1
|
Jacobson A, Mack D, Herrera G, Bowe SN, Highland KB, Patzkowski MS. Incidence of Surgically Managed Post-Tonsillectomy Hemorrhage Associated With NSAID Prescribing for Postoperative Pain Management. Mil Med 2024:usae194. [PMID: 38758073 DOI: 10.1093/milmed/usae194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 12/28/2023] [Accepted: 04/03/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Tonsillectomy ranks high among the most common pediatric surgical procedures in the United States. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen, are routinely prescribed to manage post-tonsillectomy pain, but may carry the risk of hemorrhage. MATERIALS AND METHODS This retrospective, longitudinal, secondary-data analysis study compared the incidence of surgically managed post-tonsillectomy hemorrhage (sPTH) in pediatric patients prescribed ibuprofen at Brooke Army Medical Center (BAMC) after tonsillectomy compared to a similar cohort of pediatric patients at the Children's Hospital of Philadelphia (CHOP) not prescribed ibuprofen. Additional regression analysis examined predictors of sPTH at BAMC. RESULTS The odds of sPTH was lower in patients who were prescribed ibuprofen at BAMC, relative to patients who were not at CHOP (OR 0.57, 95% CI, 0.37, 0.87; P < 0.01). In a generalized linear model evaluating BAMC patient data, there was a lack of a relationship between reason for tonsillectomy (tonsillitis versus tonsillar obstruction), primary procedure (tonsillectomy-only versus tonsillectomy with adenoidectomy), and presence of a co-occurring procedure. CONCLUSIONS Post-tonsillectomy ibuprofen prescribing practices were not associated with an elevated risk of sPTH, relative to patients at CHOP not exposed to ibuprofen.
Collapse
Affiliation(s)
- Andrew Jacobson
- Department of Anesthesia, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234-6200, USA
| | - Douglas Mack
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, JBSA Fort Sam Houston, TX 78234-6200, USA
| | - Germaine Herrera
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation, Inc., Rockville, MD 20852, USA
- Defense and Veterans Center for Integrative Pain Management, Bethesda, MD 20814, USA
| | - Sarah N Bowe
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, JBSA Fort Sam Houston, TX 78234-6200, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
| | - Michael S Patzkowski
- Department of Anesthesia, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234-6200, USA
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
| |
Collapse
|
2
|
Herrera GF, Patzkowski JC, Patzkowski MS, Giordano NA, Scott-Richardson M, Kent M, Highland KB. Discharge Opioid Dose Indirectly Associated With Functional Outcomes 2 Weeks After Shoulder and Knee Arthroscopy in a US Military Sample. Mil Med 2024:usad495. [PMID: 38602453 DOI: 10.1093/milmed/usad495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/13/2023] [Accepted: 12/21/2023] [Indexed: 04/12/2024] Open
Abstract
INTRODUCTION Postsurgical opioid utilization may be directly and indirectly associated with a range of patient-related and surgery-related factors, above and beyond pain intensity. However, most studies examine postsurgical opioid utilization without accounting for the multitude of co-occurring relationships among predictors. Therefore, this study aimed to identify factors associated with opioid utilization in the first 2 weeks after arthroscopic surgery and examine the relationship between discharge opioid prescription doses and acute postsurgical outcomes. METHODS In this prospective longitudinal observational study, 110 participants undergoing shoulder or knee arthroscopies from August 2016 to August 2018 at Walter Reed National Military Medical Center completed self-report measures before and at 14 days postoperatively. The association between opioid utilization and both patient-level and surgery-related factors was modeled using structural equation model path analysis. RESULTS Participants who were prescribed more opioids took more opioids, which was associated with worse physical function and sleep problems at day 14, as indicated by the significant indirect effects of discharge opioid dose on day 14 outcomes. Additional patient-level and surgery-related factors were also significantly related to opioid utilization dose and day 14 outcomes. Most participants had opioid medications leftover at day 14. CONCLUSION Excess opioid prescribing was common, did not result in improved pain alleviation, and was associated with poorer physical function and sleep 14 days after surgery. As such, higher prescribed opioid doses could reduce subacute functioning after surgery, without benefit in reducing pain. Future patient-centered studies to tailor opioid postsurgical prescribing are needed.
