyond diagnosis (long-term), compared to those without cancer (controls). Among participants in the Prostate, Lung, Colorectal, and Ovarian (PLCO) screening trial with linkages to Medicare Part D data during 2011-2015, we used multivariable logistic regression to estimate the association between cancer diagnosis and opioid use outcomes controlling for demographics. The primary outcome of opioid use was measured with the following metrics: Any opioid use, chronic use (90 consecutive days supply of opioid use while allowing for a 7-day gap between refills), high use (average daily morphine equivalent (MME) ≥120 mg for any 90-day period), and total MME dose above 2,000 mg (MME₂₀₀₀ ).

RESULTS

The short-term cohort included 1,491 cancer patients and 24,930 controls. Any use in the 2-year post-diagnosis period was higher among cancer patients OR 3.3 (95% CI: 3.0-3.7). Chronic use rates were similar by cancer status (4.6% vs. 3.8% for cases and controls, respectively). The long-term cohort included 4,377 cancer patients and 27,545 controls. Rates of any use were similar among cancer patients and controls (63% vs. 59%).

CONCLUSIONS

Any opioid use was similar among long-term cancer survivors compared to controls, but differed among short-term survivors for any opioid use and marginally for chronic opioid use.

Importance of Radiologists in Optimizing Outcomes for Older Americans with Acute Abdomen

BACKGROUND

Patients presenting with acute abdominal pain often undergo a computed tomography (CT) scan as part of their diagnostic workup. We investigated the relationship between availability, timeliness, and interpretation of CT imaging and outcomes for life-threatening intra-abdominal diseases or "acute abdomen," in older Americans.

METHODS

Data from a 2015 national survey of 2811 hospitals regarding emergency general surgery structures and processes (60.1% overall response, n = 1690) were linked to 2015 Medicare inpatient claims data. We identified beneficiaries aged ≥65 admitted emergently with a confirmatory acute abdomen diagnosis code and operative intervention on the same calendar date. Multivariable regression models adjusted for significant covariates determined odds of complications and mortality based on CT resources.

RESULTS

We identified 9125 patients with acute abdomen treated at 1253 hospitals, of which 78% had ≥64-slice CT scanners and 85% had 24/7 CT technicians. Overnight CT reads were provided by in-house radiologists at 14% of hospitals and by teleradiologists at 66%. Patients were predominantly 65-74 y old (43%), white (88%), females (60%), and with ≥3 comorbidities (67%) and 8.6% died. STAT radiology reads by a board-certified radiologist rarely/never available in 2 h was associated with increased odds of systemic complication and mortality (adjusted odds ratio 2.6 [1.3-5.4] and 2.3 [1.1-4.8], respectively).

CONCLUSIONS

Delays obtaining results are associated with adverse outcomes in older patients with acute abdomen. This may be due to delays in surgical consultation and time to source control while waiting for imaging results. Processes to ensure timely interpretation of CT scans in patients with abdominal pain may improve outcomes in high-risk patients.

Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach

BACKGROUND

Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients.

METHODS

We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project.

RESULTS

Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations.

DISCUSSION

Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease.

CONCLUSIONS

Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).

The Need for Accurate Risk Assessment in a High-Risk Patient Population: A NSQIP Study Evaluating Outcomes of Cholecystectomy in the Patient With Cancer

BACKGROUND

Cholecystectomy is considered a low-risk procedure with proven safety in many high-risk patient populations. However, the risk of cholecystectomy in patients with active cancer has not been established.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried to identify all patients with disseminated cancer who underwent cholecystectomy from 2005 to 2016. Postcholecystectomy outcomes were defined for patients with cancer and those without by comparing several outcomes measures. A multivariate model was used to estimate the odds of 30-d mortality.

RESULTS

We compared outcomes in 3097 patients with disseminated cancer to a matched cohort of patients without cancer. Patients with cancer had more comorbidities at baseline: dyspnea (10.5% versus 7.0%, P < 0.0001), steroid use (10.1% versus 3.0%, P < 0.0001), and loss of >10% body weight in 6-mo prior (9.3% versus 1.6%, P < 0.0001). Patients with cancer sustained higher rates of wound (2.3% versus 5.6%, P < 0.0001), respiratory (1.4% versus 3.9%, P < 0.0001), and cardiovascular (2.0% versus 6.8%, P < 0.0001) complications. In addition, patients with disseminated cancer experienced a longer length of stay and higher 30-d mortality. Multivariate modeling showed that the odds of 30-d mortality was 3.3 times greater in patients with cancer.

CONCLUSIONS

Compared to patients without cancer, those with disseminated cancer are at higher risk of complication and mortality following cholecystectomy. Traditional treatment algorithms should be used with caution and care decisions individualized based on the patient's disease status and treatment goals.

Analyzing Outcomes Among Older Adults With Necrotizing Soft-Tissue Infections in the United States

BACKGROUND

Necrotizing soft-tissue infections (NSTIs) encompass a group of severe, life-threatening diseases with high morbidity and mortality. Evidence suggests advanced age is associated with worse outcomes. To date, no large data sets exist describing outcomes in older individuals, and risk factor identification is lacking.

