Importance:Hospital ratings including the US News & World Report's Best Hospitals rankings and the Centers for Medicare & Medicaid Services' (CMS') Overall Hospital Quality Star Rating (Overall Star Rating) measure different outcomes and are weakly correlated. Therefore, methods for defining and measuring reliable excellence, defined as consistently great performance across all quality measures, are needed. Objective:To assess a measure of reliable excellence using the 45 quality measures reported in the Overall Star Ratings. Design, Setting, and Participants:This cross-sectional study used hospital-level data from the 2023 and 2024 CMS Overall Star Ratings at all US hospitals with a 2023 and 2024 CMS Overall Star Rating. Exposures:The exposure was the CMS Overall Star Rating summary score, a continuous variable calculated from the weighted z scores of 45 quality measures used in the Overall Star Rating. A total of 100 000 simulations were run in which all US hospitals' CMS Overall Star Rating summary scores were calculated through summation of z scores from randomly generated measure weights, as opposed to the existing weights used in the Overall Star Rating method. Main Outcomes and Measures:Reliable excellence, defined as achieving a 90th percentile (or better) CMS Overall Star Rating summary score on at least 50 000 of 100 000 simulations. The percentage of hospitals achieving reliable excellence was calculated both overall and stratified by CMS Ovearll Star Ratings. Results:There were 2700 hospitals in the analysis, with 335 5-star hospitals (12.4%), 727 4-star hospitals (26.9%), 799 3-star hospitals (29.6%), 572 2-star hospitals (21.2%), and 267 1-star hospitals (9.9%) in the 2024 CMS Overall Star Rating. A total of 244 of 2700 hospitals (9.0%) met the study definition of reliable excellence, whereas 1287 of 2700 hospitals (47.7%) achieved excellence in at least 1 simulation. Conclusions and Relevance:This cross-sectional study of 2700 US hospitals found that only 244 hospitals (9.0%), including less than two-thirds of the CMS 5-star rated hospitals, were reliably excellent across 100 000 CMS Overall Star Rating scoring simulations using random measure weightings. These findings lend credence to the ubiquity of inconsistent greatness in health care quality and illuminate the need for methods to distinguish hospitals that provide reliably excellent care.

In this article, the authors discuss the creation of HealthLocator, a public, digital platform designed to address the confusion and inconsistencies between hospital rating systems. HealthLocator aims to empower patients with transparent, data-driven insights on more than 5,000 U.S. hospitals, helping them make informed decisions based on reliable metrics. Developed by the Mayo Clinic's Kern Center, HealthLocator integrates three core domains - quality outcomes, patient experience, and patient safety - into a single composite score. These domains draw from publicly available U.S. Centers for Medicare & Medicaid Services (CMS) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data, spanning measures of readmissions, mortality, timeliness of care, patient experience, and hospital-acquired conditions, subsequently transformed into percentiles to more clearly present and interpret performance. An unique complementary feature is the reliable excellence indicator, which identifies top-tier hospitals consistently scoring highly across all CMS measures through robust simulations. In addition, HealthLocator includes high-volume and high-6-month-survival indicators for surgeries and specialized care, using CMS claims data. The novel 6-month mortality model adjusts for patient risk while avoiding the potential for methodological manipulation through inappropriate use of observation stays that are excluded from mortality measurement in other rating and ranking systems. The Mayo Clinic plans to continually refine HealthLocator based on user feedback, with future updates focusing on personalization, outpatient and long-term care quality measures, expanded data sources, and broader stakeholder input via an external advisory board. The platform's goal is to become the definitive, patient-centered resource for hospital performance - advancing transparency, trust, and clinical quality across the U.S. health care system. In essence, HealthLocator is not just another ranking system - it is a public service initiative rooted in peer-reviewed methods and designed to help patients find high-quality care while promoting accountability and improvement in health care delivery.

