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OBJECTIVE Describe the incidence of new persistent opioid use after inguinal hernia repair as well as its associated risk factors. SUMMARY BACKGROUND DATA The development of new persistent opioid use after surgery is a common complication, however its incidence following inguinal hernia repair has not been described. Given that roughly 800,000 inguinal hernia repairs are performed annually in the United States, any incidence could have profound implications for patients. METHODS Retrospective cross-sectional study of the incidence of new persistent opioid use after inguinal hernia repair using a national database of de-identified administrative health claims of opioid-naive patients undergoing surgery from 2008-2016. RESULTS During the study period, 59,795 opioid-naive patients underwent inguinal hernia repair and met inclusion criteria. Mean (SD) age was 57.8 (16.1) years old and 55,014 (92%) patients were male. 922 (1.5%) patients continued filling opioids prescriptions for at least 3 months after surgery. The most significant risk factor for developing new persistent opioid use after surgery was filling an opioid prescription in the 30 days prior to surgery (OR 4.34, 95% CI 3.75-5.01). These prescriptions were provided by surgeons in 52% of cases and primary care physicians in 16% of cases. Other risk factors for new persistent opioid use included receiving a larger opioid prescription, having more comorbidities, having a major postoperative complication, and certain mental health disorders and pain disorders. CONCLUSION After undergoing inguinal hernia repair, 1.5% of patients developed new persistent opioid use. Filling an opioid prescription in the 30 days prior to surgery had the strongest association with this complication.

OBJECTIVE: Opioid use is common among patients with peripheral arterial disease (PAD), given that pain is a defining symptom. Unfortunately, long-term opioid use places patients at dramatically increased risk of overdose and death. Although surgical revascularization is extremely effective in alleviating ischemic pain related to PAD, it is unclear whether this practice results in the discontinuation of opioids after surgery. Therefore, we conducted the following study to investigate trends in opioid use before and after surgical bypass in patients with PAD, as well as the risk factors for continued opioid use after surgery. METHODS: We conducted a retrospective analysis of patients undergoing open lower extremity bypass for claudication or rest pain between June 1, 2017, and March 31, 2021. Patients were grouped according to whether they reported preoperative opioid use at the time of surgery. The primary outcome was continued opioid use at 30-day follow-up after discharge. A multivariable logistic regression was conducted to estimate the association of continued opioid use with patient characteristics, preoperative opioid use, and receiving a postoperative opioid prescription. RESULTS: Among 3873 patients undergoing surgery, the mean age was 65.7 (10.2) years and 2650 (68.4%) patients were male. There were 913 patients (23.6%) who used opioids preoperatively and hydrocodone was the most common preoperative opioid (583 [63.9%]). At discharge, 2506 patients (64.7%) received a postoperative opioid prescription. Postoperative opioid prescriptions were significantly more common for preoperative opioid users than opioid-naïve patients (813 [89.0%] vs 1693 [57.2%]; P < .001) and were significantly larger in size (24.3 [21.1] pills vs 19.9 [10.5] pills; P < .001). On 30-day follow-up, 522 preoperative opioid users (61.3%) and 616 opioid-naïve patients (28.4%) reported that they were still using opioids (P < .001). Continued opioid use at follow-up was associated with preoperative opioid use (adjusted odds ratio, 3.23; 95% confidence interval, 2.70–3.89) and receiving a postoperative opioid prescription (adjusted odds ratio, 10.83; 95% confidence interval, 7.96–15.06). CONCLUSIONS: Most patients with PAD who use opioids preoperatively do not discontinue opioids after lower extremity bypass. Moreover, a significant proportion of previously opioid-naïve patients are still using opioids 1 month after surgery. In both cases, postoperative opioid prescriptions had the strongest association with continued opioid use. These findings underscore the need for improved prescribing practice and increased attentiveness to discontinuation of unnecessary medications after surgery. (J Vasc Surg 2022;75:998–1007.)

Objective Tobacco use is common among vascular surgery patients and negatively impacts outcomes and longevity. In the second quarter of 2018, a statewide vascular quality collaborative launched an initiative across its 35 participating hospitals to promote smoking cessation at the time of surgery. This intervention was based on the Vascular Physician Offer and Report (VAPOR) trial and consisted of 3 components: brief physician-delivered advice, referral to telephone-based counseling, and nicotine replacement therapy. The goal of this study is to evaluate the results of this intervention. Methods We performed a retrospective analysis of patients undergoing vascular surgery between 2018 and 2020. Procedures included open abdominal aortic aneurysm repair, endovascular aneurysm repair, open vascular bypass, open thrombectomy, carotid endarterectomy, and carotid stenting. The primary explanatory variables were receipt of tobacco cessation interventions as documented in the medical record. The primary outcome was tobacco cessation, captured during 30-day and 1-year chart review and/or patient follow-up. A multivariable logistic regression model was calculated to estimate the association of covariates with smoking cessation while adjusting for patient and clinical characteristics. Results A total of 13,890 patients underwent surgery during the study period. The mean age was 69.4 ± 10 years; 4687 patients (34%) were female, and 5158 patients (37%) were current smokers. At least one smoking cessation component was delivered to 2245 patients (44% of smokers). The quit rate was 35% among 4671 patients with 30-day follow-up and 43% among 2936 patients with 1-year follow up. On multivariable regression, at 30 days, receiving two intervention components was associated with 1.29 (95% confidence interval [CI], 1.07-1.55) higher odds of quitting. At both time points, smoking cessation was also associated with undergoing an emergent procedure (30-day odds ratio [OR], 1.52; 95% CI, 1.16-1.99; 1-year OR, 1.41; 95% CI, 1.01-1.97) and undergoing open abdominal aortic aneurysm repair (30-day OR, 1.71; 95% CI, 1.20-2.43; 1-year OR, 1.75; 95% CI, 1.11-2.78). Conclusions In a cohort of vascular surgical patients where tobacco use was common, nearly one-half of patients quit smoking 1 year after surgery. Receiving two smoking cessation intervention components was associated with quitting at 30 days. Overall, these results demonstrate encouraging quit rates and identify an opportunity for longer-term intervention to maintain even greater 1-year tobacco cessation.