METHODS

Retrospective data were obtained from the 2015 Medicare 100% sample. Included in the analysis were those aged ≥65 y with a primary diagnosis of an NSTI (gas gangrene, necrotizing fasciitis, cutaneous gangrene, or Fournier's gangrene). Risk factors for in-hospital mortality and discharge disposition were examined. Continuous variables were assessed using central tendency, t-tests, and Wilcoxon rank-sum tests. Categorical variables were assessed using the chi-squared and Fisher's exact tests. Statistical significance was defined as P < 0.05.

RESULTS

1427 patient records were reviewed. 59% of patients were male, and the overall mean age was 75.4±8.6 y. 1385 (97.0%) patients required emergency surgery for their NSTI diagnosis. The overall mortality was 5.3%. Several underlying comorbidities were associated with higher rates of mortality including cancer (OR: 3.50, P = 0.0009), liver disease (OR: 2.97, P = 0.03), and kidney disease (OR: 2.15, P = 0.01). While associated with high in-hospital mortality, these diagnoses were not associated with a difference in the rate of discharge to home compared with skilled nursing or rehab. Overall, patients discharged to skilled nursing facilities or rehab had higher rates of underlying comorbidities than patients who were discharged home (3 or more comorbid illness 84.3% versus 68.6%, P < 0.0001); however, no individual comorbid illness was associated with discharge location.

CONCLUSIONS

In our Medicare data set, we identified several medical comorbidities that are associated with increased rates of in-hospital mortality. Patients with underlying cancers had the highest odds of increased mortality. The effect on outcomes of the potentially immunosuppressive cancer treatments in these patients is unknown. These data suggest that patients with underlying illnesses, especially cancer, kidney disease, or liver disease have higher mortalities and are more likely to be discharged to skilled nursing facilities or rehab. It is unclear why these illnesses were associated with these worse outcomes while others including diabetes and heart disease were not. These data suggest that these particular comorbid illnesses may have special prognostic implications, although further analysis is necessary to identify the causative factors.

The association between self-declared acute care surgery services and critical care resources: Results from a national survey

PURPOSE

We examined differences in critical care structures and processes between hospitals with Acute Care Surgery (ACS) versus general surgeon on call (GSOC) models for emergency general surgery (EGS) care.

METHODS

2811 EGS-capable hospitals were surveyed to examine structures and processes including critical care domains and ACS implementation. Differences between ACS and GSOC hospitals were compared using appropriate tests of association and logistic regression models.

RESULTS

272/1497 hospitals eligible for analysis (18.2%) reported they use an ACS model. EGS patients at ACS hospitals were more likely to be admitted to a combined trauma/surgical ICU or a dedicated surgical ICU. GSOC hospitals had lower adjusted odds of having 24-h ICU coverage, in-house intensivists or respiratory therapists, and 4/6 critical-care protocols.

CONCLUSIONS

Critical care delivery is a key component of EGS care. While harnessing of critical care structures and processes varies across hospitals that have implemented ACS, overall ACS models of care appear to have more robust critical care practices.

Discharge disposition to skilled nursing facility after emergent general surgery predicts a poor prognosis

BACKGROUND

Emergency general surgery can have a profound impact on the functional status of even previously independent patients. The role and influence of discharging a patient to a skilled nursing facility, however, remains largely unknown.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program for community-dwelling adults who underwent 1 of 7 emergency general surgery procedures and were discharged home or to a skilled nursing facility from 2012 to 2016. Propensity score matching and multivariable regression analyses were performed to determine the relationship between discharge disposition and outcomes.

RESULTS

Overall, 140,922 patients met the inclusion criteria. The majority were discharged home (95.9%). After applying 1:1 propensity score matching, in comparison to patients discharged home, individuals discharged to a skilled nursing facility had a greater odds of respiratory (odds ratio 2.32; 95% confidence interval, 1.59-3.38) and septic complications (odds ratio 1.63, 95% confidence interval 1.12-2.36) after discharge. Furthermore, following surgery, individuals discharged to a skilled nursing facility had a greater odds of 30-day readmission (odds ratio 1.14; 95% confidence interval, 1.01-1.29), and death within 30 days of the procedure (odds ratio 2.07; 95% confidence interval, 1.65-2.61).

CONCLUSION

After accounting for patient severity and perioperative course, discharge to a skilled nursing facility is an independent risk factor for death, readmission, and postdischarge complications.

Women surgeons and the emergence of acute care surgery programs

BACKGROUND

In parallel to women entering general surgery training, acute care surgery (ACS) has been developing as a team-based approach to emergency general surgery (EGS). We sought to examine predictors of women surgeons in EGS generally, and ACS particularly.