Collapse
Affiliation(s)
- Germaine F Herrera
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Rockville, MD 20852, USA
| | - Jeanne C Patzkowski
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200, USA
| | - Michael S Patzkowski
- Department of Anesthesia, Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200, USA
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
| | - Nicholas A Giordano
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30322, USA
| | | | - Michael Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
| |
Collapse
|
3
|
Highland KB, Sowa HA, Herrera GF, Bell AG, Cyr KL, Velosky AG, Patzkowski JC, Kanter T, Patzkowski MS. Post-total joint arthroplasty opioid prescribing practices vary widely and are not associated with opioid refill: an observational cohort study. Arch Orthop Trauma Surg 2023; 143:5539-5548. [PMID: 37004553 DOI: 10.1007/s00402-023-04853-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 03/18/2023] [Indexed: 04/04/2023]
Abstract
INTRODUCTION Optimized health system approaches to improving guideline-congruent care require evaluation of multilevel factors associated with prescribing practices and outcomes after total knee and hip arthroplasty. MATERIALS AND METHODS Electronic health data from patients who underwent a total knee or hip arthroplasty between January 2016-January 2020 in the Military Health System Data were retrospectively analyzed. A generalized linear mixed-effects model (GLMM) examined the relationship between fixed covariates, random effects, and the primary outcome (30-day opioid prescription refill). RESULTS In the sample (N = 9151, 65% knee, 35% hip), the median discharge morphine equivalent dose was 660 mg [450, 892] and varied across hospitals and several factors (e.g., joint, race and ethnicity, mental and chronic pain conditions, etc.). Probability of an opioid refill was higher in patients who underwent total knee arthroplasty, were white, had a chronic pain or mental health condition, had a lower age, and received a presurgical opioid prescription (all p < 0.01). Sex assigned in the medical record, hospital duration, discharge non-opioid prescription receipt, discharge morphine equivalent dose, and receipt of an opioid-only discharge prescription were not significantly associated with opioid refill. CONCLUSION In the present study, several patient-, care-, and hospital-level factors were associated with an increased probability of an opioid prescription refill within 30 days after arthroplasty. Future work is needed to identify optimal approaches to reduce unwarranted and inequitable healthcare variation within a patient-centered framework.
Collapse
Affiliation(s)
- Krista B Highland
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.
| | - Hillary A Sowa
- School of Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Germaine F Herrera
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, 6720A Rockledge Dr., #100, Bethesda, MD, 20817, USA
| | - Austin G Bell
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
- Department of Anesthesia, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20910, USA
- Department of Anesthesiology, Dwight D. Eisenhower Army Medical Center, 300, E Hospital Rd, Fort Gordon, GA, 30905, USA
| | - Kyle L Cyr
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
- Department of Anesthesia, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20910, USA
| | - Alexander G Velosky
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, 6720A Rockledge Dr., #100, Bethesda, MD, 20817, USA
| | - Jeanne C Patzkowski
- Department of Orthopaedic Surgery, Brooke Army Medical Center, 3551 Roger Brooke Drive, TX, 78234-6200, Fort Sam Houston, USA
- Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Trevor Kanter
- Emory University, 201 Dowman Drive, Atlanta, GA, 30322, USA
| | - Michael S Patzkowski
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
- Department of Anesthesiology, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX, 78234-6200, USA
| |
Collapse
|
4
|
Patzkowski MS, Highland KB, Hudson A, Herrera GF, Bodily KR, Ruffin DM, Via DK. Anesthesiology Fellowships in the Military Health System: An Education Analysis of the Supply and Demand. Mil Med 2023; 188:e3210-e3215. [PMID: 36976714 DOI: 10.1093/milmed/usad065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/05/2023] [Accepted: 02/23/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION Evidence indicates that desire for fellowship training is most influenced by personal interest, enhancement of career options, and a specific interest in an academic medicine career. The overall objective of this study is to evaluate anesthesiology fellowship interest and its potential impact on military retention and other outcomes. We hypothesized that current fellowship training accessibility is outpaced by the interest for fellowship training and that additional factors will be associated with the desire for fellowship training. METHODS This prospective cross-sectional survey study was approved as Exempt Research by the Brooke Army Medical Center Institutional Review Board in November 2020. Participants were eligible to complete the online voluntary survey if they were active duty anesthesiologists. Anonymous surveys were administered via the Research Electronic Data Capture System from December 2020 to January 2021. Aggregated data were evaluated using univariate statistics, bivariate analyses, and a generalized linear model. RESULTS Seventy-four percent of general anesthesiologists (those without fellowship training) were interested in pursuing future fellowship training versus 23% of subspecialist anesthesiologists (those currently in fellowship training or have completed fellowship training), odd ratio 9.71 (95% CI, 4.3-21.7). Of subspecialist anesthesiologists, 75% indicated serving in a nongraduate medical education (GME) leadership position (e.g., service/department chief), with 38% serving in a GME leadership position (e.g., program or associate program director). Almost half (46%) of subspecialist anesthesiologists reported being "extremely likely" to serve ≥20 years, versus 28% of general anesthesiologists. CONCLUSIONS There is a high demand among active duty anesthesiologists for fellowship training, which in turn, may improve military retention. The demand for fellowship training is outpaced by what the Services currently offer, including training in Trauma Anesthesiology. Leveraging this interest in subspecialty fellowship training, particularly when the skills align with combat casualty care-related requirements, would greatly benefit the Services.
