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This case series investigates whether do-not-resuscitate orders were reevaluated before surgery among patients treated at 1 health system.

Key Points Question Was the release of the 2016 US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain associated with changes in opioid dispensing after surgery? Findings In this cross-sectional study of 361 556 opioid-naive patients undergoing 8 common surgical procedures, time-series analysis found that the amount of opioid dispensed after surgery decreased progressively in the 2 years after the guideline release, whereas it was increasing in the 2 years prior. Meaning These findings suggest that the release of the 2016 CDC guideline coincided with a decrease in postoperative opioid dispensing across a range of surgical procedures and may have been associated with decreases in overprescribing of opioids for postoperative pain management., This cross-sectional study assesses changes in postoperative opioid dispensing after vs before the US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids was released in March 2016., Importance While the 2016 US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain was not intended to address postoperative pain management, observers have noted the potential for the guideline to have affected postoperative opioid prescribing. Objective To assess changes in postoperative opioid dispensing after vs before the CDC guideline release in March 2016. Design, Setting, and Participants This cross-sectional study included 361 556 opioid-naive patients who received 1 of 8 common surgical procedures between March 16, 2014, and March 15, 2018. Data were retrieved from a private insurance database, and a retrospective interrupted time series analysis was conducted. Data analysis was conducted from March 2014 to April 2018. Exposure Outcomes were measured before and after release of the 2016 CDC guideline. Main Outcomes and Measures The primary outcome was the total amount of opioid dispensed in the first prescription filled within 7 days following surgery in morphine milligram equivalents (MMEs); secondary outcomes included the total amount of opioids prescribed and the incidence of any opioid refilled within 30 days after surgery. To characterize absolute opioid dispensing levels, the amount dispensed in initial prescriptions was compared with available procedure-specific recommendations. Results The sample included 361 556 opioid-naive patients undergoing 8 general and orthopedic surgical procedures; 164 009 (45.4%) were male patients, and the median (interquartile range) age of the sample was 58 (45 to 69) years. The total amount of opioids dispensed in the first prescription after surgery decreased in the 2 years following the CDC guideline release, compared with an increasing trend in the 2 years prior (prerelease trend: 1.43 MME/month; 95% CI, 0.62 to 2.24 MME/month; P = .001; postrelease trend: −2.18 MME/month; 95% CI, −3.01 to −1.35 MME/month; P

Key Points Question Is adding preoperative and intraoperative data associated with improved risk stratification of patients undergoing noncardiac surgery for postoperative acute kidney injury? Findings In this prognostic study of 42 615 patients who underwent noncardiac surgery, the addition of preoperative to prehospitalization data improved model performance (area under the curve increased from 0.71 to 0.80) as did adding preoperative plus intraoperative data (area under the curve further increased to 0.82). Meaning Although electronic health record data may be used to accurately stratify patients at risk of postoperative acute kidney injury, there appears to be only modest improvement in performance when adding intraoperative data to risk stratification models., Importance Acute kidney injury (AKI) is one of the most common complications after noncardiac surgery. Yet current postoperative AKI risk stratification models have substantial limitations, such as limited use of perioperative data. Objective To examine whether adding preoperative and intraoperative data is associated with improved prediction of noncardiac postoperative AKI. Design, Setting, and Participants A prognostic study using logistic regression with elastic net selection, gradient boosting machine (GBM), and random forest approaches was conducted at 4 tertiary academic hospitals in the United States. A total of 42 615 hospitalized adults with serum creatinine measurements who underwent major noncardiac surgery between January 1, 2014, and April 30, 2018, were included in the study. Serum creatinine measurements from 365 days before and 7 days after surgery were used in this study. Main Outcomes and Measures Postoperative AKI (defined by the Kidney Disease Improving Global Outcomes within 7 days after surgery) was the primary outcome. The area under the receiver operating characteristic curve (AUC) was used to assess discrimination. Results Among 42 615 patients who underwent noncardiac surgery, the mean (SD) age was 57.9 (15.7) years, 23 943 (56.2%) were women, 27 857 (65.4%) were white, and the most frequent surgery types were orthopedic (15 718 [36.9%]), general (8808 [20.7%]), and neurologic (6564 [15.4%]). The rate of postoperative AKI was 10.1% (n = 4318). The progressive addition of clinical data improved model performance across all modeling approaches, with GBM providing the highest discrimination by AUC. In GBM models, the AUC increased from 0.712 (95% CI, 0.694-0.731) using prehospitalization variables to 0.804 (95% CI, 0.788-0.819) using preoperative variables (inclusive of prehospitalization variables) (P, This prognostic study evaluates the addition of preoperative and intraoperative data to prehospitalization data to identify patients at risk for postoperative acute kidney injury after undergoing major noncardiac surgery.