METHODS

From our national survey, we determined the proportion of women surgeons within EGS hospitals. We compared the proportion of women surgeons based on hospitals characteristics using chi-squared tests, then used regression models to measure odds of ACS relative to the proportion of women.

RESULTS

779 (50.4%) hospitals had zero women surgeons. These hospitals were more likely non-ACS and non-teaching with <200 beds. ACS had a higher median proportion of women surgeons (17%) compared to non-ACS (0%).

CONCLUSION

Our study highlights the dearth of women representation within EGS hospitals nationally and illuminates some of the underlying characteristics of ACS that may draw women: urban, academic, and staffed by more recently trained surgeons.

SUMMARY

Using a national survey of Emergency General Surgery (EGS) hospitals, we sought to examine predictors of women surgeons in EGS generally, and acute care surgery (ACS) particularly. We found that 779 (50.4%) hospitals had zero women surgeons. Women were more likely to be among EGS surgeons at hospitals with ACS models. Our study highlights the dearth of women representation within EGS hospitals nationally and illuminates some of the underlying characteristics of ACS that may draw women: urban, academic, and staffed by a higher proportion of newly trained surgeons.

Loss of Community-Dwelling Status Among Survivors of High-Acuity Emergency General Surgery Disease

OBJECTIVES

To examine loss of community-dwelling status 9 months after hospitalization for high-acuity emergency general surgery (HA-EGS) disease among older Americans.

DESIGN

Retrospective analysis of claims data.

SETTING

US communities with Medicare beneficiaries.

PARTICIPANTS

Medicare beneficiaries age 65 years or older hospitalized urgently/emergently between January 1, 2015, and March 31, 2015, with a principal diagnosis representing potential life or organ threat (necrotizing soft tissue infections, hernias with gangrene, ischemic enteritis, perforated viscus, toxic colitis or gastroenteritis, peritonitis, intra-abdominal hemorrhage) and an operation of interest on hospital days 1 or 2 (N = 3319).

MEASUREMENTS

Demographic characteristics (age, race, and sex), comorbidities, principal diagnosis, complications, and index hospitalization disposition (died; discharged to skilled nursing facility [SNF], long-term acute care [LTAC], rehabilitation, hospice, home (with or without services), or acute care hospital; other) were measured. Survivors of index hospitalization were followed until December 31, 2015, on mortality and community-dwelling status (SNF/LTAC vs not). Descriptive statistics, Kaplan-Meier plots, and χ² tests were used to describe and compare the cohort based on disposition. A multivariable logistic regression model, adjusted for age, sex, comorbidities, complications, and discharge disposition, determined independent predictors of loss of community-dwelling status at 9 months.

RESULTS

A total of 2922 (88%) survived index hospitalization. Likelihood of discharge to home decreased with increasing age, baseline comorbidities, and in-hospital complications. Overall, 418 (14.3%) HA-EGS survivors died during the follow-up period. Among those alive at 9 months, 10.3% were no longer community dwelling. Initial discharge disposition to any location other than home and three or more surgical complications during index hospitalization were independent predictors of residing in a SNF/LTAC 9 months after surviving HA-EGS.

CONCLUSION

Older Americans, known to prioritize living in the community, will experience substantial loss of independence due to HA-EGS. Long-term expectations after surviving HA-EGS must be framed from the perspective of the outcomes that older patients value the most. Further research is needed to examine the quality-of-life burden of EGS survivorship prospectively. J Am Geriatr Soc 67:2289-2297, 2019.

The association between self-declared acute care surgery services and operating room access: Results from a national survey

BACKGROUND

Timely access to the operating room (OR) for emergency general surgery (EGS) diseases is key to optimizing outcomes. We conducted a national survey on EGS structures and processes to examine if implementation of acute care surgery (ACS) would improve OR accessibility compared with a traditional general surgeon on call (GSOC) approach.

METHODS

We surveyed 2,811 acute care general hospitals in the United States capable of EGS care. The questionnaire included queries regarding structures and processes related to OR access and on the model of EGS care (ACS vs. GSOC). Associations between the EGS care model and structures and processes to ensure OR access were measured using univariate and multivariate models (adjusted for hospital characteristics).

RESULTS

Of 1,690 survey respondents (60.1%), 1,497 reported ACS or GSOC. 272 (18.2%) utilized an ACS model. The ACS hospitals were more likely to have more than 5 days of block time and a tiered system of booking urgent/emergent cases compared with GSOC hospitals (34.2% vs. 7.4% and 85.3% vs. 57.6%, respectively; all p values <0.001). Surgeons at ACS hospitals were more likely to be free of competing clinical duties, be in-house overnight, and cover at a single hospital overnight when covering EGS (40.1% vs. 4.7%, 64.7% vs. 25.6%, and 84.9% vs. 64.9%, respectively; all p values <0.001). The ACS hospitals were more likely to have overnight in-house scrub techs, OR nurses, and recovery room nurses (69.9% vs. 13.8%, 70.6% vs. 13.9%, and 45.6% vs. 5.4%, respectively; all p values <0.001). On multivariable analysis, ACS hospitals had higher odds of all structures and processes that would improve OR access.