Collapse
Affiliation(s)
- Michael S Patzkowski
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200, USA
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
| | - Arlene Hudson
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
| | - Germaine F Herrera
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Rockville, MD 20852, USA
| | - Kory R Bodily
- Department of Anesthesiology, Mike O'Callaghan Military Medical Center, Nellis AFB, NV 89191, USA
| | - David M Ruffin
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Department of Anesthesia and Operative Services, Womack Army Medical Center, Fort Bragg, NC 28310, USA
| | - Darin K Via
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- US Navy Bureau of Medicine and Surgery (BUMED), Falls Church, VA 22042-5113, USA
| |
Collapse
|
5
|
Highland KB, Kent M, McNiffe N, Patzkowski JC, Patzkowski MS, Kane A, Giordano NA. Longitudinal Predictors of PROMIS Satisfaction With Social Roles and Activities After Shoulder and Knee Sports Orthopaedic Surgery in United States Military Servicemembers: An Observational Study. Orthop J Sports Med 2023; 11:23259671231184834. [PMID: 37529526 PMCID: PMC10387780 DOI: 10.1177/23259671231184834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/11/2023] [Indexed: 08/03/2023] Open
Abstract
Background Satisfaction with social roles and activities is an important outcome for postsurgical rehabilitation and quality of life but not commonly assessed. Purpose To evaluate longitudinal patterns of the Patient-Reported Outcomes Measurement Information System (PROMIS) Satisfaction with Social Roles and Activities measure, including how it relates to other biopsychosocial factors, before and up to 6 months after sports-related orthopaedic surgery. Study Design Cohort study (diagnosis); Level of evidence, 3. Methods Participants (N = 223) who underwent knee and shoulder sports orthopaedic surgeries between August 2016 and October 2020 completed PROMIS computer-adaptive testing item banks and pain-related measures before surgery and at 6-week, 3-month, and 6-month follow-ups. In a generalized additive mixed model, covariates included time point; peripheral nerve block; the PROMIS Anxiety, Sleep Disturbance, and Pain Behavior measures; and previous 24-hour pain intensity. Patient-reported outcomes were modeled as nonlinear (smoothed) effects. Results The linear (estimate, 2.06; 95% CI, 0.77-3.35; P = .002) and quadratic (estimate, 2.93; 95% CI, 1.78-4.08; P < .001) effects of time, as well the nonlinear effects of PROMIS Anxiety (P < .001), PROMIS Sleep Disturbance (P < .001), PROMIS Pain Behavior (P < .001), and pain intensity (P = .02), were significantly associated with PROMIS Satisfaction with Social Roles and Activities. The cubic effect of time (P = .06) and peripheral nerve block (P = .28) were not. The proportion of patients with a 0.5-SD improvement in the primary outcome increased from 23% at 6 weeks to 52% by 6 months postsurgery, whereas those reporting worsening PROMIS Satisfaction with Social Roles and Activities decreased from 30% at 6 weeks to 13% at 6 months. Conclusion The PROMIS Satisfaction with Social Roles and Activities measure was found to be related to additional domains of function (eg, mental health, behavioral, pain) associated with postsurgical rehabilitation.
Collapse
Affiliation(s)
- Krista B. Highland
- Department of Anesthesiology, Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Bethesda, Maryland, USA
| | - Michael Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Nicholas McNiffe
- School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Jeanne C. Patzkowski
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Michael S. Patzkowski
- Department of Anesthesiology, Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Bethesda, Maryland, USA
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Alexandra Kane
- Department of Anesthesiology, Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Nicholas A. Giordano
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
6
|
Highland KB, Parry J, Kent M, Patzkowski JC, Patzkowski MS, Herrera G, Kane A, Giordano NA. Lagged effect of Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance on subacute postsurgical PROMIS Pain Behavior. J Orthop Res 2023; 41:711-717. [PMID: 35803596 DOI: 10.1002/jor.25412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/07/2022] [Accepted: 07/02/2022] [Indexed: 02/04/2023]
Abstract
Sleep disturbance is a modifiable risk factor that, when reduced, may improve subacute postsurgical outcomes (e.g., pain-related impact). Evidence also indicates that pain and sleep may have a bidirectional longitudinal relationship before to (sub) acutely after surgery. The objective of the present study is to examine the degree to which sleep disturbances and pain behavior have uni- or bidirectional relationships in a sample of patients undergoing sports orthopedic surgery. In this observational, longitudinal cohort study, participants ( = 296) were adult (ages 18+) active duty service members who underwent open or arthroscopic shoulder or knee surgery at Walter Reed National Military Medical Center. Participants were asked to complete PROMIS Sleep Disturbance and Pain Behavior computer adaptive testing item banks before surgery, 6 weeks postsurgery, and 3 months postsurgery. Patient-level covariates were analyzed for interrelationships using nonparametric bivariate statistics. Autoregressive and cross-lagged structural equation modeling examined the bidirectional relationships of patient-level covariates and PROMIS outcomes. When controlling for patient-level covariates, sleep disturbance at presurgical and 2-week postsurgical timepoints were positively associated with both sleep disturbance and pain behavior at the subsequent timepoint. Sleep disturbance may contribute to pain-related functioning and quality of life after sports orthopedic surgery. Future studies utilizing multidimensional patient report outcomes and robust analytics are needed to better understand whether sleep-targeted interventions can improve subacute and long-term orthopedic sports surgery outcomes.