Postoperative pain control after total knee arthroplasty (TKA) remains challenging, particularly in patients utilizing chronic opioids preoperatively. Our study aimed to evaluate the effect of regional nerve blockade on perioperative pain control outcomes after TKA in patients using or not using chronic preoperative opioids. A retrospective review of our institutional database identified 434 chronic opioid patients defined as documented ongoing use greater than 3 months prior to contemporary TKA. Patients were 1:1 matched to nonopioid users based upon age, sex, body mass index, and regional block type (single-shot adductor canal block [ACB, 29%], 3-day ACB catheter [31%], or no block [41%]). All patients underwent primary TKA using periarticular injections and contemporary multimodal pain management. Immediate and 90-day postoperative outcomes, including Knee Osteoarthritis Outcome Score, Junior (KOOS, Jr), were compared via univariate analysis among the matched cohort and regional block type among chronic opioid patients. Chronic opioid patients demonstrated higher inpatient opioid use than controls (90 vs. 65 oral morphine equivalents [OMEs], respectively, p < 0.01), but no significant differences existed in length of stay (LOS), discharge pain scores, 90-day readmission or KOOS, Jr (all p ≥ 0.05). When comparing chronic opioid patients according to block type, those receiving no block had the highest LOS (1.6 days, p < 0.01), discharge pain score (5.0, p < 0.01), and inpatient opioid use (80 OMEs, p < 0.01) compared with either ACB. The subgroup receiving an ACB catheter demonstrated a significantly higher 90-day readmission rate (9%, p < 0.05). Patients utilizing chronic opioids preoperatively require more opioids in the immediate postoperative period after TKA compared with nonopioid users despite contemporary modalities. Nonetheless, the use of any type of ACB provides improved pain control in these patients.

BACKGROUND:The purpose of this study was to compare the effect of spinal anesthesia (SA) versus general anesthesia (GA) on acute 90-day outcomes in same-day discharge (SDD) total hip (THA) and total knee arthroplasty (TKA) patients, including subgroup analysis of peripheral nerve block usage. METHODS:A retrospective review of 1,002 SDD patients (402 THAs, 600 TKAs) was performed, including 868 and 134 undergoing SA and GA, respectively. All patients received periarticular injections and multimodal analgesia; 80% of THAs received a paravertebral block (PVB), and 58% of TKAs received an adductor canal block (ACB). Intraoperative and postoperative narcotic usage (morphine milligram equivalents, MMEs) through SDD, numerical pain scores, first ambulation distance, hospital length of stay, and 90-day complications (readmissions or reoperations) were compared. RESULTS:The SA performed in SDD THA resulted in decreased intraoperative MME (0.1 versus 8.7, P < 0.01), postoperative MME (12.3 versus 16.1, P < 0.02), and pain scores (1.6 versus 3.8, P < 0.01). A similar result was found in TKA, as SA patients had decreased intraoperative MME (0.1 versus 13.1, respectively, P < 0.01), postoperative MME (9.7 versus 15.5, P < 0.01), and pain scores (1.5 versus 3.2, P < 0.01). There was no difference in hospital length of stay between groups, but THA patients undergoing GA showed an increased 90-day readmission rate (4.8 versus 0.3%, P < 0.01). For SA, the use of PVBs in THA reduced postoperative MMEs and pain scores, while there were minimal effects with ACBs in TKA. CONCLUSIONS:For SDD THA and TKA patients, SA improved intraoperative and immediate postoperative pain control compared to GA without affecting acute recovery. The use of PVBs modestly improved acute pain for THA, while ACBs for TKA did not demonstrate the same effect in the setting of contemporary multimodal analgesia. LEVEL OF EVIDENCE:Level 4, retrospective review.

BACKGROUND: There has been concern among colon and rectal surgery residency programs in the United States that IPAA procedures have been decreasing, but evidence is limited. OBJECTIVE: The study aimed to evaluate the number of IPAAs performed by colon and rectal surgery residents in the United States and analyze the distribution of these cases on a national level. DESIGN: Retrospective. SETTINGS: The Accreditation Council for Graduate Medical Education Case Log National Data Reports were used to evaluate the number of IPAAs performed by residents from 2005 to 2021. The Nationwide Inpatient Sample database was used to identify all patients undergoing these procedures from 2005 to 2019. PATIENTS: All IPAA procedures regardless of indication. MAIN OUTCOME MEASURES: The primary outcome was the number of IPAAs performed by residents yearly. The secondary outcome was the national distribution of these procedures. RESULTS: Among colon and rectal surgery residents, case log data revealed an increase in mean and total number of IPAAs from 2005 to 2013, followed by a decline in both metrics after 2013. Despite the decrease, the mean number of cases per resident remained fewer than 6 between 2011 and 2021. A weighted national estimate of 48,532 IPAA patients were identified in the Nationwide Inpatient Sample database. A significant decrease was noted in the number of IPAAs after 2015 that persisted through 2019. There was a significant decrease in rural and urban nonteaching hospitals (from 2.1% to 1.6% and 25.6% to 4.3%, respectively; p < 0.001) and an increase in urbanteaching hospitals (from 72.4% to 94.1%; p < 0.001). LIMITATIONS: Nonrandomized retrospective study design. CONCLUSIONS: Despite the recent increase in the percentage of IPAAs performed at urban academic centers, there has been a decrease in cases performed by colon and rectal surgery residents. This can have significant implications for residents who graduate without adequate experience in performing this complex procedure independently, as well as training programs that may face challenges with maintaining accreditation. See Video Abstract.