IMPORTANCE: Sleeve gastrectomy and gastric bypass are the most common bariatric surgical procedures in the world; however, their long-term medication discontinuation and comorbidity resolution remain unclear. OBJECTIVE: To compare the incidence of medication discontinuation and restart of diabetes, hypertension, and hyperlipidemia medications up to 5 years after sleeve gastrectomy or gastric bypass. DESIGN, SETTING, AND PARTICIPANTS: This comparative effectiveness research study of adult Medicare beneficiaries who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between January 1, 2012, to December 31, 2018, and had a claim for diabetes, hypertension, or hyperlipidemia medication in the 6 months before surgery with a corresponding diagnosis used instrumental-variable survival analysis to estimate the cumulative incidence of medication discontinuation and restart. Data analyses were performed from February to June 2021. EXPOSURES: Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. MAIN OUTCOMES AND MEASURES: The primary outcome was discontinuation of diabetes, hypertension, and hyperlipidemia medication for any reason. Among patients who discontinued medication, the adjusted cumulative incidence of restarting medication was calculated up to 5 years after discontinuation. RESULTS: Of the 95 405 patients included, 71 348 (74.8%) were women and the mean (SD) age was 56.6 (11.8) years. Gastric bypass compared with sleeve gastrectomy was associated with a slightly higher 5-year cumulative incidence of medication discontinuation among 30 588 patients with diabetes medication use and diagnosis at the time of surgery (74.7% [95% CI, 74.6%-74.9%] vs 72.0% [95% CI, 71.8%-72.2%]), 52 081 patients with antihypertensive medication use and diagnosis at the time of surgery (53.3% [95% CI, 53.2%-53.4%] vs 49.4% [95% CI, 49.3%-49.5%]), and 35 055 patients with lipid-lowering medication use and diagnosis at the time of surgery (64.6% [95% CI, 64.5%-64.8%] vs 61.2% [95% CI, 61.1%-61.3%]). Among the subset of patients who discontinued medication, gastric bypass was also associated with a slightly lower incidence of medication restart up to 5 years after discontinuation. Specifically, the 5-year cumulative incidence of medication restart was lower after gastric bypass compared with sleeve gastrectomy among 19 599 patients who discontinued their diabetes medication after surgery (30.4% [95% CI, 30.2%-30.5%] vs 35.6% [95% CI, 35.4%-35.9%]), 21 611 patients who discontinued their antihypertensive medication after surgery (67.2% [95% CI, 66.9%-67.4%] vs 70.6% [95% CI, 70.3%-70.9%]), and 18 546 patients who discontinued their lipid-lowering medication after surgery (46.2% [95% CI, 46.2%-46.3%] vs 52.5% [95% CI, 52.2%-52.7%]). CONCLUSIONS AND RELEVANCE: Findings of this study suggest that, compared with sleeve gastrectomy, gastric bypass was associated with a slightly higher incidence of medication discontinuation and a slightly lower incidence of medication restart among patients who discontinued medication. Long-term trials are needed to explain the mechanisms and factors associated with differences in medication discontinuation and comorbidity resolution after bariatric surgery.

ImportanceThe health of the US population is decreasing, and novel strategies are needed to reverse the trajectory. The surgical episode may be an opportune time to screen for poor health behaviors and social needs, yet little is known about the feasibility or acceptability of such efforts.ObjectiveTo assess the feasibility and acceptability of a pilot program that engages patients in health behavior change and addresses unmet social needs at the time of surgery.Design, Setting, and, ParticipantsThis quality improvement study was conducted among 10 338 patients seen in a preoperative clinic for elective surgery between February 8 and August 31, 2021. Patients who received a referral for institutional resources were contacted via telephone to complete follow-up surveys 30 to 90 days after surgery and between July 1, 2021, and March 31, 2022.InterventionsImplementation of a tool to screen patients for smoking and food insecurity in a preoperative clinic. Those who screened positive were offered referrals for institutional resources. Telephone surveys were conducted with patients who accepted referrals to understand attitudes toward addressing health behaviors and social needs.Main Outcomes and MeasuresScreening and referral rates, patient-perceived acceptability of addressing health behaviors and social needs at the time of surgery, smoking cessation rates, and resolution of food insecurity.ResultsA total of 10 338 patients (6052 women [58.5%]; mean [SD] age, 56.5 [17.9] years) were evaluated in the preoperative clinic. Of the 10 338 patients, 7825 (75.7%) were successfully screened. Of the 641 identified smokers, 152 (23.7%) accepted a referral for smoking cessation counseling. Of the 181 identified patients with food insecurity, 121 (66.9%) accepted a referral for nonmedical needs assistance. On follow-up surveys, 64 of 78 smokers (82.1%) agreed that the preoperative appointment was an appropriate time to discuss smoking cessation, and 34 of 78 smokers (43.6%) reported quitting smoking. Similarly, 69 of 84 patients with food insecurity (82.1%) agreed it was a good or very good idea for health systems to address nonmedical needs at the time of surgery, and 27 patients (32.1%) reported no longer being insecure about food since their preoperative visit.Conclusions and RelevanceThis study suggests that it is feasible to address patients’ foundational health at the time of surgery. Most patients agreed that these interventions were appropriate during the perioperative period. These results support using the surgical episode as an opportunity to address foundational health.

Background Variable approaches to intraoperative communication impede our understanding of surgical decision-making and best practices. This is critical among hernia repairs, where improved outcomes are reliant on understanding the impact of different patient characteristics and surgical approaches. In this context, a hernia-specific synoptic operative note was piloted as part of an effort to create a statewide hernia registry. We aimed to understand the impact of the synoptic operative note on variable missingness and evaluate barriers and facilitators to improved intraoperative communication and note adoption. Methods In January 2020, the Michigan Surgical Quality Collaborative (MSQC) registry was expanded to capture hernia-specific intraoperative variables. A synoptic operative note for hernia repair was piloted at 8 hospitals. The primary outcome was change in hernia variable communication, measured by missingness. Using a sequential explanatory mixed-methods design, we performed semi-structured interviews with data abstractors (n = 4) and surgeons (n = 4) at 5 pilot sites to assess barriers and facilitators of implementation. Interviews were iteratively analyzed using content analysis with both deductive and inductive approaches. Results From January to June 2020, 870 hernia repairs were performed across 8 pilot and 53 control sites. Pilot sites had significantly less missingness for all hernia-specific variables. At pilot sites, 46% of notes were fully complete in regard to hernia variables, compared to 21% at control sites (p value

Objective To evaluate the association between postoperative opioid prescription size and patient-reported satisfaction among surgical patients. Summary background data Opioids are overprescribed after surgery, which negatively impacts patient outcomes. The assumption that larger prescriptions increase patient satisfaction has been suggested as an important driver of excessive prescribing. Methods This prospective cohort study evaluated opioid-naive adult patients undergoing laparoscopic cholecystectomy, laparoscopic appendectomy, and minor hernia repair between January 1 and May 31, 2018. The primary outcome was patient satisfaction, collected via a 30-day postoperative survey. Satisfaction was measured on a scale of 0-10 and dichotomized into "highly satisfied" (9-10) and "not highly satisfied" (0-8). The explanatory variable of interest was size of opioid prescription at discharge from surgery, converted into milligrams of oral morphine equivalents (OME). Hierarchical logistic regression was performed to evaluate the association between prescription size and satisfaction while adjusting for clinical covariates. Results 1520 patients met the inclusion criteria. Mean age was 53 years and 43% of patients were female. 1279 (84.1%) patients were highly satisfied and 241 (15.9%) were not highly satisfied. After multivariable adjustment, there was no significant association between opioid prescription size and satisfaction (OR 1.00, 95% CI 0.99-1.00). The predicted probability of being highly satisfied ranged from 83% for the smallest prescription (25 mg OME) to 85% for the largest prescription (750 mg OME). Conclusions In a large cohort of patients undergoing common surgical procedures, there was no association between opioid prescription size at discharge after surgery and patient satisfaction. This implies that surgeons can provide significantly smaller opioid prescriptions after surgery without negatively affecting patient satisfaction.