Collapse
Affiliation(s)
- Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland, USA.,Henry M. Jackson Foundation For the Advancement of Military Medicine, Rockville, Maryland, USA
| | - James Parry
- School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - Michael Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeanne C Patzkowski
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas, USA.,Department of Surgery, Uniformed Services University, Bethesda, Maryland, USA
| | - Michael S Patzkowski
- Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland, USA.,Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Germaine Herrera
- Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland, USA.,Henry M. Jackson Foundation For the Advancement of Military Medicine, Rockville, Maryland, USA
| | - Alexandra Kane
- Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland, USA.,Henry M. Jackson Foundation For the Advancement of Military Medicine, Rockville, Maryland, USA
| | - Nicholas A Giordano
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
7
|
Patzkowski MS, Hauser JM, Liu M, Herrera GF, Highland KB, Capener DC. Medical School Clinical Knowledge Exam Scores, Not Demographic or Other Factors, Associated With Residency In-Training Exam Performance. Mil Med 2023; 188:e388-e391. [PMID: 34363086 DOI: 10.1093/milmed/usab332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/08/2021] [Accepted: 07/30/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The anesthesiology in-training exam (ITE) is a 200-item multiple-choice assessment completed annually by physician residents. Because all matriculated U.S. Department of Defense (DoD) anesthesiology residents are "hired" by the DoD after residency graduation, it is important to ensure that ITE performance, as a proxy for core competencies achievement, is maximized. METHODS Graduated resident program files from 2013 to 2020 were queried for age, sex, matriculant status (medical student vs. other), medical school (Uniformed Services University vs. other), military service (Army vs. Air Force), preresidency military service (yes vs. no), U.S. Medical Licensing Exam (USMLE) Step 2 Clinical Knowledge (CK) score, and the American Board of Anesthesiologists ITE Score from the third clinical anesthesia year (CA-3 year). RESULTS For every 1-point increase in USMLE Step 2 CK true z-score, the CA-3 ITE z-score increased by 0.59 points. Age was not associated with CA-3 ITE z-score in any dataset regression. Categorical covariates of sex, application status, medical school, service, and preresidency military service were not significantly associated with CA-3 ITE z-score (all P >.05), as shown by estimated adjusted marginal means. The estimated adjusted grand mean of CA-3 ITE z-scores was 0.48 (standard error ± 0.14). CONCLUSION Resident physicians enter residency with varying degrees of past academic success, and it is important to develop early strategies to support them in acquiring the requisite knowledge base.
Collapse
Affiliation(s)
- Michael S Patzkowski
- Department of Anesthesia, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Joshua M Hauser
- Department of Anesthesia, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Mark Liu
- Department of Anesthesia, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Germaine F Herrera
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation Inc, Rockville, MD 20852, USA
| | - Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation Inc, Rockville, MD 20852, USA
| | - Dale C Capener
- Department of Anesthesia, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| |
Collapse
|
8
|
Patzkowski MS, Hammond KL, Herrera G, Highland KB. Factors Associated With Postoperative Opioid Prescribing After Primary Elective Cesarean Section. Mil Med 2023; 188:e339-e342. [PMID: 34226932 DOI: 10.1093/milmed/usab263] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/16/2021] [Accepted: 06/18/2021] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Guidelines indicate the need to balance the risks of opioid prescribing with the need to adequately manage pain after cesarean section (CS). Although guidelines suggest the need for tailored opioid prescribing, it is unclear whether providers currently tailor opioid prescribing practices given patient-related factors. Thus, research is needed to first understand post-CS pain management and opioid prescribing. The objective of the present study was to identify factors related to CS discharge opioid prescriptions. MATERIAL AND METHODS This retrospective cohort study was approved by the Brooke Army Medical Center Institutional Review Board (San Antonio, Texas; #C.2020.094e) on June 23, 2020. Electronic health record data of healthy adult women undergoing primary elective CS, performed under regional neuraxial anesthesia at a single, academic, tertiary medical center from 2018 to 2019, were included. Multivariable regression examined patient and medical factors associated with post-CS opioid prescriptions. RESULTS In the present sample (N = 169), 23% (n = 39) of patients did not use opioids postoperatively, while inpatient and almost all of those patients (n = 36) received a discharge prescription for opioids with a median amount of 225 morphine milligram equivalent doses. There was a lack of evidence indicating that patient and medical factors were associated with discharge opioid dose. CONCLUSION Patient and medical factors were not associated with post-CS opioid prescribing. Larger studies are needed to better elucidate optimal post-CS pain management in the days and months that follow CS. Such findings are needed to better tailor opioid prescribing, consistent with clinical practice guidelines.