Background:There is growing data on strategies to reduce opioid prescriptions in pediatric orthopaedics. Our institution implemented tiered guidelines for opioid discharge prescriptions in 2018 to standardize prescribing patterns across our entire pediatric orthopaedics practice. In 2022, we updated the tiered system with a goal to further minimize the quantity of opioids prescribed and eliminate opioids altogether for certain procedures. The aim of this project was to evaluate the effects of the updated tiered guidelines for discharge opioid prescribing following common pediatric orthopaedic procedures. Methods:A quality improvement project was conducted at a single academic institution. Guidelines for discharge opioid prescriptions were updated in January 2022 and established 5 tiers of increasing invasiveness for 28 procedures. The updated guidelines included a "Tier 0" which provided no opioids, reorganized surgical tiers based on prior data, and decreased the doses recommended for tiers. Opioid prescriptions were reported as oral morphine equivalents (OMEs). Univariate tests were performed to assess statistically significant differences before and after implementation of updated guideline eras, comparing 2020-2021 and 2022. Results:Overall, 747 patients (2020-2021, n ​= ​500; 2022, n ​= ​247) were included. The proportion of patients receiving discharge opioid prescriptions decreased from 89.8% to 80.6% (P ​< ​0.05), between 2020 and 2021 and 2022. This resulted in decreased overall OME prescribed (median 75 vs 45, P ​< ​0.05) and OME prescribed in those >10 years (135 vs 113, P ​< ​0.05) while 30-day refill rates (9.4% vs 6.1%), and OME per kilogram in those <11 years of age (median 0.9 vs 0.8) remained unchanged (both P ​> ​0.05). Discharge prescriptions falling within overall guidelines increased after guideline implementation (83.3% vs 85.4%), though this was not statistically significant and guideline adherence was low among Tier 0 ​at 31%. Conclusions:Including "Tier 0" of procedures receiving no opioid prescriptions, reorganizing procedures within tiers, and decreasing the recommended doses to an already strict tiered guideline for discharge opioid prescriptions significantly decreased the quantity of opioids prescribed. We noted continued excellent overall adherence and, importantly, no overall increase in refills, with areas for improvement in Tier 0. Quality improvement projects can continue to reduce the amount of opioids prescribed following pediatric orthopaedic procedures. Key Concepts:(1)Updated tiered guidelines, including a "Tier 0" for discharge opioid prescriptions following pediatric orthopaedic procedures were effective in reducing the quantity of opioids provided at discharge.(2)A continued high adherence rate was observed with the updated guidelines, though areas for improvement include adherence to no opioids in Tier 0.(3)Refill rates remained similar after implementation of the updated guidelines.(4)The study results suggest opportunities for continued improvement projects to reduce the number of unnecessary opioids prescribed to pediatric orthopaedic patients. Level of Evidence:III.

Objective: To compare patient-reported outcomes before and after implementation of evidence-based, procedure-specific opioid prescribing guidelines. Background: The opioid epidemic remains a significant public health issue. Many institutions have responded by reducing opioid prescribing after surgery. However, the impact of this on patient-reported outcomes remains poorly understood. Methods: Opioid-naïve adults undergoing 12 elective general surgery procedures at a single institution prospectively completed telephone surveys at median 26 days from discharge. Patients were compared before (March 2017–January 2018) and after (May 2019–November 2019) implementation of evidence-based, procedure-specific opioid prescribing guidelines. Results: A total of 603 preguideline and 138 postguideline patients met inclusion criteria and completed surveys. Overall, 60.5% of preguideline and 92.5% of postguideline prescriptions fell within recommendations ( P <0.001), while refill rates were similar (4.5% vs 5.8%, P =0.50). A statistically significant drop in median morphine milligram equivalent prescribed was observed for 9 of 12 procedures (75%). No opioids were prescribed for 16.7% of patients in both cohorts ( P =0.98). While 93.3% of preguideline and 87.7% of postguideline patients were very/somewhat satisfied with their pain control, the proportion of patients who were very/somewhat dissatisfied increased from 4.2% to 9.4% ( P =0.039). Conclusions: Prescribing guidelines successfully reduced opioid prescribing without increased refill rates. Despite decreased prescribing overall, there was a continued reluctance to prescribe no opioids after surgery. Although most patients experienced good pain control, there remains a subset of patients whose pain is not optimally managed in the era of reduced opioid prescribing.