Small studies and anecdotal evidence suggest marked differences in the use of opioids after surgery internationally; however, this has not been evaluated systematically across populations receiving similar procedures in different countries.To determine whether there are differences in the frequency, amount, and type of opioids dispensed after surgery among the United States, Canada, and Sweden.This cohort study included patients without previous opioid prescriptions aged 16 to 64 years who underwent 4 low-risk surgical procedures (ie, laparoscopic cholecystectomy, laparoscopic appendectomy, arthroscopic knee meniscectomy, and breast excision) between January 2013 and December 2015 in the United States, between July 2013 and March 2016 in Canada, and between January 2013 and December 2014 in Sweden. Data analysis was conducted in all 3 countries from July 2018 to October 2018.The main outcome was postoperative opioid prescriptions filled within 7 days after discharge; the percentage of patients who filled a prescription, the total morphine milligram equivalent (MME) dose, and type of opioid dispensed were compared.The study sample consisted of 129 379 patients in the United States, 84 653 in Canada, and 9802 in Sweden. Overall, 52 427 patients (40.5%) in the United States were men, with a mean (SD) age of 45.1 (12.7) years; in Canada, 25 074 patients (29.6%) were men, with a mean (SD) age of 43.5 (13.0) years; and in Sweden, 3314 (33.8%) were men, with a mean (SD) age of 42.5 (13.0). The proportion of patients in Sweden who filled an opioid prescription within the first 7 days after discharge for any procedure was lower than patients treated in the United States and Canada (Sweden, 1086 [11.1%]; United States, 98 594 [76.2%]; Canada, 66 544 [78.6%]; P .001). For patients who filled a prescription, the mean (SD) MME dispensed within 7 days of discharge was highest in United States (247 [145] MME vs 169 [93] MME in Canada and 197 [191] MME in Sweden). Codeine and tramadol were more commonly dispensed in Canada (codeine, 26 136 patients [39.3%]; tramadol, 12 285 patients [18.5%]) and Sweden (codeine, 170 patients [15.7%]; tramadol, 315 patients [29.0%]) than in the United States (codeine, 3210 patients [3.3%]; tramadol, 3425 patients [3.5%]).The findings indicate that the United States and Canada have a 7-fold higher rate of opioid prescriptions filled in the immediate postoperative period compared with Sweden. Of the 3 countries examined, the mean dose of opioids for most surgical procedures was highest in the United States.

Adverse events related to opioid analgesics are common.1,2 Although opioids represent a component of pain treatment regimens following low-risk surgery,3,4 few data exist regarding patterns of postoperative opioid prescribing over time. We assessed trends in the amount of hydrocodone/acetaminophen and oxycodone/acetaminophen prescribed, 2 opioids commonly used for postoperative pain management.

Importance More than 300 000 hip fractures occur each year in the United States. Recent practice guidelines have advocated greater use of regional anesthesia for hip fracture surgery. Objective To test the association of regional (ie, spinal or epidural) anesthesia vs general anesthesia with 30-day mortality and hospital length of stay after hip fracture. Design, Setting, and Patients We conducted a matched retrospective cohort study involving patients 50 years or older who were undergoing surgery for hip fracture at general acute care hospitals in New York State between July 1, 2004, and December 31, 2011. Our main analysis was a near-far instrumental variable match that paired patients who lived at different distances from hospitals that specialized in regional or general anesthesia. Supplementary analyses included a within-hospital match that paired patients within the same hospital and an across-hospital match that paired patients at different hospitals. Exposures Spinal or epidural anesthesia; general anesthesia. Main Outcomes and Measures Thirty-day mortality and hospital length of stay. Because the distribution of length of stay had long tails, we characterized this outcome using the Huber M estimate with Huber weights, a robust estimator similar to a trimmed mean. Results Of 56 729 patients, 15 904 (28%) received regional anesthesia and 40 825 (72%) received general anesthesia. Overall, 3032 patients (5.3%) died. The M estimate of the length of stay was 6.2 days (95% CI, 6.2 to 6.2). The near-far matched analysis showed no significant difference in 30-day mortality by anesthesia type among the 21 514 patients included in this match: 583 of 10 757 matched patients (5.4%) who lived near a regional anesthesia–specialized hospital died vs 629 of 10 757 matched patients (5.8%) who lived near a general anesthesia–specialized hospital (instrumental variable estimate of risk difference, −1.1%; 95% CI, −2.8 to 0.5; P = .20). Supplementary analyses of within and across hospital patient matches yielded mortality findings to be similar to the main analysis. In the near-far match, regional anesthesia was associated with a 0.6-day shorter length of stay than general anesthesia (95% CI, −0.8 to −0.4, P Conclusions and Relevance Among adults in acute care hospitals in New York State undergoing hip repair, the use of regional anesthesia compared with general anesthesia was not associated with lower 30-day mortality but was associated with a modestly shorter length of stay. These findings do not support a mortality benefit for regional anesthesia in this setting.