CONCLUSION

The ACS implementation is associated with factors that may improve OR access. This finding has implications for potential expansion of EGS care models that ensure prompt OR access for the EGS diseases that warrant emergency surgery.

LEVEL OF EVIDENCE

Therapeutic, Level III.

Geographic variation in hospital costs, payments, and length of stay for opioid-related hospital visits in the USA

PURPOSE

Despite the rise in opioid-related hospitalizations, there has been little research regarding opioid-related healthcare utilization. The objective of this study was to estimate the mean adjusted hospital costs, payments, and length of stay (LOS) for opioid-related visits for the nation and each of the nine US census regions.

METHODS

An observational study of retrospective claims data from the Vizient health system database was conducted. Eligible visits had a principal diagnosis of opioid use or dependence defined by ICD, ninth and tenth revision (ICD-9/10), and occurred between January 2014 and June 2017. Separate regression models for inpatient and outpatient visits were generated to estimate the adjusted costs, payments, and LOS for opioid-related visits.

RESULTS

A total of 193,614 (32,713 inpatient and 160,901 outpatient) visits met the inclusion criteria. The overall adjusted mean cost, payment, and LOS for an inpatient opioid-related visit were $4,383 (range between regions: $2,894-$5,835), $6,689 (range between regions: $4,038-$9,001), and 4.35 days (range between regions: 3.8-5.7 days), respectively. The overall adjusted mean cost and payment for an outpatient opioid-related visit were $533 (range between regions: $395-$802) and $374 (range between regions: $187-$574), respectively. Opioid-related hospital costs, payments, and LOS varied across the US. Data on the regional variation and national averages are necessary for hospitals to benchmark their services and more effectively manage this population.

CONCLUSION

Future research should examine intraregion utilization to understand the effect of prices and level of services.

Estimating the Effect of Intravenous Acetaminophen for Postoperative Pain Management on Length of Stay and Inpatient Hospital Costs

Introduction

The provision of safe, effective, cost-efficient perioperative inpatient acute pain management is an important concern among clinicians and administrators within healthcare institutions. Overreliance on opioid monotherapy in this setting continues to present health risks for patients and increase healthcare costs resulting from preventable adverse events. The goal of this study was to model length of stay (LOS), potential opioid-related complications, and costs for patients reducing opioid use and adding intravenous acetaminophen (IV APAP) for management of postoperative pain.

Methods

Data for this study were de-identified inpatient encounters from The Advisory Board Company across 297 hospitals from 2012–2014, containing 2,238,433 encounters (IV APAP used in 12.1%). Encounters for adults ≥18 years of age admitted for cardiovascular, colorectal, general, obstetrics and gynecology, orthopedics, or spine surgery were included. The effects of reducing opioids and adding IV APAP were estimated using hierarchical statistical models. Costs were estimated by multiplying modeled reductions in LOS or complication rates by observed average volumes for medium-sized facilities, and by average cost per day or per complication (LOS: US$2383/day; complications: derived from observed charges).

Results

Across all surgery types, LOS showed an average reduction of 18.5% (10.7–32.0%) for the modeled scenario of reducing opioids by one level (high to medium, medium to low, or low to none) and adding IV APAP, with an associated total LOS-related cost savings of $4.5 M. Modeled opioid-related complication rates showed similar improvements, averaging a reduction of 28.7% (5.4–44.0%) with associated cost savings of $0.2 M. In aggregate, costs decreased by an estimated $4.7 M for a medium-sized hospital. The study design demonstrates associations only and cannot establish causal relationships. The cost impact of LOS is modeled based on observed data.

Conclusions

This investigation indicates that reducing opioid use and including IV APAP for postoperative pain management has the potential to decrease LOS, opioid-related complication rates, and costs from a hospital perspective.

Funding

Mallinckrodt Pharmaceuticals.

Comparative Analysis of Length of Stay and Inpatient Costs for Orthopedic Surgery Patients Treated with IV Acetaminophen and IV Opioids vs. IV Opioids Alone for Post-Operative Pain

Introduction

Recovery from orthopedic surgery is oriented towards restoring functional health outcomes while reducing hospital length of stay (LOS) and medical expenditures. Optimal pain management is a key to reaching these objectives. We sought to compare orthopedic surgery patients who received combination intravenous (IV) acetaminophen and IV opioid analgesia to those who received IV opioids alone and compared the two groups on LOS and hospitalization costs.

Methods

We performed a retrospective analysis of the Premier Database (Premier, Inc.; between January 2009 and June 2015) comparing orthopedic surgery patients who received post-operative pain management with combination IV acetaminophen and IV opioids to those who received only IV opioids starting on the day of surgery and continuing up to the second post-operative day. The quarterly rate of IV acetaminophen use for all hospitalizations by hospital served as the instrumental variable in two-stage least squares regressions controlling for patient and hospital covariates to compare the LOS and hospitalization costs of IV acetaminophen recipients to opioid monotherapy patients.