BACKGROUND AND OBJECTIVES Surgical oncology patients are vulnerable to persistent opioid use. As such, we aim to compare opioid prescribing to opioid consumption for common surgical oncology procedures. METHODS We prospectively identified patients undergoing common surgical oncology procedures at a single academic institution (August 2017-March 2018). Patients were contacted by telephone within 6 months of surgery and asked to report their opioid consumption and describe their discharge instructions and opioid handling practices. RESULTS Of the 439 patients who were approached via telephone, 270 completed at least one survey portion. The median quantity of opioid prescribed was significantly larger than consumed following breast biopsy (5 vs. 2 tablets of 5 mg oxycodone, p

BackgroundOpioids are prescribed in excess after surgery. We leveraged our continuous quality improvement infrastructure to implement opioid prescribing guidelines and subsequently evaluate changes in postoperative opioid prescribing, consumption and patient satisfaction/pain in a statewide regional health system.MethodsWe collected data regarding postoperative prescription size, opioid consumption and patient-reported outcomes from February 2017 to May 2019, from a 70-hospital surgical collaborative. Three iterations of prescribing guidelines were released. An interrupted time series analysis before and after each guideline release was performed. Linear regression was used to identify trends in consumption and patient-reported outcomes over time.ResultsWe included 36 022 patients from 69 hospitals who underwent one of nine procedures in the guidelines, of which 15 174 (37.3%) had complete patient-reported outcomes data following surgery. Before the intervention, prescription size was decreasing over time (slope: −0.7 tablets of 5 mg oxycodone/month, 95% CI −1.0 to −0.5 tablets, pConclusionsThe use of procedure-specific prescribing guidelines reduced statewide postoperative opioid prescribing by 50% while providing satisfactory pain care. These results demonstrate meaningful impact on opioid prescribing using evidence-based best practices and serve as an example of successful utilisation of a regional health collaborative for quality improvement.

Vascular Ehlers-Danlos syndrome (vEDS), also known as type IV Ehlers-Danlos syndrome, is a rare inherited connective tissue disease that affects 1 in 50,000 to 250,000 individuals. It is characterized by catastrophic vascular complications and hollow viscus rupture; 80% of patients with vEDS experience a vascular complication by the age of 40 years, and median life expectancy is 40 to 50 years. The central vasculature and visceral vasculature are most commonly affected; peripheral involvement is much less common. We describe the case of a 40-year-old woman with vEDS previously complicated by ruptured splenic and posterior tibial artery aneurysms who presented with a ruptured left ulnar artery aneurysm resulting in compartment syndrome. Keywords: Connective tissue disorder, Ehlers-Danlos syndrome, Peripheral aneurysm

Objective Opioid prescriptions after surgery are effective for pain management but have been a significant contributor to the current opioid epidemic. Our objective is to review pragmatic approaches to develop and implement evidence-based guidelines based on a learning health system model. Summary background data During the last 2 years there has been a preponderance of data demonstrating that opioids are overprescribed after surgery. This contributes to a number of adverse outcomes, including diversion of leftover pills in the community and rising rates of opioid use disorder. Methods We conducted a MEDLINE/PubMed review of published examples and reviewed our institutional experience in developing and implementing evidence-based postoperative prescribing recommendations. Results Thirty studies have described collecting data regarding opioid prescribing and patient-reported use in a cohort of 13,591 patients. Three studies describe successful implementation of opioid prescribing recommendations based on patient-reported opioid use. These settings utilized learning health system principles to establish a cycle of quality improvement based on data generated from routine practice. Key components of this pathway were collecting patient-reported outcomes, identifying key stakeholders, and continual assessment. These pathways were rapidly adopted and resulted in a 37% to 63% reduction in prescribing without increasing requests for refills or patient-reported pain scores. Conclusion A pathway for creating evidence-based opioid-prescribing recommendations can be utilized in diverse practice environments and can lead to significantly decreased opioid prescribing without adversely affecting patient outcomes.

This Medicare database review tracks the long-term incidence of operative hernia recurrence up to 10 years after surgery among older US adults.

First-line treatment of peripheral artery disease (PAD) involves medical therapy and lifestyle modification. Multiple professional organizations such as the Society for Vascular Surgery and the American Heart Association/American College of Cardiology make Class I recommendations for medical management including antiplatelet, statin, antihypertensive, and cilostazol medications, as well as lifestyle therapy including exercise and smoking cessation. Although evidence supports up-front medical and lifestyle management prior to surgical intervention, it is unclear how well this occurs in contemporary clinical practice. It is also unclear whether variability in first-line treatment prior to revascularization is associated with postoperative outcomes. This study examined the proportion of patients with claudication actively receiving evidence-based therapy prior to surgery in a statewide surgical registry.We conducted a retrospective cohort study of adult patients undergoing elective open lower extremity bypass for claudication from 2012 to 2021 within a statewide surgical quality registry. The primary exposure was optimal medical therapy, defined as an antiplatelet agent, a statin, and an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (if the patient had hypertension) on the patient's home medication list on admission for surgery, all of which are Class I recommendations. Despite also being Class I recommendations, cilostazol was not included in the primary exposure due to its highly selective use and our inability to capture intolerance and/or contraindications that are common, and lifestyle therapies were not included as they were only recorded at the time of discharge rather than preoperatively. The primary outcomes were mortality, hospital readmission, amputation, wound complication, myocardial infarction (MI), non-patent bypass, and non-independent ambulatory status at 30 days and 1 year after surgery. Multivariable logistic regression was performed to estimate the association of receiving optimal vs non-optimal medical therapy.A total of 3829 patients with claudication underwent bypass surgery during the study period, with a mean age of 64.8 years (standard deviation, 9.8 years); 2690 (70.3%) were males, and 1873 (48.9%) were current smokers. Of the patients, 1822 (47.6%) were on optimal medical therapy prior to surgery. Additionally, at discharge, 66.5% of smokers received referral to smoking cessation therapy, and 54.1% of patients received referral to exercise therapy. In a multivariable logistic regression, compared with patients not on optimal medical therapy, patients on optimal medical therapy prior to surgery had lower 30-day odds of mortality (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.26-0.78) and MI (aOR, 0.46; 95% CI, 0.28-0.76), lower 1-year odds of mortality (aOR, 0.57; 95% CI, 0.39-0.82), MI (aOR, 0.48; 95% CI, 0.32-0.74), and lower readmission (aOR, 0.79; 95% CI, 0.64-0.96).Although medical and lifestyle management is recommended as first-line treatment for patients with PAD, only one-half of patients were on optimal medical therapy prior to surgery. Patients receiving optimal therapy had a lower risk of postoperative mortality, MI, and readmission. This suggests that not only are there significant opportunities to improve clinical utilization of evidence-based treatment of PAD, but that doing so can benefit patients postoperatively.

This study investigates the prevalence and potential etiologies of citation inaccuracies in surgical literature by systematically characterizing influential surgical articles and references they cited.

ImportanceHealth care mergers and acquisitions have increased vertical integration of skilled nursing facilities (SNFs) in health care networks. While vertical integration may result in improved care coordination and quality, it may also lead to excess utilization, as SNFs are paid a per diem rate.ObjectiveTo determine the association of vertical integration of SNFs within hospital networks with SNF utilization, readmissions, and spending for Medicare beneficiaries undergoing elective hip replacement.Design, Setting, and ParticipantsThis cross-sectional study evaluated 100% Medicare administrative claims for nonfederal acute care hospitals performing at least 10 elective hip replacements during the study period. Fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent elective hip replacement between January 1, 2016, and December 31, 2017, with continuous Medicare coverage for 3 months before and 6 months after surgery were included. Data were analyzed from February 2 to August 8, 2022.ExposuresTreatment at a hospital within a network that also owns at least 1 SNF based on the 2017 American Hospital Association survey.Main Outcomes and MeasuresRates of SNF utilization, 30-day readmissions, and price-standardized 30-day episode payments. Hierarchical multivariable logistic and linear regression clustered at hospitals was performed with adjusting for patient, hospital, and network characteristics.ResultsA total of 150 788 patients (61.4% women; mean [SD] age, 74.3 [6.4] years) underwent hip replacement. After risk adjustment, vertical SNF integration was associated with a higher rate of SNF utilization (21.7% [95% CI, 20.4%-23.0%] vs 19.7% [95% CI, 18.7%-20.7%]; adjusted odds ratio [aOR], 1.15 [95% CI, 1.03-1.29]; P = .01) and lower 30-day readmission rate (5.6% [95% CI, 5.4%-5.8%] vs 5.9% [95% CI, 5.7%-6.1%]; aOR, 0.94 [95% CI, 0.89-0.99]; P = .03). Despite higher SNF utilization, the total adjusted 30-day episode payments were slightly lower ($20 230 [95% CI, $20 035-$20 425] vs $20 487 [95% CI, $20 314-$20 660]; difference, −$275 [95% CI, −$15 to −$498]; P = .04) driven by lower postacute payments and shorter SNF length of stays. Adjusted readmission rates were particularly low for patients not sent to an SNF (3.6% [95% CI, 3.4%-3.7%]; P P Conclusions and RelevanceIn this cross-sectional study of Medicare beneficiaries undergoing elective hip replacements, vertical integration of SNFs in a hospital network was associated with higher rates of SNF utilization and lower rates of readmissions without evidence of higher overall episode payments. These findings support the purported value of integrating SNFs into hospital networks but also suggest that there is room for improving the postoperative care of patients in SNFs early in their stay.