Collapse
Affiliation(s)
- Michael S Patzkowski
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Kevin L Hammond
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Germaine Herrera
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation Inc, Rockville, MD 20852, USA
| | - Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation Inc, Rockville, MD 20852, USA
| |
Collapse
|
9
|
Webber R, Patzkowski MS, Costantino RC, Velosky AG, Lee V, Cyr KL, Harris LM, Scott-Richardson M, Highland KB. Procedural Benzodiazepine and Post-Vasectomy Opioid and Nonopioid Prescribing Variation in a Large Health Care System. Urol Pract 2022; 9:431-440. [PMID: 37145714 DOI: 10.1097/upj.0000000000000324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Our goal was to describe variation in procedural benzodiazepine and post-vasectomy nonopioid pain and opioid prescription dispense events, and multilevel factors associated with the probability of an opioid refill. METHODS Patients (40,584) undergoing vasectomies in the U.S. Military Health System between January 2016-January 2020 were included in this observational retrospective study. The main outcome was the probability of being dispensed an opioid prescription refill within 30 days post-vasectomy. Bivariate analyses examined the relationships between patient- and care-level characteristics, prescription dispense and 30-day opioid prescription refill. A generalized additive mixed-effects model and sensitivity analyses examined factors associated with opioid refill. RESULTS There was wide variation in procedural benzodiazepine (32%) and post-vasectomy nonopioid (71%) and opioid (73%) prescription dispense patterns across facilities. Only 5% of the patients dispensed opioids received a refill. Probability of an opioid refill was associated with race (White), younger age, opioid dispense history, documented mental health or pain condition, lack of post-vasectomy nonopioid pain medication dispense events and higher dispensed post-vasectomy opioid prescription dose; albeit the effect of dose did not replicate in sensitivity analyses. CONCLUSIONS Despite the wide variation in vasectomy-related pharmacological pathways across a large health care system, most patients do not require an opioid refill. Significant variation in prescribing practices indicated racial inequities. Given the low rates of opioid prescription refill, combined with the wide variation in opioid prescription dispense events and American Urological Association recommendations for conservative opioid prescribing after vasectomy, intervention to address excessive opioid prescribing is warranted.
Collapse
Affiliation(s)
- Robert Webber
- School of Medicine, Uniformed Services University, Bethesda, Maryland
| | - Michael S Patzkowski
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, Texas
- Department of Anesthesiology, Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Bethesda, Maryland
| | - Ryan C Costantino
- Program Executive Office, Enterprise Intelligence and Data Solutions (EIDS) Program Office, San Antonio, Texas
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland
| | - Alexander G Velosky
- Department of Anesthesiology, Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Vivian Lee
- Walter Reed National Military Medical Center, Graduate Medical Education, Bethesda, Maryland
| | - Kyle L Cyr
- Walter Reed National Military Medical Center, Department of Anesthesia, Bethesda, Maryland
| | - Lisa M Harris
- Department of Family Medicine, Uniformed Services University, Bethesda, Maryland
| | - Maya Scott-Richardson
- Department of Anesthesiology, Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Krista B Highland
- Department of Anesthesiology, Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, Bethesda, Maryland
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| |
Collapse
|
10
|
Highland KB, Robertson I, Lutgendorf M, Herrera GF, Velosky AG, Costantino RC, Patzkowski MS. Variation by default: cesarean section discharge opioid prescription patterns and outcomes in Military Health System hospitals: a retrospective longitudinal cohort study. BMC Anesthesiol 2022; 22:218. [PMID: 35820819 PMCID: PMC9277874 DOI: 10.1186/s12871-022-01765-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/04/2022] [Indexed: 12/03/2022] Open
Abstract