Background: Experimental evidence suggests sex dependent differences in liver regeneration. Limited evidence is available examining sex differences in post-hepatectomy liver failure (PHLF) and post-operative outcomes. Our aim was to assess the influence of sex on the outcomes after liver resection.Methods: The hepatectomy targeted National Surgical Quality Improvement Program (NSQIP) data-base was assessed for associations between sex and outcomes.Results: A total of 13,401 patients underwent elective hepatic resection between 2014-2017. PHLF was highest among male patients with hepatocellular carcinoma (HCC) (OR = 2.81,95%CI:1.40-5.62). Male sex was independently associated with increased PHLF (OR = 1.47,95%CI:1.15-1.88), major compli-cations (OR = 1.25,95%CI:1.08-1.45), mortality (OR = 1.61,95%CI:1.03-2.50), and if only major re-sections were assessed (OR = 1.38,95%CI:1.03-1.84). Diagnosis specific subgroup analyses revealed that effects of sex were predominantly HCC associated.Conclusions: This is the largest series investigating the effects of gender on outcomes after hepatic resection. We documented that women undergoing liver resection have significantly lower risk of PHLF. This difference seemed influenced by the striking increase of PHLF in male HCC patients. These hy-pothesis suggest that sex might play a role in preoperative risk stratification.Received 15 September 2021; accepted 21 February 2022

BACKGROUND:Opioids are associated with negative transplant outcomes. We sought to identify patient and center effects on over-prescribing of opioids (> 200 OME (oral morphine equivalents)). STUDY DESIGN:Clinical and opioid prescription data (2014-2017) were collected from three academic transplant centers for kidney (KT), liver (LT), and simultaneous liver-kidney transplant (SLK) patients. Multivariable models were used to identify predictors of opioid over-prescribing at discharge and the occurrence of refill prescriptions at 90 days. RESULTS:Three-thousand seven-hundred and two patients underwent transplant in the cohort (KT: n = 2358, LT: n = 1221, SLK: n = 123). More than 80% of recipients were over-prescribed opioids at discharge (Median OME (mOME) = 300 (IQR 225-375). LT and SLK had the largest prescription size (LT mOME 338 (IQR 300-450); SLK mOME 338 (IQR 225-450) and refill rate (LT: 64%, SLK 59%) (all, P < .001). Multivariable analysis indicated that transplant center was a significant predictor of opioid over-prescription after KT and LT (all, P < .001); older age (in KT) and length of stay (LOS) (in LT) were protective factors (both, P < .05). Refill occurrence was associated with initial prescription size and was reduced by older age and initial LOS (all, P < .05). CONCLUSIONS:The wide variation in opioid prescribing patterns has implications for transplant practice innovation, guideline development, and further study.

INTRODUCTION Evidence-based, procedure-specific guidelines for opioid prescribing after orthopaedic surgery are urgently needed to standardize care and minimize excess opioids. METHODS We developed a prospective, multicenter survey study conducted from March 2017 to January 2018 including 7 common elective orthopaedic surgical procedures (total knee arthroplasty, total hip arthroplasty, lumbar fusion, lumbar laminectomy, rotator cuff repair, arthroscopic meniscectomy, and carpal tunnel release). Phone surveys were conducted between 21 and 35 days postoperatively. We aimed to document both the amount and length of time patients consumed opioid medications to inform further improvements in opioid management and prescribing. RESULTS Among the 919 orthopaedic patients who completed the survey, 94.3% received opioids at discharge with a median of 388 oral morphine equivalents (OMEs) (interquartile range [IQR] 225 to 675). A median of 128 (IQR 23 to 360) OME were consumed with 77% of patients having leftover opioids. Sixty percent of prescribed opioids were unused; 18.2% of patients used no opioids, and 34.7% required <50 OME. In comparison to departmental guidelines, 50.2% of patients consumed <50% of the recommended prescription maximum per procedure. DISCUSSION Most patients used far fewer opioids after orthopaedic surgery than prescribed. These data have informed further improvement of our opioid prescription guidelines to more precisely align with anticipated procedure- and patient-specific requirements.