The surgical treatment of claudication can be associated with significant morbidity and costs. There are growing concerns that some patients proceed to interventions without first attempting evidence-based nonoperative management. We used a direct, cross-site, blinded expert review to evaluate the appropriateness of the surgical treatment of claudication.We enlisted practicing vascular surgeons to perform retrospective clinical assessments of lower extremity bypass procedures in a statewide clinical registry. Cases were limited to elective, open, infrainguinal bypasses performed for claudication using prosthetic grafts. Reviewing surgeons were randomly assigned 10 cases from a sample of 139 anonymized bypass operations and instructed to evaluate procedural appropriateness based on their expert opinion and evidence-based guidelines for preoperative treatment, namely, antiplatelet, statin, cilostazol, exercise, and smoking cessation therapy as documented in the medical record. Ninety-day episode payments were estimated from a distinct but similar cohort of patients undergoing lower extremity bypass for claudication.Of 325 total reviews, surgeons stated they would not have recommended bypass in 134 reviews (41%) and deemed bypass inappropriate in 122 reviews (38%). The most common reason for inappropriateness was lack of preoperative medical and lifestyle therapy, which was present in 63% of reviews where bypass was deemed appropriate and 39% of reviews where bypass was deemed inappropriate (P .001). Surgeons stated they would have recommended additional preoperative therapy in 65% of reviews where bypass was deemed inappropriate and 35% of reviews where bypass was deemed appropriate (P .001). The mean total episode payments in a similar cohort of 1458 patients undergoing elective open lower extremity bypass for claudication were $31,301 ± $21,219. Extrapolating to the 325 reviews, the 134 reviews in which surgeons would not have recommended bypass were associated with potentially avoidable estimated total payments of $4,194,334, and the 122 reviews in which bypass was deemed inappropriate were associated with potentially avoidable estimated total payments of $3,818,722.In this cross-site expert peer review study, 40% of lower extremity bypasses were deemed premature and, therefore, potentially avoidable, primarily owing to a lack of medical and lifestyle management before surgery. Reviews deemed inappropriate were associated with approximately $4 million in potentially avoidable costs. This approach could inform performance feedback among surgeons to help align clinical practice with evidence-based recommendations for the treatment of claudication.

The SARS-CoV-2 pandemic has strained manufacturing capacity worldwide, resulting in significant shortages of laboratory supplies both directly and indirectly. Such shortages include probe-based kits for detection of the Mycobacterium tuberculosis complex from positive liquid broth cultures. These shortages and possible loss of this particular assay have consequences for laboratory testing algorithms and public health in the United States. As there are no FDA-approved, commercially available options that currently exist which could immediately fill this gap, laboratories must identify alternatives and plan for modifying current testing algorithms to accommodate this change.

BackgroundGiven the increasing morbidity and mortality related to prescription opioids in the United States, it is critical for patients to understand the risks and proper usage of opioid analgesics.MethodsWe surveyed 166 patients undergoing elective surgery at a single tertiary care facility preoperatively. We queried patients regarding aspects of prescription opioid use, side effects and adverse effects, and storage and disposal behaviors.ResultsOverall knowledge regarding prescription opioids was high (mean score = 8.05/12, range 0–12). The average number of questions answered correctly was not significantly different based on opioid use at the time of the survey (65% vs 67.5%, p = 0.52). Characteristics significantly associated with higher knowledge included young age (p = 0.01), female gender (p < 0.01), and white race (p = 0.01).ConclusionsPatient knowledge regarding prescription opioids is high preceding surgery, but gaps remain regarding side effects and adverse effects. Knowledge did not differ by prior or current opioid use, and these findings may help target important knowledge gaps to improve patient education regarding opioids during the preoperative period.

The Opioid Prescribing Engagement Network (OPEN) at the University of Michigan was established in 2016 with the goal of reducing excessive opioid prescribing after surgery using evidence-based prescribing guidelines. Beginning in July 2016, OPEN began a statewide quality improvement campaign to educate providers and share prescribing best practices. In October 2017, the first prescribing guidelines were released. Although these efforts have been associated with significant decreases in postoperative opioid prescribing, it is unknown whether the incidence of new persistent opioid use after surgery has changed as well. This retrospective study examines the effect of these efforts on new persistent opioid use after surgery compared to the rest of the United States - including other states where no such program existed - using a difference-in-differences approach.

IMPORTANCE: Patient reported outcomes (PROs) are an important marker of the quality of patient care. However, the extent to which PROs reflect care quality and clinical outcomes in surgical patients remains unclear. OBJECTIVE: To measure the association between patient-reported satisfaction and regret and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective, population-based analysis of adults ages 18 and older undergoing surgery across 38 hospitals in Michigan between January 1, 2017 and May 31, 2018. Patients were included if they responded to a PRO survey administered between 30–90 days after surgery. EXPOSURES: Postoperative complications. MAIN OUTCOMES AND MEASURES: Patient satisfaction (dichotomized as highly satisfied and not highly satisfied) and patient regret (dichotomized as absolutely no regret and regret). RESULTS: In this study, 9953 patients (mean age 56 years; 5634 women (57%)) underwent 1 of 16 procedures. 9550 (96%) patients experienced no complication, while 240 (2%) and 163 (2%) patients experienced Grade 1 and Grade 2–3 complications, respectively. Postoperative pain scores were: none (908 (9%) patients), mild (3863 (40%) patients), moderate (3893 (40%) patients), and severe (1075 (11%) patients). Overall, 7881 (79%) patients were highly satisfied and 8911 (91%) had absolutely no regret after surgery. Patients were less likely to be highly satisfied if they experienced a Grade 1 complication (OR 0.50, 95% CI 0.37–0.66 ), Grade 2–3 complication (OR 0.44, 95% CI 0.31–0.62), minimal pain (OR 0.80, 95% CI 0.64–0.99, moderate pain (OR 0.39, 95% CI 0.32–0.49), or severe pain (OR 0.23, 95% CI 0.18–0.29 ). Patients were less likely to have no regret if they experienced a Grade 1 complication (OR 0.48, 95% CI 0.33–0.70), Grade 2–3 complication (OR 0.39, 95% CI 0.25–0.60), moderate pain (OR 0.55, 95% CI 0.40–0.76), or severe pain (OR 0.22, 95% CI 0.16–0.31). The predicted probability of being highly satisfied was 79% for patients who had no complications and 88% for patients who had no pain. CONCLUSIONS AND RELEVANCE: Patients who experienced postoperative complications and pain were less likely to be highly satisfied or have no regret. Importantly, postoperative pain had a more significant effect on satisfaction and regret after surgery, suggesting this as an important opportunity to improve patient experience.