Results

We identified 4,85,895 orthopedic surgery patients with 1,74,805 (36%) who had received IV acetaminophen. Study subjects averaged 64 years of age and were predominantly non-Hispanic Caucasians (78%) and female (58%). The mean unadjusted LOS for IV acetaminophen patients was 3.2 days [standard deviation (SD) 2.6] compared to 3.9 days (SD 3.9) with only IV opioids (P < 0.0001). Average unadjusted hospitalization costs were $19,024.9 (SD $13,113.7) for IV acetaminophen patients and $19,927.6 (SD $19,578.8) for IV opioid patients (P < 0.0001). These differences remained statistically significant in our instrumental variable models, with IV acetaminophen associated with 0.51 days shorter hospitalization [95% confidence interval (CI) −0.58 to −0.44, P < 0.0001] and $634.8 lower hospitalization costs (95% CI −$1032.5 to −$237.1, P = 0.0018).

Conclusion

Compared to opioids alone, managing post-orthopedic surgery pain with the addition of IV acetaminophen is associated with shorter LOS and decreased hospitalization costs.

Funding

Mallinckrodt Pharmaceuticals.

Estimates of charges associated with emergency department and hospital inpatient care for opioid abuse-related events

The economic burden of prescription opioid abuse is substantial; however, no study has estimated the monetary burden of hospital services (emergency department [ED] and inpatient) using a single, nationally representative database. We sought to estimate total and average (adjusted for demographic and clinical factors) charges billed for opioid abuse-related events, and magnitude of difference in charges between ED visits resulting in inpatient admission to the same hospital and treat-and-release ED visits in the United States. We used the 2006, 2007, and 2008 files of the Healthcare Cost and Utilization Project's Nationwide Emergency Departments Sample (HCUP-NEDS) to identify events and charges assigned opioid abuse, dependence, or poisoning ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) diagnosis codes (304.0X, 304.7X, 305.5X, 965.00, 965.02, 965.09). Using methods to account for the complex sampling design of the NEDS and a log-linked gamma regression model, we estimated national total and mean charges (in 2010 USD). Total charges were $9.8, $9.6, and $9.5 billion for 2006, 2007, and 2008, respectively. Medicaid-covered events had the highest total charges ($3 billion), followed by events covered by Medicare ($2 billion) for each year. The national estimate of adjusted, mean, per-event charges, was $18,891 (95% confidence interval [CI] = $18,167-$19,616). Compared with events covered by private insurance, mean charges for Medicare- and Medicaid-covered events were higher (t = 28.14, P < .001; t = 6.42, P < .001, respectively), whereas self-paid events had significantly lower charges (t = -11.14, P < .001). ED visits resulting in subsequent inpatient admission had approximately 6 times higher charges than treat-and-release visits. This study provides estimates of differences in hospital costs of opioid abuse by insurance status, resulting in a better understanding of the economic burden of opioid abuse on the health care system.

Core competencies for pain management: results of an interprofessional consensus summit

Objective

The objective of this project was to develop core competencies in pain assessment and management for prelicensure health professional education. Such core pain competencies common to all prelicensure health professionals have not been previously reported.

Methods

An interprofessional executive committee led a consensus-building process to develop the core competencies. An in-depth literature review was conducted followed by engagement of an interprofessional Competency Advisory Committee to critique competencies through an iterative process. A 2-day summit was held so that consensus could be reached.

Results

The consensus-derived competencies were categorized within four domains: multidimensional nature of pain, pain assessment and measurement, management of pain, and context of pain management. These domains address the fundamental concepts and complexity of pain; how pain is observed and assessed; collaborative approaches to treatment options; and application of competencies across the life span in the context of various settings, populations, and care team models. A set of values and guiding principles are embedded within each domain.

Conclusions

These competencies can serve as a foundation for developing, defining, and revising curricula and as a resource for the creation of learning activities across health professions designed to advance care that effectively responds to pain.

Consensus recommendations from the strategic planning summit for pain and palliative care pharmacy practice

Pain and symptoms related to palliative care (pain and palliative care [PPC]) are often undertreated. This is largely owing to the complexity in the provision of care and the potential discrepancy in education among the various health care professionals required to deliver care. Pharmacists are frequently involved in the care of PPC patients, although pharmacy education currently does not offer or require a strong curriculum commitment to this area of practice. The Strategic Planning Summit for the Advancement of Pain and Palliative Care Pharmacy was convened to address opportunities to improve the education of pharmacists and pharmacy students on PPC. Six working groups were charged with objectives to address barriers and opportunities in the areas of student and professional assessment, model curricula, postgraduate training, professional education, and credentialing. Consensus was reached among the working groups and presented to the Summit Advisory Board for adoption. These recommendations will provide guidance on improving the care provided to PPC patients by pharmacists through integrating education at all points along the professional education continuum.