BACKGROUND:Data regarding opioid prescribing patterns following pediatric orthopaedic procedures is limited. The aim of this work was to evaluate the effects of tiered guidelines for discharge opioid prescriptions following common pediatric orthopaedic procedures.METHODS:Quality improvement project conducted at a single academic institution. Guidelines for discharge opioid prescriptions were implemented January 2018 and established 4 tiers of increasing invasiveness for 28 common pediatric orthopaedic procedures. Patients who underwent these procedures in 2017 comprised the preguideline cohort (N=258), while patients treated in 2019 comprised the postguideline cohort (N=212). Opioid prescriptions were reported as oral morphine equivalents (OMEs). Univariate tests were performed to assess statistically significant differences before and after implementation of the guidelines.RESULTS:There was a significant decrease in OME prescribed between preguideline and postguideline cohorts (median OME 97.5 vs. 37.5). When analyzed according to procedure tiers, tiers 1, 2, and 4 showed significant decreases in OME prescribed between 2017 and 2019. The rate of no opioids prescribed at discharge increased from 13% to 23% between preguideline and postguideline cohorts. The 30-day refill rate did not significantly change. After implementation of guidelines, 91% of all prescriptions were within the guideline parameters, and there was a significant reduction in prescription variability. In tier 4 procedures, median OME prescribed decreased from 375 preguideline to 188 postguideline, but was associated with greater opioid refills within 30 days of discharge (10.2% preguideline vs. 28.8% postguideline).CONCLUSIONS:Tiered guidelines for discharge opioid prescriptions following pediatric orthopaedic procedures can significantly decrease the quantity of opioids prescribed. Furthermore, we noted excellent adherence and no overall increase in the rates of narcotic refills. Such guidelines may improve pediatric orthopaedists' ability to responsibly treat postoperative pain while limiting the distribution of unneeded opioids.LEVEL OF EVIDENCE:Level IV-quality improvement project.

Background: To help control opioid overprescription, we conducted a large institutional, 3-site initiative to provide discharge prescribing guidelines for different procedures. Our aim is to refine institutional guidelines for parathyroidectomy. Methods: Patients undergoing parathyroidectomy completed a 28-question survey about opioid consumption. Discharge opioid prescription amounts were converted into morphine milligram equivalents (MMES) and reported as median and interquartile range (IQR). Consumption was dichotomized into top quartile MME users (Q4) versus standard users (Q1, Q3). Univariate analysis compared opioid consumption. Results: A total of 91 patients were included; 90% were opioid-naive. While the median prescribed was 75 (IQR 75, 150) MME, the median consumed was 0 (IQR 0, 20). Top users reported higher pain scores [median (IQR): 2 (2, 4)] compared to standard users [1 (0, 3), P = 0.01]. However, there was no difference in opioid consumption between unilateral neck exploration, bilateral exploration, or thyroidectomy and parathyroidectomy, P = 0.11. There was no difference in opioid consumption by age, sex, or BMI (all P > 0.05). Of those receiving a prescription, 94.6% had left-over opioids at the time of survey, resulting in 82% of prescribed opioids being unused. Conclusions: Over half of patients undergoing parathyroidectomy did not consume any opioid, and very few needed more than 2 d of opioid. Moreover, most patients did not dispose the unused opioids, which put these pills at risk of diversion and misuse. Surgical approach did not change consumption, illustrating that these guidelines are applicable to thyroidectomy given the similarity between techniques. We recommend prescribing nonopioid analgesics for patients undergoing parathyroidectomy. (C) 2019 Elsevier Inc. All rights reserved.