OBJECTIVE To evaluate the effects of shared decision making using a simple decision aid for opioid prescribing after hysterectomy. METHODS We conducted a prospective quality initiative study including all patients undergoing hysterectomy for benign, nonobstetric indications between March 1, 2018, and July 31, 2018, at our academic institution. Using a visual decision aid, patients received uniform education regarding postoperative pain management. They were then educated on the department's guidelines regarding the maximum number of tablets recommended per prescription and the mean number of opioid tablets used by a similar cohort of patients in a previously published study at our institution. Patients were then asked to choose their desired number of tablets to receive on discharge. Structured telephone interviews were conducted 14 days after surgery. The primary outcome was total opioids prescribed before compared with after implementation of the decision aid. Secondary outcomes included opioid consumption, patient satisfaction, and refill requests after intervention implementation. RESULTS Of 170 eligible patients, 159 (93.5%) used the decision aid (one patient who used the decision aid was subsequently excluded from the analysis owing to significant perioperative complications), including 110 (69.6%) laparoscopic, 40 (25.3%) vaginal, and eight (5.3%) abdominal hysterectomies. Telephone surveys were completed for 89.2% (n=141) of participants. Student's t-test showed that patients who participated in the decision aid (post-decision aid cohort) were discharged with significantly fewer oral morphine equivalents than patients who underwent hysterectomy before implementation of the decision aid (pre-decision aid cohort) (92±35 vs 160±81, P

Background Opioids are overprescribed after surgical procedures, leading to dependence and diversion into the community. This can be mitigated by evidence-based prescribing practices. We investigated the feasibility of an opioid-sparing pain management strategy after surgical procedures. Study Design Patients undergoing 6 procedures were offered the opportunity to participate in an opioid-sparing pain management pathway. Patients were advised to use acetaminophen and ibuprofen, and were provided with a small “rescue” opioid prescription for breakthrough pain. They were then surveyed postoperatively about opioid use and patient-reported outcomes measures. Overall cohort characteristics and differences between opioid users and non-users were analyzed. Results A total of 190 patients were analyzed. Median prescription size was 5 (interquartile range [IQR] 4 to 6) pills and opioid use was 0 (IQR 0 to 4) pills. Fifty-two percent of patients used no opioids after procedures. Median number of leftover pills was 2 (IQR 0 to 5). Median pain score was 1 (IQR 1 to 2) and satisfaction score was 10 (IQR 8 to 10). Almost all (91%) patients agreed that their pain was manageable. Patients who used opioids were younger (52 ± 14 vs 59 ± 13 years; p = 0.001), reported higher pain scores (2 [IQR 1 to 2] vs 1 [1 to 2]; p = 0.014), received larger rescue prescriptions (6 ± 3 vs 4 ± 4 pills; p = 0.003), and were less likely to agree that their pain was manageable (82% vs 98%; p = 0.001). There were no other significant differences between opioid users and non-users. Conclusions Patients reported minimal or no opioid use after implementation of an opioid-sparing pathway, and still reported high satisfaction and pain control. These results demonstrate the effectiveness and acceptability of major reduction and even elimination of opioids after discharge from minor surgical procedures.

Instrumental variables can control for selection bias in observational research. However, valid instruments are challenging to identify.To evaluate regional variation in sleeve gastrectomy following insurance coverage implementation as an instrumental variable in comparative effectiveness research.This serial cross-sectional study included adult patients in a national Medicare claims database who underwent sleeve gastrectomy or Roux-en-Y gastric bypass from 2012 to 2017. Data analysis was performed from January to June 2021.Laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.The association of the instrumental variable with treatment (ie, undergoing sleeve gastrectomy), as well as mortality, complications, emergency department visits, hospitalization, reinterventions, and surgical revision.A total of 76 077 patients underwent bariatric surgery, of whom 44 367 underwent sleeve gastrectomy (mean [SD] age, 56.9 [11.9] years; 32 559 [73.5%] women) and 31 710 underwent gastric bypass (mean (SD) age, 55.9 (11.8) years; 23 750 [74.9%] women). After insurance coverage initiation, there was substantial regional and temporal variation in adoption of sleeve gastrectomy. Prior-year state-level utilization of sleeve gastrectomy was highly associated with undergoing sleeve gastrectomy (Kleibergen-Paap Wald F statistic, 910.3). All but 2 patient characteristics (race and diagnosis of depression) were well-balanced between the top and bottom quartiles of the instrumental variable. Regarding 1-year outcomes, compared with patients undergoing gastric bypass, patients undergoing sleeve gastrectomy had a lower 1-year risk of mortality (0.9%; 95% CI, 0.8%-1.1% vs 1.7%; 95% CI, 1.3%-2.0%), complications (11.6%; 95% CI, 10.9%-12.3% vs 14.1%; 95% CI, 13.0%-15.3%), emergency department visits (48.3%; 95% CI, 46.9%-49.8% vs 53.6%; 95% CI, 52.3%-55.0%), hospitalization (23.4%; 95% CI, 22.4%-24.4% vs 26.5%; 95% CI, 25.1%-28.0%), and reinterventions (8.7%; 95% CI, 8.0%-9.4% vs 12.2%; 95% CI, 11.2%-13.3%). The risk of revision was not different between groups (0.6%; 95% CI, 0.3%-0.8% vs 0.4%; 95% CI, 0.3%-0.6%).In this cross-sectional study of patients undergoing bariatric surgery, there was significant geographic variation in the use of sleeve gastrectomy following initiation of insurance coverage, which served as a strong instrument to compare 2 bariatric surgical procedures. This approach could be applied to other areas of health services research to serve as a complement to clinical trials.

Importance Real-world surgical practice often lags behind the best scientific evidence. For example, although optimizing comorbidities such as smoking and morbid obesity before ventral and incisional hernia repair improves outcomes, as many as 25% of these patients have a high-risk characteristic at the time of surgery. Implementation strategies may effectively increase use of evidence-based practice. Objective To describe current trends in preoperative optimization among patients undergoing ventral hernia repair, identify barriers to optimization, develop interventions to address these barriers, and then pilot these interventions. Design, setting, and participants This quality improvement study used a retrospective medical record review to identify hospital-level trends in preoperative optimization among patients undergoing ventral and incisional hernia repair. Semistructured interviews with 21 practicing surgeons were conducted to elicit barriers to optimizing high-risk patients before surgery. Next, a task force of experts was convened to develop pragmatic interventions to increase surgeon use of preoperative optimization. Finally, these interventions were piloted at 2 sites to assess acceptability and feasibility. This study was performed from January 1, 2014, to December 31, 2019. Main outcomes and measures The main outcome was rate of referrals for preoperative patient optimization at the 2 pilot sites. Results Among 23 000 patients undergoing ventral hernia repair, the mean (SD) age was 53.9 (14.3) years, and 12 315 (53.5%) were men. Of these, 8786 patients (38.2%) had at least 1 high-risk characteristic at the time of surgery, including 7683 with 1, 1079 with 2, and 24 with 3. At the hospital level, the mean proportion of patients with at least 1 of 3 high-risk characteristics at the time of surgery was 38.2% (95% CI, 38.1%-38.3%). This proportion varied widely from 21.5% (95% CI, 17.6%-25.5%) to 52.8% (95% CI, 43.9%-61.8%) across hospitals. Interviews with surgeons identified 3 major barriers to improving this practice: lost financial opportunity by not offering a patient an operation, lack of surgeon awareness of available resources for optimization, and organizational barriers. A task force therefore developed 3 interventions: a financial incentive to optimize high-risk patients, an educational intervention to make surgeons aware of available optimization resources, and on-site facilitation. These strategies were piloted at 2 sites where preoperative risk optimization referrals increased 860%. Conclusions and relevance This study demonstrates a stepwise process of identifying a practice gap, eliciting barriers that contribute to this gap, using expert consensus and local resources to develop strategies to address these barriers, and piloting these strategies. This implementation strategy can be adopted to diverse settings given that it relies on developing and implementing strategies based on local practice patterns.