Adherence to oral antidiabetic medications in the pediatric population with type 2 diabetes: a retrospective database analysis

BACKGROUND

Little has been done in assessing adherence to oral antidiabetic (OAD) medications in the pediatric population presenting with type 2 diabetes. This study provided information on adherence rates in the Texas Medicaid pediatric population with type 2 diabetes, which is rare in the literature. The knowledge of adherence rates in the pediatric population with type 2 diabetes might help improve the care given to pediatric patients with type 2 diabetes.

OBJECTIVE

To describe OAD medication use, and assess trends in medication adherence and persistence among Texas pediatric Medicaid patients.

METHODS

Texas Medicaid prescription claims data of patients between 10 and 18 years of age, with at least 2 prescriptions of the same OAD medication from January 1, 2006 to December 31, 2009, were analyzed. Adherence was assessed using the medication possession ratio (MPR) as a proxy.

RESULTS

A total of 3109 patients met the study's inclusion criteria. The mean (SD) age of the 3109 eligible patients was 14.2 (2.3) years; 60% were Hispanics, 14% were blacks, 13% were whites, and another 13% were other minority races; 67% of the population were females; and 91% were on metformin of the 6 OAD medications included in the study The overall mean (SD) MPR for patients was 44.69% (27.06%). Adherence differed by gender (P < 0.0001), race (P < 0.0001), and age category (P < 0.0001). Males had higher mean (SD) MPR (47.47% [27.42%]) compared with females (43.29% [26.78%]). Mean MPR for whites (50.04% [29.65%]) was significantly higher compared with blacks (44.24% [26.16%]) and Hispanics (42.50% [26.10%]). Patients ≤12 years of age had significantly higher mean MPR (48.82% [27.37%]) compared with those in older age categories. Logistic regression analysis suggested that age was significantly related (odds ratio [OR] = 0.91; 95% CI, 0.87-0.95) to being adherent (MPR ≥80%). Males were 25% (OR = 1.25; 95% CI, 1.02-1.53; P = 0.034) more likely to be adherent (MPR ≥80%) compared with females, and whites were twice as likely to be adherent (MPR ≥80%) compared with Hispanics (OR = 2.02; 95% CI, 1.54-2.66; P = 0.0012). Overall, mean (SD) days to nonpersistence was 108 (86) days. Persistence was significantly and negatively associated with age (P < 0.0001). White race was significantly related to longer persistence.

CONCLUSION

Adherence and persistence to OAD medications in the selected Texas Medicaid pediatric population between 10 and 18 years was generally suboptimal, especially in adolescents.

Does sensory stimulation threshold affect lumbar facet radiofrequency denervation outcomes? A prospective clinical correlational study

BACKGROUND

Radiofrequency facet denervation is one of the most frequently performed procedures for chronic low back pain. Although sensory stimulation is generally used as a surrogate measure to denote sufficient proximity of the electrode to the nerve, no study has examined whether stimulation threshold influences outcome.

METHODS

We prospectively recorded data in 61 consecutive patients undergoing lumbar facet radiofrequency denervation who experienced significant pain relief after medial branch blocks. For each nerve lesioned, multiple attempts were made to maximize sensory stimulation threshold (SST). Mean SST was calculated on the basis of the lowest stimulation perceived at 0.1-V increments for each medial branch. A positive outcome was defined as a ≥50% reduction in back pain coupled with a positive satisfaction score lasting ≥3 months. The relationship between mean SST and denervation outcomes was evaluated via a receiver's operating characteristic (ROC) curve, and stratifying outcomes on the basis of various cutoff values.

RESULTS

No correlation was noted between mean SST and pain relief at rest (Pearson's r=-0.01, 95% confidence interval [CI]: -0.24 to 0.23, P=0.97), with activity (r=-0.17, 95% CI: -0.40 to 0.07, P=0.20), or a successful outcome. No optimal SST could be identified.

CONCLUSIONS

There is no significant relationship between mean SST during lumbar facet radiofrequency denervation and treatment outcome, which may be due to differences in general sensory perception. Because stimulation threshold was optimized for each patient, these data cannot be interpreted to suggest that sensory testing should not be performed, or that high sensory stimulation thresholds obtained on the first attempt should be deemed acceptable.

Diagnoses and factors associated with medical evacuation and return to duty among nonmilitary personnel participating in military operations in Iraq and Afghanistan

BACKGROUND

Nonmilitary personnel play an increasingly critical role in modern wars. Stark differences exist between the demographic characteristics, training and missions of military and nonmilitary members. We examined the differences in types of injury and rates of returning to duty among nonmilitary and military personnel participating in military operations in Iraq and Afghanistan.

METHODS

We collected data for nonmilitary personnel medically evacuated from military operations in Iraq and Afghanistan between 2004 and 2007. We compared injury categories and return-to-duty rates in this group with previously published data for military personnel and identified factors associated with return to duty.