Background To examine factors associated with post-Cesarean section analgesic prescription variation at hospital discharge in patients who are opioid naïve; and examine relationships between pre-Cesarean section patient and care-level factors and discharge morphine equivalent dose (MED) on outcomes (e.g., probability of opioid refill within 30 days) across a large healthcare system. Methods The Walter Reed Institutional Review Board provided an exempt determination, waiver of consent, and waiver of HIPAA authorization for research use in the present retrospective longitudinal cohort study. Patient records were included in analyses if: sex assigned in the medical record was “female,” age was 18 years of age or older, the Cesarean section occurred between January 2016 to December 2019 in the Military Health System, the listed TRICARE sponsor was an active duty service member, hospitalization began no more than three days prior to the Cesarean section, and the patient was discharged to home < 4 days after the Cesarean section. Results Across 57 facilities, 32,757 adult patients had a single documented Cesarean section procedure in the study period; 24,538 met inclusion criteria and were used in analyses. Post-Cesarean section discharge MED varied by facility, with a median MED of 225 mg and median 5-day supply. Age, active duty status, hospitalization duration, mental health diagnosis, pain diagnosis, substance use disorder, alcohol use disorder, gestational diabetes, discharge opioid type (combined vs. opioid-only medication), concurrent tubal ligation procedure, single (vs. multiple) births, and discharge morphine equivalent dose were associated with the probability of an opioid prescription refill in bivariate analyses, and therefore were included as covariates in a generalized additive mixed model (GAMM). Generalized additive mixed model results indicated that non-active duty beneficiaries, those with mental health and pain conditions, those who received an opioid/non-opioid combination medication, those with multiple births, and older patients were more likely to obtain an opioid refill, relative to their counterparts. Conclusion Significant variation in discharge pain medication prescriptions, as well as the lack of association between discharge opioid MED and probability of refill, indicates that efforts are needed to optimize opioid prescribing and reduce unnecessary healthcare variation. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01765-8.
Collapse
Affiliation(s)
- Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr., #100, Bethesda, MD, 20817, USA
| | - Ian Robertson
- School of Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.
| | - Monica Lutgendorf
- Department of Gynecological and Obstetrics Surgery, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Germaine F Herrera
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr., #100, Bethesda, MD, 20817, USA
| | - Alexander G Velosky
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr., #100, Bethesda, MD, 20817, USA
| | - Ryan C Costantino
- Enterprise Intelligence and Data Solutions (EIDS) Program Office, Program Executive Office, Defense Healthcare Management Systems (PEO DHMS), San Antonio, TX, USA.,Department of Military and Emergency Medicine, School of Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Michael S Patzkowski
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.,Department of Anesthesiology, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX, 78234-6200, USA
| |
Collapse
|
11
|
Patzkowski MS, Costantino RC, Kane TM, Nghiem VT, Kroma RB, Highland KB. Military Health System Opioid, Tramadol, and Gabapentinoid Prescription Volumes Before and After a Defense Health Agency Policy Release. Clin Drug Investig 2022; 42:439-446. [PMID: 35499818 DOI: 10.1007/s40261-022-01152-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Clinical practice guidelines (CPGs) and health system policies to mitigate inappropriate opioid prescribing practices may have an extended impact on low-dose opioid (e.g., tramadol) and non-opioid (e.g., gabapentinoid) pain medication prescribing practices. OBJECTIVE To evaluate changes in opioid, tramadol, and gabapentinoid prescribing rates from January 2016 to February 2020 within the Military Health System, including the degree to which prescribing rates changed after release of a US Defense Health Agency Procedural Instruction. METHODS In this observational health services research study, opioid, tramadol, and gabapentin prescription dispense events of US Military Health System beneficiaries enrolled in care at military treatment facilities prior to US Defense Health Agency Procedural Instruction release (January 2016-May 2018) were used to forecast values from the post-intervention period (June 2018-February 2020). RESULTS The median opioid and tramadol prescribing rates decreased from January 2016 to February 2020, aside from tramadol prescribing in Surgery Clinics, which increased. Gabapentinoid prescribing rate changes were mixed. In Bayesian time series models, the forecasted proportion of patients receiving each of the three medications, regardless of age group or clinic type, did not significantly vary from the actual prescribing rates in the post-intervention period. CONCLUSION Overall, CPGs and policies targeting opioid prescribing practices may have provided the maximal impetus for providers to re-evaluate their prescribing practices, as the policy did not appear to change the slope in prescribing rates. However, it is unclear whether the policies mitigated the likelihood of plateaus in prescribing rates. Further work is needed to assess the degree to which providers simultaneously altered other non-opioid pain medication prescribing practices, self-management recommendations, and non-pharmacological therapy referrals.