Larger opioid prescriptions are associated with increased consumption without improvements in pain, and the majority of opioids prescribed go unused. We examined postoperative opioid prescription and use in patients undergoing vascular access surgery, where preoperative opioid exposure is common.A retrospective analysis was conducted in adult CKD patients who underwent outpatient vascular access surgery. Patients were surveyed by telephone2 weeks after surgery to assess pain level and opioid and non-opioid medication use.Of 117 patients contacted, 76 responded (65% response rate), with a median (interquartile range) age of 56 (42-69) years. Sixty-three patients (83%) were prescribed an opioid postoperatively. Respondents were prescribed 60 (38-75) oral morphine equivalents (OMEs) and consumed 0 (0-15) OMEs over 1 day with a pain score of 5 out of 10. Thirty-nine patients (50%) used no opioids. There were no differences in postoperative opioid prescribing or use in patients with recent opioid exposure compared to patients without. Patients who underwent arteriovenous fistula (AVF) creation (short surgical incision procedure) were prescribed 60 (38-75) OMEs, compared with 75 (56-111) OMEs for patients who underwent AVF superficialization, AVG, or BVT (long surgical incision procedure; P0.01) and consumed 0 (0-15) OMEs compared with 10 (0-43) OMEs, respectively (P = 0.07).Regardless of preoperative opioid exposure, CKD patients undergoing vascular access surgery consumed fewer opioids than prescribed, with a median of10% of opioids used. Therefore, we've reduced our institutional prescribing recommendations to 4 and 6 oxycodone 5mg pills for short and long surgical incision procedures, respectively.

BACKGROUND: New persistent opioid use is a common postoperative complication, with 6% of previously opioid-naïve patients continuing to fill opioid prescriptions 3–6 months after surgery. Despite these risks, it is unknown which specialties prescribe opioids to these vulnerable patients. OBJECTIVE: To identify specialties prescribing opioids to surgical patients who develop new persistent opioid use. DESIGN, SETTING, AND PARTICIPANTS: Using a national dataset of insurance claims, we identified opioid-naïve patients aged 18–64 years undergoing surgical procedures (2008–2014) who continued filling opioid prescriptions 3 to 6 months after surgery. We then examined opioid prescriptions claims during the 12 months after surgery, and identified prescribing physician specialty using National Provider Identifier codes. MAIN MEASURES: Percentage of opioid prescriptions provided by each specialty evaluated at 90-day intervals during the 12 months after surgery. KEY RESULTS: We identified 5276 opioid-naïve patients who developed new persistent opioid use. During the first 3 months after surgery, surgeons accounted for 69% of opioid prescriptions, primary care physicians accounted for 13%, Emergency Medicine accounted for 2%, Physical Medicine & Rehabilitation (PM&R)/Pain Medicine accounted for 1%, and all other specialties accounted for 15%. In contrast, 9 to 12 months after surgery, surgeons accounted for only 11% of opioid prescriptions, primary care physicians accounted for 53%, Emergency Medicine accounted for 5%, PM&R/Pain Medicine accounted for 6%, and all other specialties provided 25%. CONCLUSIONS: Among surgical patients who developed new persistent opioid use, surgeons provide the majority of opioid prescriptions during the first 3 months after surgery. By 9 to 12 months after surgery, however, the majority of opioid prescriptions were provided by primary care physicians. Enhanced care coordination between surgeons and primary care physicians could allow earlier identification of patients at risk for new persistent opioid use to prevent misuse and dependence. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-018-4463-1) contains supplementary material, which is available to authorized users.

Access to care for pediatric burns remsains a major public health problem in the United States. Telemedicine has an opportunity to improve access to care, but current models are expensive and inefficient. They have developed and pilot-tested the TeleBurn App, a novel smartphone application, to treat partial thickness burns while outpatient. The app allows the provision of expert clinical burn care directly in the patient's home through text and image messaging, video conferencing, and instructional videos. They retrospectively reviewed clinical outcomes and usability in pediatric partial thickness burn patients treated using the TeleBurn App compared with standard therapy alone. Standard therapy is considered to be face-to-face delivery of care. Burn wound care was provided to 32 patients via the app and 35 patients with standard therapy. Most (74%) patients offered the app, used it as their primary source of follow-up care. This group had no wound infections or unexpected returns to clinic or hospital. Both TeleBurn App and standard therapy groups had similar burn severity, age, and burn mechanism. Mean healing time was shorter in the app group (mean ± standard deviation: 11.6 ± 4.7 days versus standard therapy: 14.3 ± 5.4 [P = .03]) with fewer clinical encounters (0.93 ± 0.6 vs standard therapy: 3.3 ± 1.0 [P = .001]). Adherence with completion of therapy in patients using the app was 80 vs 64 per cent with standard therapy. They describe a functional, scalable mobile health application in clinical use in a pediatric burn program. Further prospective, randomized studies may validate this mobile health platform, improving access to expert burn care for a vulnerable population.

This Surgical Perspective presents the case for leveraging the surgical episode to impact population health. We describe a novel screening and referral pilot and propose several policy changes aimed at delivering population-health focused surgical care.

Key Points Question Can a low-cost optimization clinic be implemented to successfully manage high-risk patients seeking hernia repair? Findings In this quality improvement study, 1 year after the implementation of a preoperative optimization clinic, 9.1% of high-risk patients became eligible for hernia repair through the optimization of a high-risk characteristic, and the number of emergency surgery events was low. Meaning These findings suggest that this model represents a scalable and sustainable framework for preoperative optimization with the potential to improve the care of patients with hernias., This quality improvement study evaluates the feasibility of a low-cost preoperative optimization clinic that was implemented to improve the care of high-risk patients seeking elective hernia repair., Importance Preoperative optimization is an important clinical strategy for reducing morbidity; however, nearly 25% of persons undergoing elective abdominal hernia repairs are not optimized with respect to weight or substance use. Although the preoperative period represents a unique opportunity to motivate patient health behavior changes, fear of emergent presentation and financial concerns are often cited as clinician barriers to optimization. Objective To evaluate the feasibility of evidence-based patient optimization before surgery by implementing a low-cost preoperative optimization clinic. Design, Setting, and Participants This quality improvement study was conducted 1 year after a preoperative optimization clinic was implemented for high-risk patients seeking elective hernia repair. The median (range) follow-up was 197 (39-378) days. A weekly preoperative optimization clinic was implemented in 2019 at a single academic center. Referral occurred for persons seeking elective hernia repair with a body mass index greater than or equal to 40, age 75 years or older, or active tobacco use. Data analysis was performed from February to July 2020. Exposures Enrolled patients were provided health resources and longitudinal multidisciplinary care. Main Outcomes and Measures The primary outcomes were safety and eligibility for surgery after participating in the optimization clinic. The hypothesis was that the optimization clinic could preoperatively mitigate patient risk factors, without increasing patient risk. Safety was defined as the occurrence of complications during participation in the optimization clinic. The secondary outcome metric centered on the financial impact of implementing the preoperative optimization program. Results Of the 165 patients enrolled in the optimization clinic, most were women (90 patients [54.5%]) and White (145 patients [87.9%]). The mean (SD) age was 59.4 (15.8) years. Patients’ eligibility for the clinic was distributed across high-risk criteria: 37.0% (61 patients) for weight, 26.1% (43 patients) for tobacco use, and 23.6% (39 patients) for age. Overall, 9.1% of persons (15 patients) were successfully optimized for surgery, and tobacco cessation was achieved in 13.8% of smokers (8 patients). The rate of hernia incarceration requiring emergent surgery was 3.0% (5 patients). Economic evaluation found increased operative yield from surgical clinics, with a 58% increase in hernia-attributed relative value units without altering surgeon workflow. Conclusions and Relevance In this quality improvement study, a hernia optimization clinic safely improved management of high-risk patients and increased operative yield for the institution. This represents an opportunity to create sustainable and scalable models that provide longitudinal care and optimize patients to improve outcomes of hernia repair.