RESULTS

Of the 2155 medically evacuated nonmilitary personnel, 74.7% did not return to duty. War-related injuries in this group accounted for 25.6% of the evacuations, the most common causes being combat-related injuries (55.4%) and musculoskeletal/spinal injuries (22.9%). Among individuals with non-war-related injuries, musculoskeletal injuries accounted for 17.8% of evacuations. Diagnoses associated with the highest return-to-duty rates in the group of nonmilitary personnel were psychiatric diagnoses (15.6%) among those with war-related injuries and noncardiac chest or abdominal pain (44.0%) among those with non-war-related injuries. Compared with military personnel, nonmilitary personnel with war-related injuries were less likely to return to duty (4.4% v. 5.9%, p = 0.001) but more likely to return to duty after non-war-related injuries (32.5% v. 30.7%, p = 0.001).

INTERPRETATION

Compared with military personnel, nonmilitary personnel were more likely to be evacuated with non-war-related injuries but more likely to return to duty after such injuries. For evacuations because of war-related injuries, this trend was reversed.

Constipation in persons receiving hospice care

CONTEXT

Symptom burden at the end of life is incompletely understood.

OBJECTIVES

To estimate the natural history of constipation and the relation of clinical and demographic characteristics to moderate or severe constipation among persons who received hospice care in the United States starting in 2005.

METHODS

Data were obtained from a national provider of hospice pharmacy services and included information about the hospice organization, patient demographics and clinical characteristics, constipation intensity, and drugs prescribed. Hospice nurses assessed patients' constipation during the previous 24 hours periodically, using a 0-10 numeric rating scale (NRS; 0=no intensity and 10=worst imaginable; none [NRS 0], mild [NRS 1-3], moderate [NRS 4-6], or severe [NRS 7-10]). Regression models were constructed to identify factors associated with last reported constipation severity scores.

RESULTS

Fifty thousand six hundred forty-one persons received hospice services, had at least two constipation assessments, and had complete clinical and demographic information; 55.3% of these individuals were female, 87.1% were Caucasian, and mean age was 75.9 years. Constipation was assessed a mean of four times per person; 12% of persons had moderate or severe constipation at their first or last assessment, and 19% of persons who reported moderate or severe constipation at the first assessment also had moderate or severe constipation at the last assessment. First constipation and last pain scores, having cancer, and prescription of a laxative were associated with increased likelihood of moderate or severe constipation at the last assessment.

CONCLUSIONS

These data provide insight into a common and potentially distressing symptom and also may be useful as process indicators of the quality of hospice care.

Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for quality improvement of pain management in hospitalized adults: preliminary psychometric evaluation

Quality improvement (QI) is a compilation of methods adapted from psychology, statistics, and operations research to identify factors that contribute to poor treatment outcomes and to design solutions for improvement. Valid and reliable measurement is essential to QI using rigorously developed and tested instruments. The purpose of this article is to describe the evolution of the American Pain Society Patient Outcome Questionnaire (APS-POQ) for QI purposes and present a revised version (R) including instrument psychometrics. An interdisciplinary task force of the APS used a step-wise, empiric approach to revise, test, and examine psychometric properties of the society's original POQ. The APS-POQ-R is designed for use in adult hospital pain management QI activities and measures 6 aspects of quality, including (1) pain severity and relief; (2) impact of pain on activity, sleep, and negative emotions; (3) side effects of treatment; (4) helpfulness of information about pain treatment; (5) ability to participate in pain treatment decisions; and (6) use of nonpharmacological strategies. Adult medical-surgical inpatients (n = 299) from 2 hospitals in different parts of the United States participated in this study. Results provide support for the internal consistency of the instrument subscales, construct validity and clinical feasibility.

PERSPECTIVE

This article presents the initial psychometric properties of the APS-POQ-R for quality improvement purposes of hospitalized adult patients. Validation in additional groups of patients will be needed to demonstrate its generalizability.

Out-of-pocket prices of opioid analgesics in the United States, 1999-2004

OBJECTIVE

To determine the out-of-pocket prices of common opioid analgesics by medication, drug coverage, region, and year.

DESIGN

Retrospective cohort study using 1999-2004 data from the Medical Expenditure Panel Survey and the Medicare Current Beneficiary Survey.

SETTING

U.S. civilian noninstitutionalized population.

PATIENTS

Adults not enrolled in Medicaid who filled prescriptions for opioid analgesics between 1999 and 2004.

OUTCOME MEASURES

Prices of prescribed analgesics were collected from receipts, medication containers, patient recall, and administrative records (N = 20,926 and 31,500, respectively).

RESULTS

Average out-of-pocket price of an opioid analgesic prescription was around $10, but the estimate is potentially misleading: A typical adult patient without drug coverage paid $12.86-$61.60 to fill his or her analgesic prescription, depending on medication. The extended-release formulations cost more than double the immediate release prices. For the analgesics studied, drug coverage lowered out-of-pocket prices by 50-85%, while market prices increased at a rate of 5.7-9% per year with little regional variation. Data did not include prices for medications not prescribed or prescribed, but not acquired.