BACKGROUND:Evidence-based, procedure-specific guidelines for prescribing opioids are urgently needed to optimize pain relief while minimizing excessive opioid prescribing and potential opioid diversion in our communities. A multidisciplinary panel at our institution recently developed procedure-specific guidelines for discharge opioid prescriptions for common orthopaedic surgical procedures. The purpose of this study was to evaluate postoperative opioid prescription quantities, variability, and 30-day refill rates before and after implementation of the guidelines.METHODS:This retrospective cohort study was conducted at a single academic institution from December 2016 to March 2018. Guidelines were implemented on August 1, 2017, with a recommended maximum opioid prescription quantity for 14 common orthopaedic procedures. Patients who underwent these 14 procedures during the period of December 2016 to May 2017 made up the pre-guideline cohort (n = 2,223), and patients who underwent these procedures from October 2017 to March 2018 made up the post-guideline cohort (n = 2,300). Opioid prescription quantities were reported as oral morphine equivalents (OME), with medians and interquartile ranges (IQRs). Four levels were established for recommended prescription maximums, ranging from 100 to 400 OME.RESULTS:In the pre-guideline cohort, the median amount of prescribed opioids across all procedures was 600 OME (IQR, 390 to 863 OME), which decreased by 38% in the post-guideline period, to a median of 375 OME (IQR, 239 to 400 OME) in the post-guideline cohort (p < 0.001). The 30-day refill rate did not change significantly, from a rate of 24% in the pre-guideline cohort to 25% in the post-guideline cohort (p = 0.43). Multivariable analysis demonstrated that guideline implementation was the factor most strongly associated with prescriptions exceeding guideline maximums (odds ratio [OR] = 9.9; p < 0.001). Age groups of <80 years (OR = 2.0 to 2.4; p < 0.001) and males (OR = 1.2; p = 0.025) were also shown to have higher odds of exceeding guideline maximums.CONCLUSIONS:Procedure-specific guidelines are capable of substantially decreasing opioid prescription amounts and variability. Furthermore, the absence of change in refill rates suggests that pain control remains similar to pre-guideline prescribing practices. Evidence-based guidelines are a readily employable solution that can drive rapid change in practice and enhance the ability of orthopaedic surgeons to provide responsible pain management.

Sada, Alaa MD; Ubl, Daniel S. MPH; Reidt, Wendy S. MHA; Kendrick, Michael L. MD, FACS; McKenzie, Travis MD, FACS; Andrew Kellogg, Todd MD, FACS; Habermann, Elizabeth B. PhD, MPH Author Information

BACKGROUND:With the opioid epidemic in the United States, evaluating opioid prescribing patterns is essential. We evaluated opioids prescribed at discharge following breast surgery and their association with patient factors and pain scores.METHODS:We retrospectively identified adult patients who underwent a mastectomy for cancer at Mayo Clinic sites from January 2010 to December 2016. Pain scores and prescription data were compared across operations and patient factors by univariate and multivariable analyses.RESULTS:Of 4021 patients, 3782 (94.1%) received an opioid prescription. Median oral milligram morphine equivalents (MME) were similar across all site-specific procedure groups (medians ranging from 225 to 375) while pain scores ranged from 1 to 4. Patients undergoing bilateral mastectomy (BM) and immediate breast reconstruction (IBR) reported the greatest pain scores. Pain scores did not vary with age or diagnosis for patients undergoing unilateral mastectomy or BM with lymph node surgery and IBR procedures. On multivariable analysis, variables associated with a MME discharge prescription >Q4 values included age, body mass index, site, year, inpatient status, and pain before discharge >3.CONCLUSION:Patient-reported pain following breast surgery varied by procedure, while MMEs prescribed remained similar. This suggests current opioid prescribing does not reflect intensity of pain and requires further research to optimize discharge opioid prescribing practices.

BACKGROUND:The objective of this initiative was to perform a prospective, multicenter survey of patients after lung resection to assess the amount of opioid medication consumed and the disposition of unused opioids to inform the development of evidence-based prescribing guidelines. METHODS:Adults undergoing lung resection with either minimally invasive surgery (MIS; n = 108) or thoracotomy (n = 45) were identified prospectively from 3 academic centers (from March 2017 to January 2018) to complete a 28-question telephone survey 21 to 35 days after discharge. Discharge opioids were converted into morphine milligram equivalents (MME) and were compared across patient and surgical details. RESULTS:Of the 153 patients who completed the survey, 89.5% (137) received opioids at discharge with a median prescription of 320 MME (interquartile range [IQR], 225, 450 MME) after MIS and 450 MME (IQR, 300, 600 MME) after thoracotomy (P = .001). Median opioid consumption varied by surgical approach: 90 MME (IQR, 0, 262.5) after MIS and 300 MME (IQR, 50, 382.5 MME) after thoracotomy (P < .001). The majority of patients (73.7%; 101) had residual opioid medication at the time of the survey, and patients after MIS had a relative increase in amount of remaining opioid medication: 58.3% vs 33.3% (P = .05) of the original prescription. Only 5.9% of patients with opioids remaining had properly disposed of them. CONCLUSIONS:Although patients undergoing MIS lung resection used significantly less opioid medication over a shorter duration of time than did patients after thoracotomy, they had relatively more excess opioid prescription. Evidence-based, procedure-specific guidelines with tailored pain regimens should be developed and implemented to reduce the amount of postoperative opioid medication remaining in the community.