This cross-sectional study examines the attributable association of modifiable risk factors for adverse outcomes after hernia repair and increased health care spending associated with these adverse outcomes., Key Points Question What is the attributable association of modifiable preoperative risk factors with clinical outcomes and health care spending after ventral and incisional hernia repair (VIHR)? Findings In this cross-sectional analysis of 22 664 adult patients undergoing VIHR, morbid obesity, insulin-dependent diabetes, and unhealthy alcohol use were significantly associated with adverse outcomes. Additional spending for a serious complication after surgery was $26 648, of which $3638 was associated with morbid obesity, $650 was associated with insulin-dependent diabetes, and $567 was associated with unhealthy alcohol use. Meaning Quantifying the association of individual risk factors with adverse outcomes after VIHR may help surgeons develop targeted interventions to reduce complications and surgical spending., Importance Ventral and incisional hernia repair (VIHR) is an extremely common operation, after which complications are also fairly common. A number of preoperative risk factors are known to contribute to increased complications after surgical repair; however, the individual relative association of these risk factors with adverse outcomes and increased spending is unclear. Quantifying the association of individual risk factors may help surgeons implement targeted surgical optimization, improve outcomes, and reduce spending. Objective To identify the attributable association of modifiable risk factors for adverse outcomes after VIHR on outcomes and episode-of-care payments. Design, Setting, and Participants This cross-sectional study was performed using a population-based sample of adult patients and episode spending data from January 1, 2012, to December 31, 2018, from a statewide multipayer registry. A multilevel mixed-effects logistic regression model was used to examine the contribution of patient-specific risk factors to adverse outcomes. Attributable risk and population attributable risk fraction were calculated to estimate the additional spending attributable to individual risk factors. Data were analyzed from April 2018 to September 2018. Main Outcomes and Measures Any complications, serious complication, discharge not to home, 30-day emergency department utilization, and 30-day readmission. Episode-of-care spending was calculated for these outcomes. Results This study included 22 664 patients (median [interquartile range] age, 55 [44-64] years; 10 496 [46.3%] women) undergoing VIHR with identified significant preoperative risk factors. Fourth-quartile body mass index (BMI), calculated as weight in kilograms divided by height in meters squared and defined as a mean (SD) BMI of 43 (6), was associated with increased risk of any complication (odds ratio [OR], 1.64; 95% CI, 1.30-2.06; P

BACKGROUND: Approaches to burn care in the pediatric population are highly variable and can be targeted as a potential measure in cost-reduction. We hypothesized that institutions vary significantly in treatment allocation of non-severe burns to either inpatient or outpatient care. METHODS: We queried the PHIS database for fiscal year 2017 to quantify small pediatric burn admissions and Emergency Department visits(ED). The ICD-10 code T31.0 was used to identify burns involving ≤10% of total body surface area (TBSA). Centers were categorized by burn center status and length of stay, readmissions, and charges were compared. RESULTS: Inpatient versus outpatient management distribution was significantly different across the included pediatric children’s hospitals (n=34, p

Postoperative Opioid Prescribing Guidelines To improve opioid prescribing after surgery, the Michigan Surgical Quality Collaborative developed evidence-based prescribing guidelines for nine operati...

Bitter taste receptors (T2Rs) are expressed in several tissues of the body and are involved in a variety of roles apart from bitter taste perception. Advanced glycation end-products (AGEs) are produced by glycation of amino acids in proteins. There are varying sources of AGEs, including dietary food products, as well as endogenous reactions within our body. Whether these AGEs are T2R ligands remains to be characterized. In this study, we selected two AGEs, namely, glyoxal-derived lysine dimer (GOLD) and carboxymethyllysine (CML), based on their predicted interaction with the well-studied T2R4, and its physiochemical properties. Results showed predicted binding affinities (Kd) for GOLD and CML towards T2R4 in the nM and &mu, M range, respectively. Calcium mobilization assays showed that GOLD inhibited quinine activation of T2R4 with IC50 10.52 &plusmn, 4.7 &mu, M, whilst CML was less effective with IC50 32.62 &plusmn, 9.5 &mu, M. To characterize whether this antagonism was specific to quinine activated T2R4 or applicable to other T2Rs, we selected T2R14 and T2R20, which are expressed at significant levels in different human tissues. A similar effect of GOLD was observed with T2R14, and in contrast, GOLD and CML activated T2R20 with an EC50 of 79.35 &plusmn, 29.16 &mu, M and 65.31 &plusmn, 17.79 &mu, M, respectively. In this study, we identified AGEs as novel T2R ligands that caused either activation or inhibition of different T2Rs.

Key Points Question What is the prevalence of and what clinical and demographic characteristics are associated with smoking in a large population of patients undergoing surgery? Findings In this cross-sectional study of 328 578 patients undergoing general and vascular surgical procedures from 2012 to 2019 in Michigan, nearly 1 in 4 patients smoked cigarettes at the time of surgery. Despite decreasing over the study period, in 2019 the adjusted prevalence of smoking was 22.3% among all patients, 43.0% among patients with Medicaid, and 36.3% among patients without insurance. Meaning These findings indicate that smoking cessation interventions may be particularly important for patients undergoing surgery, especially for patients who lack health insurance or have Medicaid., This cross-sectional study describes the prevalence of smoking in a population of patients undergoing common surgical procedures and identifies any clinical or demographic characteristics associated with smoking., Importance Surgery is a teachable moment, and smoking cessation interventions that coincide with an episode of surgical care are especially effective. Implementing these interventions at a large scale requires understanding the prevalence and characteristics of smoking among surgical patients. Objectives To describe the prevalence of smoking in a population of patients undergoing common surgical procedures and to identify any clinical or demographic characteristics associated with smoking. Design, Setting, and Participants This cross-sectional study included all adult patients (aged ≥18 years) in a statewide registry who underwent general and vascular surgical procedures from 2012 to 2019 at 70 hospitals in Michigan. Data analysis was conducted from August to October 2020. Exposures Undergoing a surgical procedure in any of the following categories: appendectomy, cholecystectomy, colon procedures, gastric or esophageal procedures, hepatopancreatobiliary procedures, hernia repair, small-bowel procedures, hysterectomy, vascular procedures, thyroidectomy, and other unspecific abdominal procedures. Main Outcomes and Measures The prevalence of smoking prior to surgery, defined as cigarette use in the year prior to surgery, obtained from medical record review. Multivariable logistic regression was performed to analyze smoking prevalence based on insurance type and year of surgery while adjusting for demographic and clinical factors, including age, sex, race/ethnicity (determined from the medical record), insurance type, geographic region, comorbidities (ie, hypertension, diabetes, congestive heart failure, chronic obstructive pulmonary disease, chronic steroid use, and obstructive sleep apnea), American Society of Anesthesiologists classification, admission status, surgical priority, procedure type, and year of surgery. Results From 2012 to 2019, 328 578 patients underwent surgery and were included in analysis. Mean (SD) age was 54.0 (17.0) years, and 197 501 patients (60.1%) were women. The overall prevalence of smoking was 24.1% (79 152 patients). Prevalence varied regionally from 21.5% (95% CI, 21.0%-21.9%; 6686 of 31 172 patients) in southeast Michigan to 28.0% (95% CI, 27.1%-28.9%; 2696 of 9614 patients) in northeast Michigan. When adjusting for clinical and demographic factors, there were greater odds of smoking among patients with Medicaid (odds ratio [OR], 2.75; 95% CI, 2.69-2.82) and patients without insurance (OR, 2.21; 95% CI, 2.10-2.33) compared with patients with private insurance. Among procedure categories, patients undergoing vascular surgery had greater odds of smoking (OR, 3.24; 95% CI, 3.11-3.38) than those undergoing cholecystectomy. Compared with 2012, the adjusted odds of smoking decreased significantly each year (eg, 2019: OR, 0.78; 95% CI, 0.74-0.81). In 2019, the adjusted prevalence of smoking was 22.3% (95% CI, 22.0%-22.7%) among all patients, 43.0% (95% CI, 42.4%-43.6%) among patients with Medicaid, and 36.3% (95% CI, 35.2%-37.4%) among patients without insurance. Conclusions and Relevance In a statewide population of surgical patients, nearly one-quarter of patients smoked cigarettes, which is higher than the national average. The prevalence of smoking was especially high among patients without insurance and among those receiving Medicaid. Given the established association between undergoing a major surgical procedure and health behavior change, targeted smoking cessation interventions at the time of surgery may be an effective strategy to improve population health, especially among at-risk patient groups.

