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Background: Hospital-related factors associated with mortality and morbidity after hip fracture surgery are not completely understood. The Veterans Health Administration (VHA) is the largest single-payer, networked healthcare system in the country serving a relatively homogenous patient population with facilities that vary in size and resource availability. These characteristics provide some degree of financial and patient-level controls to explore the association, if any, between surgical volume and facility resource availability and hospital performance regarding postoperative complications after hip fracture surgery.Questions/purposes: (1) Do VHA facilities with the highest complexity level designation (Level 1a) have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-complexity level facilities? (2) Do VHA facilities with higher hip fracture surgical volume have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-volume facilities?Methods: We explored the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database from October 2001 to September 2012 for records of hip fracture surgery performed. Data reliability of the VASQIP database has been previously validated. We excluded nine of the 98 VHA facilities for contributing fewer than 30 records. The remaining 89 VHA facilities provided 23,029 records. The VHA designates a complexity level to each facility based on multiple criteria. We labeled facilities with a complexity Level 1a (38 facilities)-the highest achievable VHA designated complexity level-as high complexity; we labeled all other complexity level designations as low complexity (51 facilities). Facility volume was divided into tertiles: high (> 277 hip fracture procedures during the sampling frame), medium (204 to 277 procedures), and low (< 204 procedures). The patient population treated by low-complexity facilities was older, had a higher prevalence of severe chronic obstructive pulmonary disease (26% versus 22%, p < 0.001), and had a higher percentage of patients having surgery within 2 days of hospital admission (83% versus 76%, p < 0.001). High-complexity facilities treated more patients with recent congestive heart failure exacerbation (4% versus 3%, p < 0.001). We defined major postoperative complications as having at least one of the following: death within 30 days of surgery, cardiac arrest requiring cardiopulmonary resuscitation, new q-wave myocardial infarction, deep vein thrombosis and/or pulmonary embolism, ventilator dependence for at least 48 hours after surgery, reintubation for respiratory or cardiac failure, acute renal failure requiring renal replacement therapy, progressive renal insufficiency with a rise in serum creatinine of at least 2 mg/dL from preoperative value, pneumonia, or surgical site infection. We used the observed-to-expected ratio (O/E ratio)-a risk-adjusted metric to classify facility performance-for major postoperative complications to assess the performance of VHA facilities. Outlier facilities with 95% confidence intervals (95% CI) for O/E ratio completely less than 1.0 were labeled "exceed expectation;" those that were completely greater than 1.0 were labeled "below expectation." We compared differences in the distribution of outlier facilities between high and low-complexity facilities, and between high-, medium-, and low-volume facilities using Fisher's exact test.Results: We observed no association between facility complexity level and the distribution of outlier facilities (high-complexity: 5% exceeded expectation, 5% below expectation; low-complexity: 8% exceeded expectation, 2% below expectation; p = 0.742). Compared with high-complexity facilities, the adjusted odds ratio for major postoperative complications for low-complexity facilities was 0.85 (95% CI, 0.67-1.09; p = 0.108).We observed no association between facility volume and the distribution of outlier facilities: 3% exceeded expectation and 3% below expectation for high-volume; 10% exceeded expectation and 3% below expectation for medium-volume; and 7% exceeded expectation and 3% below expectation for low-volume; p = 0.890). The adjusted odds ratios for major postoperative complications were 0.87 (95% CI, 0.73-1.05) for low- versus high-volume facilities and 0.89 (95% CI, 0.79-1.02] for medium- versus high-volume facilities (p = 0.155).Conclusions: These results do not support restricting facilities from treating hip fracture patients based on historical surgical volume or facility resource availability. Identification of consistent performance outliers may help health care organizations with multiple facilities determine allocation of services and identify characteristics and processes that determine outlier status in the interest of continued quality improvement.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

The article discusses a study conducted by Jashvant Poeran and colleagues which aims to assess the perioperative use of the medication tranexamic acid in total hip and total knee arthroplasties without the need for blood transfusions and risks for thromboembolic and renal problems. Topics discussed include the summary answer and the main result of the study, what the research adds on previous studies on tranexamic acid use, and the methodology of the study.