Background: Despite the current strategies aimed at avoiding opioid overprescription by implementing institutional guidelines, the use of opioids after surgical procedures remains highly variable. It is well known that opioids are activated by the cytochrome p450 CYP2D6 enzyme to exert pharmacologic effect. Individual variation in CYP2D6 activity affects drug metabolism, and genotyping can be performed to predict an individual's ability to metabolize CYP2D6 substrates. We postulate that the pharmacogenomic identification of patients with different opioid metabolism capacity may allow for the individualization of postsurgical opioid prescription. Methods: This study was generated by the unison of data from 2 prior initiatives taking place at our Institution. In the first study, patients undergoing 1 of 25 elective surgical procedures were prospectively identified as part of a quality initiative and surveyed by phone 21 to 35 days after hospital discharge to complete a 29-question survey regarding opioid utilization and pain experience. Additional chart abstraction was conducted to obtain prescribing data and pain scores during the hospitalization. The second study was the Mayo Clinic Right Drug, Right Dose, Right Time study protocol, in which 5 pharmacogenes, including CYP2D6, were genotyped for 1,000 Mayo Clinic Biobank participants. The goal of this study was to implement preemptive pharmacogenomics in an academic health care setting and to generate data for further pharmacogenomic research. Patients were classified by their predicted CYP2D6 activity based on their CYP2D6 genotype. Results: Of the 2,486 patients with prospective opioid utilization data, 21 had pharmacogenetic data available and were included in the analysis. These patients were classified according to their activity as opioid metabolizers, with 10 patients (48%) classified as intermediate, 4 patients (19%) as intermediate to normal, and 7 patients (33%) as normal or extensive. Compared with the intermediate to normal and intermediate phenotypes, normal or extensive patients had the highest percentages of preoperative opioid naivety and recorded pain scores throughout the surgical experience. The percentage of unused opioids for intermediate, intermediate to normal, and normal or extensive categories was 79%, 63%, and 46%, respectively. Moreover, of the 14 patients declaring the highest level of satisfaction for their pain control after discharge. 60% belonged to intermediate, 100% to intermediate to normal, and 57% to the normal or extensive group. Conclusion: This study outlines a possible correlation between genetically controlled metabolism and opioid requirements after surgery. In this setting, an increased CYP2D6 enzymatic activity was associated to a greater opioid consumption, lesser amount of unused opioids, and a lower satisfaction level from opioid prescription. (C) 2019 Elsevier Inc. All rights reserved.

Background: Open inguinal hernia repair is thought to cause worse postoperative pain than minimally invasive surgery, and thus patients are often prescribed more opioids at discharge. This study evaluates opioid use in inguinal hernia repair patients to optimize discharge prescribing practices for this common procedure. Methods: Opioid-naive adults undergoing open or minimally invasive surgery inguinal hernia repair were identified prospectively from 3 centers to complete a 29-question telephone interview after discharge as part of a larger initiative. Opioid prescription and consumption data were converted into morphine milligram equivalents and compared between minimally invasive surgery and open inguinal hernia repair. Univariate chi(2), Fisher exact test, univariate, and multivariable logistic regression were used. Results: Of 249 contacted patients, 195 (74%) completed the survey (n = 97 open, n = 98 minimally invasive surgery). Patients undergoing open inguinal hernia repair were slightly older (71 vs 65 years, P < .001) and less likely to be female (3% vs 17%, P = .001) than minimally invasive surgery patients. Open patients were more likely to have a unilateral inguinal hernia repair (95% open vs 52% minimally invasive surgery, P < .001). Discharge pain scores using the 10-point, patient-reported Numeric Pain Rating scale were similar (open 2.3 +/- 1.7 vs minimally invasive surgery 2.4 +/- 1.6; P = .80), and most patients were satisfied with postoperative pain control (open 86% vs minimally invasive surgery 95%; P = .13). Open inguinal hernia repair patients were just as likely to receive opioids at discharge as those undergoing minimally invasive surgery inguinal hernia repair (98% vs 91% minimally invasive surgery; P .06) and were prescribed similar amounts of opioids (open 155 [IQR 113, 225] morphine milligram equivalents vs 150 [IQR 100, 210] minimally invasive surgery; P = .08). There was no difference in opioid use by approach (open 15 [IQR 0, 60] morphine milligram equivalents vs 9 [IQR 0, 50] minimally invasive surgery; P = .33). More than one-third of patients used no opioids (open 38% vs minimally invasive surgery 44%; P = .42). Bilateral repair was not associated with increased opioid use (univariate odds ratio 1.23, P = .58). On multivariable analysis, low discharge pain and normal body mass index were independently associated with needing no opioids at discharge. Overall, 75% of prescribed opioids remained unused at time of survey, yet only 12% of patients had disposed of unused opioids at the time of survey. Conclusion: Postdischarge opioid utilization was clinically similar between patients undergoing open and minimally invasive surgery inguinal hernia repair and those requiring unilateral or bilateral repair. Given that more than one-third of patients required no opioids after discharge, 0 to 8 tablets of 5 mg oxycodone is sufficient for most opioid-naive patients undergoing inguinal hernia repair. (C) 2019 Elsevier Inc. All rights reserved.