This study compares patient-reported outcomes after surgery between opioid-sparing recovery and standard of care.

Background Surgery is a major physiologic stress comparable to intense exercise. Diminished cardiopulmonary reserve is a major predictor of poor outcomes. Current preoperative workup focuses mainly on identifying risk factors; however, little attention is devoted to improving cardiopulmonary reserve beyond counseling. We propose that patients could be optimized for a "surgical marathon" similar to the preparation of an athlete. Study Design The Michigan Surgical and Health Optimization Program (MSHOP) is a formal prehabilitation program that engages patients in 4 activities before surgery: physical activity, pulmonary rehabilitation, nutritional optimization, and stress reduction. We prospectively collected demographic, intraoperative (first hour), and postoperative data for patients enrolled in MSHOP undergoing major abdominal surgery. Statistical analysis was performed using 2:1 propensity score matching to compare the MSHOP group (n = 40) to emergency (n = 40) and elective, non-MSHOP (n = 76) patients. Results Overall, 70% of MSHOP patients complied with the program. Age, sex, American Society of Anesthesiologists (ASA) classification, and BMI did not differ significantly between groups. One hour intraoperatively, MSHOP patients showed improved systolic and diastolic blood pressures and lower heart rate (Figure). There was a significant reduction in Clavien-Dindo class 3 to 4 complications in the MSHOP group (30%) compared with the nonprehabilitation (38%) and emergency (48%) groups (p = 0.05). This translated to total hospital charges averaging $75,494 for the MSHOP group, $97,440 for the nonprehabilitation group, and $166,085 for the emergency group (p Conclusions Patients undergoing prehabilitation before colectomy showed positive physiologic effects and experienced fewer complications. The average savings of $21,946 per patient represents a significant cost offset for a prehabilitation program, and should be considered for all patients undergoing surgery.

BACKGROUND: Excessive opioid prescribing is common in surgical oncology with 72% of prescribed opioids going unused after curative-intent surgery. In this study, we sought to reduce opioid prescribing after breast and melanoma procedures by designing and implementing an intervention focused on education and prescribing guidelines. We then evaluated the impact of this intervention. METHODS: In this single-institution study, we designed and implemented an intervention targeting key factors identified in qualitative interviews. This included mandatory education for prescribers, evidence-based prescribing guidelines, and standardized patient instructions. After the intervention, interrupted time series analysis was used to compare the mean quantity of opioid prescribed before and after the intervention (July 2016-September 2017). We also evaluated the frequency of opioid prescription refills. RESULTS: During the study, 847 patients underwent breast or melanoma procedures and received an opioid prescription. For mastectomy or wide local excision for melanoma, the mean quantity of opioid prescribed immediately decreased by 37% after the intervention (P=0.03), equivalent to 13 tablets of 5mg oxycodone. For lumpectomy or breast biopsy, the mean quantity of opioid prescribed decreased by 42% or 12 tablets of 5mg oxycodone (P=0.07). Furthermore, opioid prescription refills did not significantly change for mastectomy/wide local excision (13% vs. 14%, P=0.8), or lumpectomy/breast biopsy (4% vs. 5%, P=0.7). CONCLUSIONS: Education and prescribing guidelines reduced opioid prescribing for breast and melanoma procedures without increasing the need for refills. This suggests further reductions in opioid prescribing may be possible, and provides rationale for implementing similar interventions for other procedures and practice settings.

Opioid prescribing after operations is often excessive, resulting in leftover pills in the community available for diversion. Procedure-specific postoperative prescribing guidelines can reduce excessive prescribing, however, it is unclear whether such guidelines are associated with reductions in opioid prescribing for other procedures.A retrospective chart review was conducted for patients undergoing laparoscopic appendectomy, laparoscopic inguinal hernia repair, laparoscopic sleeve gastrectomy, and thyroidectomy/parathyroidectomy between January 1, 2016 and August 31, 2017. Postoperative opioid prescription size (in oral morphine equivalents [OME]) was compared before and after November 1, 2016, when prescribing guidelines were introduced for laparoscopic cholecystectomy. An interrupted time series analysis was conducted to evaluate changes in opioid prescribing after this intervention.A total of 1,158 patients were included in the cohort (558 pre-intervention, 600 post-intervention). Opioid prescription size was significantly reduced for laparoscopic sleeve gastrectomy (447.6 ± 74.3 OME vs 291.9 ± 104.3 OME; p0.001), laparoscopic appendectomy (173.7 ± 101.6 OME vs 85.8 ± 52.7 OME; p0.001), laparoscopic inguinal hernia repair (185.0 ± 101.8 OME vs 107.9 ± 57.9 OME; p0.001), and thyroidectomy/parathyroidectomy (81.5 ± 52.8 OME vs 42.6 ± 22.5 OME; p0.001). Interrupted time series analysis revealed that this reduction was attributable to intervention for laparoscopic sleeve gastrectomy (-24.5 ± 5.3 OME; p = 0.001), laparoscopic appendectomy (-50.2 ± 28.7 OME; p = 0.04), and thyroidectomy/parathyroidectomy (-28.8 ± 9.4 OME; p = 0.001). For laparoscopic inguinal hernia repair, the immediate decrease in prescription size was not statistically significant (-38.8 ± 33.1 OME; p = 0.24). There was a significant increase in requests for refills after laparoscopic appendectomy (0.8% vs 6.6%; p = 0.01) but not for other procedures.After implementing evidence-based opioid prescribing recommendations for a single surgical procedure, opioid prescribing decreased for 4 other surgical procedures. Requests for refills did not increase substantially. This spillover effect demonstrates the potential impact of raising awareness about safe and appropriate opioid prescribing after operations.