Background: The opioid epidemic is one of the most pressing public health crises in the USA. With fractures being amongst the most common reasons for a child to require surgical intervention and receive post-surgical pain management, characterisation of opioid prescription patterns and risk factors is critical. We hypothesised that the numbers of paediatric patients receiving opioids, or who developed persistent opioid use, are significant, and a number of risk factors for persistent opioid use could be identified.Methods: We conducted a retrospective population-based cohort study. National claims data from the Truven Health Analytics® MarketScan database were used to (i) characterise opioid prescription patterns and (ii) describe the epidemiology and risk factors for single use and persistent use of opioids amongst paediatric patients who underwent surgical intervention for fracture treatment.Results: Amongst 303 335 patients, 21.5% received at least one opioid prescription within 6 months after surgery, and 1671 (0.6%) developed persistent opioid use. Risk factors for persistent opioid use include older age; female sex; lower extremity trauma; surgeries involving the spine, rib cage, or head; closed fracture treatment; earlier surgery years; previous use of opioid; and higher comorbidity burden.Conclusions: Amongst a cohort of paediatric patients who underwent surgical fracture treatment, 21.5% filled at least one opioid prescription, and 0.6% (N=1671) filled at least one more opioid prescription between 3 and 6 months after surgery. Understanding risk factors related to persistent opioid use can help clinicians devise strategies to counter the development of persistent opioid use for paediatric patients. [ABSTRACT FROM AUTHOR]

Background Adding neuraxial to general anesthesia (GA) has been associated with improved perioperative outcome after orthopedic surgery. Presuming a similar effect in major abdominal surgery we studied its effect on perioperative outcome in open colectomy patients. Materials and methods Retrospective study using the Premier Perspective database (n = 98,290 elective open colectomies, 2006-2012). Multilevel multivariable logistic regression models measured the association between anesthesia type (GA or general and neuraxial anesthesia combined [GNA]) and perioperative outcome with odds ratios (OR) and 95% confidence intervals (CI). Outcomes were thromboembolism, acute myocardial infarction, postoperative infection, postoperative ileus, cerebrovascular events, blood transfusion, admission to an intensive care unit, and mechanical ventilation. Results GA was used in 93.9%, GNA in 6.1%, with a similar Charlson comorbidity index between the groups (2.66 versus 2.72, respectively; P = 0.121). The multivariable analyses showed GNA (versus GA) to be associated with a significantly decreased risk for thromboembolism (OR 0.74; CI 0.58-0.93) and cerebrovascular events (OR 0.67; CI 0.51-0.88), whereas the association was nonsignificant for wound infections, pneumonia, and mechanical ventilation. However, GNA use was significantly associated with increased risk for acute myocardial infarction (OR 2.74; CI 2.19-3.43), urinary tract infection (OR 1.35; CI 1.21-1.50), postoperative ileus (OR 1.17; CI 1.09-1.26), blood transfusion (OR 1.12; CI 1.01-1.24), and admission to intensive care unit (OR 1.32; CI 1.22-1.43). Conclusions We found no clear pattern of consistent favorable results for patients undergoing their open colectomy under GNA. Further prospective research is needed to help identify those who are more likely to benefit from GNA use and its mechanism of actions. [ABSTRACT FROM AUTHOR]

Study Design: Analysis of population-based national hospital discharge data collected for the National Inpatient Sample.Objective: To examine demographics of patients undergoing primary anterior spine fusion (ASF), posterior spine fusion (PSF), and anterior/posterior spine fusion (APSF) of the noncervical spine, assess the incidence of perioperative morbidity and mortality, and determine independent risk factors for in-hospital death.Summary Of Background Data: The utilization of surgical fusion has been increasing dramatically. Despite this trend, a paucity of literature addressing perioperative outcomes exists.Methods: Data collected for each year between 1998 and 2006 for the National Inpatient Sample were analyzed. Discharges with a procedure code for primary noncervical spine fusion were included in the sample. The prevalence of patient as well as health care system-related demographics were evaluated by procedure type (ASF, PSF, and APSF). Frequencies of procedure-related complications and in-hospital mortality were analyzed. Independent predictors for in-hospital mortality were determined.Results: We identified 261,256 entries representing an estimated 1,273,228 hospitalizations for primary spine fusion. Patients undergoing ASF and APSF were significantly younger (44.8 ± 0.08 and 44.22 ± 0.11 years) and had lower average comorbidity indeces (0.30 ± 0.002 and 0.31 ± 0.004) than those undergoing PSF (52.12 ± 0.04 years and 0.41 ± 0.002) (P < 0.0001). The incidence of procedure-related complications was 18.68% among ASF, 15.72% in PSF, and 23.81% in APSF patients (P < 0.0001). In-hospital mortality rates after APSF were approximately twice those of PSF (0.51 ± 0.038 vs. 0.26 ± 0.012) (P < 0.0001). Adjusted risk factors for in-hospital mortality included the following: APSF and ASF compared to PSF, male gender, increasing age, and increasing comorbidity burden. Several comorbidities and complications independently increased the risk for perioperative death, as did underlying spinal pathology.Conclusion: Despite being performed in generally younger and healthier patients, APSF and ASF are associated with increased morbidity and mortality. Our findings can be used for the purposes of risk stratification, accurate patient consultation, and hypothesis formation for future research. [ABSTRACT FROM AUTHOR]