Objective: Patients receiving dialysis are at increased risk for lower extremity amputations (LEAs) and postoperative morbidity. Limited studies have examined differences in 30-day outcomes of mortality and health care use after amputation or the preoperative factors that relate to worsened outcomes in dialysis patients. Our objective was to examine dialysis dependency and other preoperative factors associated with readmission or death after LEA. Methods: A retrospective cohort study was conducted of dialysis-dependent and nondialysis patients undergoing major LEA in the 2012 to 2013 American College of Surgeons National Surgical Quality Improvement Program. Primary outcomes included death and hospital readmission within 30 days of amputation. Results: Of 6468 patients, 1166 (18%) were dialysis dependent. The dialysis cohort had more blacks (39% vs 23%), diabetes (76% vs 58%), below-knee amputations (62% vs 55%), and in-hospital deaths (8% vs 3%; all P<.001). The 30-day post-operative death rates (15% vs 7%) and readmission rates (35% vs 20% per 30 person-days; both P<.001) were higher in dialysis patients. Among the live discharges, the rate of any readmission or death within 30 days from amputation was highest in those aged $ 50 years (40% per 30 person-days). Multivariable analyses in the dialysis cohort revealed increased age, above-knee amputation, decreased physical status, heart failure, high preoperative white blood cell count, and low platelet count to be associated with death (P<.05; C statistic, 0.75). The only preoperative factor associated with readmission in dialysis patients was race (P=.04; C statistic, 0.58). Conclusions: Readmission or death after amputation is increased among dialysis patients. Predicting which dialysis patients are at highest risk for death is feasible, whereas predicting which will require readmission is less so. Risk factor identification may improve risk stratification, inform reimbursement policies, and allow targeted interventions to improve outcomes.

BACKGROUND Autograft harvesting for spine arthrodesis has been associated with longer operative times and increased blood loss. Allograft compared to autograft in spinal fusions has not been studied in a multicenter cohort. METHODS Patients enrolled in the ACS-NSQIP registry between 2012 and 2013 who underwent cervical or lumbar spinal fusion with either allograft or autograft through a separate incision were included for analysis. The primary outcomes of interest were operative time, length of stay, blood transfusion, and surgical site infection (SSI). RESULTS A total of 6790 and 6718 patients received a cervical or lumbar spinal fusion, respectively. On unadjusted analysis in both cervical and lumbar cohorts, autograft was associated with increased rates of blood transfusion (cervical: 2.9% vs. 1.0%, P<0.001; and lumbar: 21.0% vs. 15.7%, P<0.001) and increased operative time (cervical: 167 vs. 128 minutes, P<0.001; and lumbar: 226 vs. 204 minutes, P<0.001) relative to allograft. On multivariable analysis in both the cervical and lumbar cohorts, autograft was associated with increased odds of blood transfusion (cervical: OR=2.3, 95% CI: 1.0-5.1; and lumbar: OR=1.3, 95% CI: 1.1-1.6) and longer operative times (cervical: 27.8 minutes, 95% CI: 20.7-35.0; and lumbar: 25.4 minutes, 95% CI: 17.7-33.1) relative to allograft. Autograft was not associated with either length of stay or SSI. CONCLUSIONS In a multicenter cohort of patients undergoing cervical or lumbar spinal fusion, autograft was associated with increased rates of blood transfusion and increased operative time relative to allograft.