Collapse
Affiliation(s)
- Michael S Patzkowski
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Ryan C Costantino
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD, USA.,Enterprise Intelligence and Data Solutions Program Management Office, Program Executive Office, Defense Healthcare Management Systems, Arlington, VA, USA
| | - Thomas M Kane
- School of Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Vi T Nghiem
- 60th Medical Group, David Grant Medical Center/University of California-Davis at Travis Air Force Base, Fairfield, CA, USA
| | - Raymond B Kroma
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Krista B Highland
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD, USA. .,Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD, USA. .,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA.
| |
Collapse
|
12
|
Rask DMG, Puntel MR, Patzkowski JC, Patzkowski MS. Multivitamin Use in Enhanced Recovery After Surgery Protocols: A Cost Analysis. Mil Med 2021; 186:e1024-e1028. [PMID: 33242075 DOI: 10.1093/milmed/usaa505] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/14/2020] [Accepted: 11/05/2020] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Enhanced Recovery After Surgery (ERAS) protocols have shown significant benefits in multiple areas including early mobilization, improved pain control, and early oral intake. Deficient nutritional states may compromise the operative outcomes. Several essential vitamins, e.g., B12, C, D, and E, have demonstrated anti-inflammatory properties and may promote wound healing. Given the low risk of oral multivitamin supplementation and the potential benefits, we hypothesized that adding a multivitamin to our institution's ERAS protocols would be a low-cost perioperative intervention accounting for a very small fraction of the annual pharmacy budget. METHODS A cost analysis for vitamin supplementation for all adult orthopedic surgical cases for the fiscal year 2018 was conducted. To assess the potential cost for multivitamin supplementation in the perioperative period, the fiscal year 2018 pharmacy budget and current costs of multivitamins were obtained from the hospital pharmacy. Medication costs were obtained from the medical logistics ordering system at per unit (i.e., bottle) and per tablet levels for all formulary oral multivitamins. We also determined the number of adult orthopedic surgical cases for our facility in the fiscal year 2018 from our surgery scheduling system. The cost for supplementation for a single day (day of surgery), 1 week (first postoperative week), 6 weeks plus 1 week preop, and 6 months plus 1 week preop for all cases was then calculated. RESULTS Our institution's pharmacy budget for the fiscal year 2018 was $123 million dollars with two oral multivitamins on formulary. Prenatal tablets, containing vitamins A-E, calcium, iron, and zinc, cost $1.52 per bottle of 100 tablets and $0.0152 per tablet, while renal formulation tablets, containing water-soluble vitamins B and C, cost $2.79 per bottle of 100 tablets and $0.0279 per tablet. For one fiscal year, the medication cost to supplement every adult orthopedic surgery patient with an oral multivitamin for 1 day, 1 week, 6 weeks plus 1 week preop, and 6 months plus 1 week preop would range from $60.47 to $110.99, from $423.29 to $776.93, from $2,963.03 to $5,438.51, and from $10,582.25 to $19,423.25, respectively, depending on which multivitamin was prescribed. These costs would represent between 0.00005% and 0.00009% of the annual pharmacy budget for 1 day, between 0.0003% and 0.0006% for 1 week, between 0.00245% and 0.441% for 6 weeks plus 1 week preop, and between 0.00875% and 1.575% for 6 months plus 1 week preop, respectively. DISCUSSION/CONCLUSIONS The relative nutrient-deficient state in the perioperative patient from decreased oral intake contributes to the metabolic derangements resulting from the surgery. The current ERAS protocols help to mitigate this with early feeding, and the addition of multivitamin supplementation may enhance this process. Multivitamins are safe, widely accessible, and inexpensive, and early investigations of pain control and healing have shown encouraging results. Further prospective studies are needed for incorporating multivitamins into ERAS protocols in order to elucidate the effective dosages, duration of treatment, and effect on outcomes.
Collapse
Affiliation(s)
- Dawn M G Rask
- San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Matthew R Puntel
- San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Jeanne C Patzkowski
- San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Michael S Patzkowski
- San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| |
Collapse
|
13
|
Patzkowski MS, Scott MSC, Patzkowski JC, Highland KB. Femoral Nerve Blockade Does Not Lead to Subjective Functional Deficits After Anterior Cruciate Ligament Reconstruction. Mil Med 2021; 187:e644-e648. [PMID: 34244804 DOI: 10.1093/milmed/usab269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/14/2021] [Accepted: 06/25/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Anterior cruciate ligament reconstruction (ACLR) ranks among the most common surgeries performed in civilian as well as military orthopedic settings. Regional anesthesia, and the femoral nerve block (FNB) in particular, has demonstrated efficacy in reducing postoperative pain and opioid use after ACLR, however concerns linger about possible impaired functional outcomes. The purpose of the current investigation was to assess International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) scores at 6 to 12 months after ACLR in patients who did (FNB) and did not (NoFNB) receive a perioperative FNB. MATERIALS AND METHODS All patients undergoing unilateral ACLR in the study period were reviewed in this institutional process improvement analysis. The primary outcome was prospectively collected IKDC-SKF scores obtained at 6-12 