CONCLUSIONS

Independent of the diagnosis, patients' out-of-pocket price for prescribed analgesics fluctuated freely in the United States across time, region, and coverage status. These fluctuations potentially distort the delivery of effective pain management and further burden an already afflicted population.

Diagnoses and factors associated with medical evacuation and return to duty for service members participating in Operation Iraqi Freedom or Operation Enduring Freedom: a prospective cohort study

BACKGROUND

Anticipation of the types of injuries that occur in modern warfare is essential to plan operations and maintain a healthy military. We aimed to identify the diagnoses that result in most medical evacuations, and ascertain which demographic and clinical variables were associated with return to duty.

METHODS

Demographic and clinical data were prospectively obtained for US military personnel who had been medically evacuated from Operation Iraqi Freedom or Operation Enduring Freedom (January, 2004-December, 2007). Diagnoses were categorised post hoc according to the International Classification of Diseases codes that were recorded at the time of transfer. The primary outcome measure was return to duty within 2 weeks.

FINDINGS

34 006 personnel were medically evacuated, of whom 89% were men, 91% were enlisted, 82% were in the army, and 86% sustained an injury in Iraq. The most common reasons for medical evacuation were: musculoskeletal and connective tissue disorders (n=8104 service members, 24%), combat injuries (n=4713, 14%), neurological disorders (n=3502, 10%), psychiatric diagnoses (n=3108, 9%), and spinal pain (n=2445, 7%). The factors most strongly associated with return to duty were being a senior officer (adjusted OR 2.01, 95% CI 1.71-2.35, p<0.0001), having a non-battle-related injury or disease (3.18, 2.77-3.67, p<0.0001), and presenting with chest or abdominal pain (2.48, 1.61-3.81, p<0.0001), a gastrointestinal disorder (non-surgical 2.32, 1.51-3.56, p=0.0001; surgical 2.62, 1.69-4.06, p<0.0001), or a genitourinary disorder (2.19, 1.43-3.36, p=0.0003). Covariates associated with a decreased probability of return to duty were serving in the navy or coast guard (0.59, 0.45-0.78, p=0.0002), or marines (0.86, 0.77-0.96, p=0.0083); and presenting with a combat injury (0.27, 0.17-0.44, p<0.0001), a psychiatric disorder (0.28, 0.18-0.43, p<0.0001), musculoskeletal or connective tissue disorder (0.46, 0.30-0.71, p=0.0004), spinal pain (0.41, 0.26-0.63, p=0.0001), or other wound (0.54, 0.34-0.84, p=0.0069).

INTERPRETATION

Implementation of preventive measures for service members who are at highest risk of evacuation, forward-deployed treatment, and therapeutic interventions could reduce the effect of non-battle-related injuries and disease on military readiness.

FUNDING

John P Murtha Neuroscience and Pain Institute, and US Army Regional Anesthesia and Pain Management Initiative.

Economic burden of prescription opioid misuse and abuse

BACKGROUND

Prescription opioid abuse and its associated costs are a problem in the United States, with significant epidemiologic and economic consequences. The breadth and depth of these consequences are not fully understood at present.

OBJECTIVE

To summarize published, English-language biomedical evidence pertaining to the epidemiology and costs of prescription opioid analgesic misuse and abuse and to describe efforts to reduce the burden of these problems.

METHODS

Published English-language articles on the epidemiology and economics of abuse, misuse, or diversion of prescribed opioid analgesics in the United States were identified by searching PubMed, Web of Science, the Cumulative Index to Nursing and Allied Health Literature database (CINAHL), EconLit, and PsycInfo, using (economics OR epidemiology) AND (misuse OR abuse) AND opioid as search terms or Medical Subject Heading (MeSH) terms. Article bibliographies were also searched manually for applicable papers. The search was limited to articles published from 1995 through July 2009.

RESULTS

The literature search identified 2,347 titles, of which all but 41 were excluded as not pertaining specifically to the epidemiology or economics of prescription opioid abuse or misuse in the United States. In 2006, approximately 5.2 million individuals in the United States reported using prescription analgesics nonmedically in the prior month, up from 4.7 million in 2005. The total cost of prescription opioid abuse in 2001 was estimated at $8.6 billion, including workplace, health care, and criminal justice expenditures. One study of commercially insured beneficiaries in the United States found that mean per-capita annual direct health care costs from 1998 to 2002 were nearly $16,000 for abusers of prescription and nonprescription opioids compared with approximately $1,800 for nonabusers who had at least 1 prescription insurance claim.

CONCLUSIONS

The economic burden of prescription opioid misuse and abuse is large. While the existing evidence indicates that persons who abuse or misuse prescription opioids incur higher costs and health care resource use, differences in methods used to explore this question make estimating the actual societal burden imposed by this problem difficult. Efforts to establish and maintain a balance between access to these drugs for legitimate pain management while decreasing the risk of abuse and misuse are critically important and include such tools as patient and provider education, patient screening, and use of technology.