months post-surgery. Demographic and surgical information collected as potential covariates included age, sex, body mass index (BMI), preoperative IKDC-SKF score, use of an FNB, use of another (not femoral nerve) block, American Society of Anesthesiologists (ASA) score, graft type (auto vs. allograft), concomitant meniscus or cartilage procedures, tobacco use, tourniquet time, and primary vs. revision surgery. Assuming a 1:2 ratio of patients who did not vs. did receive FNBs and a clinically meaningful difference of 7 points on the IKDC-SKF, 112 patients were required for 80% power. A regression model averaging approach examined the relationships between covariates and postoperative IKDC-SKF scores. RESULTS One hundred nineteen patients met inclusion criteria (FNB 79 and NoFNB 40). The cohorts were significantly different in several factors including BMI, ASA level, graft type, and other peripheral nerve blocks, which were controlled for through regression modeling. Regressions with model averaging examined the relationship between treatment groups and postoperative IKDC-SKF scores, along with other potential predictor variables. Estimated adjusted marginal differences in postoperative IKDC-SKF scores from the best-fitting model revealed a very small 0.66-point mean (P = .86) difference between NoFNB and FNB groups that was not statistically significant. Those who reported tobacco use had a 10.51 point (P = .008) lower mean postoperative IKDC-SKF score than those who did not report tobacco use. Every 1-point increase in the preoperative IKDC-SKF score was associated with a 0.28-point (P = .02) increase in the postsurgical IKDC-SKF score. CONCLUSIONS Active tobacco use may negatively impact short-term subjective patient-reported outcomes after ACLR, as reported by the IKDC-SKF. Lower preoperative scores are also associated with significantly lower postoperative IKDC-SKF scores while the use of a FNB was not associated with lower postoperative scores. The negative association between tobacco use and patient-reported functional outcomes after ACLR lends further support to tobacco cessation programs within the military.
Collapse
Affiliation(s)
- Michael S Patzkowski
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Maj Summer C Scott
- Department of Anesthesia, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Jeanne C Patzkowski
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation Inc, Rockville, MD 20852, USA
| |
Collapse
|
14
|
Jaffe E, Patzkowski MS, Hodgson JA, Foerschler DL, Gonzalez SC, Giordano NA, Scott-Richardson MP, Highland KB. Practice Variation in Regional Anesthesia Utilization by Current and Former U.S. Military Anesthesiology Residents. Mil Med 2021; 186:e98-e103. [PMID: 33038251 DOI: 10.1093/milmed/usaa269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/20/2020] [Accepted: 08/03/2020] [Indexed: 11/14/2022] Open
Abstract
ABSTRACT
Introduction
Per Joint Trauma System guidelines, military anesthesiologists are expected to be ready to lead an Acute Pain Service with regional anesthesia in combat casualty care. However, regional anesthesia practice volume has not been assessed in the military. The objective of this study was to assess regional anesthesia utilization among current residents and graduates of U.S. military anesthesiology residency programs.
Materials and Methods
All current and former active duty military anesthesiology program residents, trained at any of the four military anesthesiology residency programs between 2013 and 2019, were anonymously surveyed about their regional anesthesia practice. Bivariate statistics described the total single-injection and catheter block techniques utilized in the last month. Cluster analysis assessed for the presence of distinct practice groups within the sample. Follow-up analyses explored potential associations between cluster membership and other variables (e.g., residency training site, residency graduation year, overall confidence in performing regional anesthesia, etc.). This protocol received exemption determination separately from each site’s institutional review board.
Results
Current and former residents reported broad variation in regional anesthesia practice and clustered into four distinct practice groups. Less than half of respondents utilized a moderate to high number of different single-injection and catheter blocks.
Conclusions
These findings highlight the need for creative solutions to increase regional anesthesia training in military anesthesiology programs and continued ability to implement skills, such that all military anesthesiologists have adequate practice for deployed responsibilities.
Collapse
Affiliation(s)
- Edward Jaffe
- School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | | | - John A Hodgson
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Derek L Foerschler
- Department of Anesthesia, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Sara C Gonzalez
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Nicholas A Giordano
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation Inc., Rockville, MD 20852, USA
| | - Maya P Scott-Richardson
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation Inc., Rockville, MD 20852, USA
| | - Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation Inc., Rockville, MD 20852, USA
| |
Collapse
|
15
|
Patzkowski MS. Peripheral nerve blocks in patients with Ehlers-Danlos syndrome, hypermobility type: a report of 2 cases. J Clin Anesth 2016; 29:50-3. [DOI: 10.1016/j.jclinane.2015.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 04/08/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
|
16
|
Patzkowski MS, Stevens G. Multimodal Analgesia in Abdominal Sepsis: A Case Report of Liposome Bupivacaine in Ultrasound-Guided Rectus Sheath Blocks After Unexpected Open Hemi-Colectomy. Mil Med 2015; 180:e728-31. [DOI: 10.7205/milmed-d-14-00512] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|