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Social isolation is an important determinant of all-cause mortality, with evidence suggesting an association with cancer-specific mortality as well. In this study, we examined the associations between social isolation and neighborhood poverty (independently and jointly) on cancer mortality in a population-based sample of US adults. Using data from the Third National Health and Nutrition Examination Survey (NHANES III; 1988-1994), NHANES III Linked Mortality File (through 2011) and 1990 Census, we estimated the relationship between social isolation and high neighborhood poverty and time-to-cancer death using multivariable-adjusted Cox proportional hazards models. We examined the associations of each factor independently and explored the multiplicative and additive interaction effects on cancer mortality risk and also analyzed these associations by sex. Among 16 044 US adults with 17-23 years of follow-up, there were 1133 cancer deaths. Social isolation (HR 1.25, 95% CI: 1.01-1.54) and high neighborhood poverty (HR 1.31, 95% CI: 1.08-1.60) were associated with increased risk of cancer mortality adjusting for age, sex, and race/ethnicity; in sex-specific estimates this increase in risk was evident among females only (HR 1.39, 95% CI: 1.04-1.86). These associations were attenuated upon further adjustment for socioeconomic status. There was no evidence of joint effects of social isolation and high neighborhood poverty on cancer mortality overall or in the sex-stratified models. These findings suggest that social isolation and higher neighborhood poverty are independently associated with increased risk of cancer mortality, although there is no evidence to support our a priori hypothesis of a joint effect.

IntroductionOver a decade ago, our study group showed improved outcomes among total hip/knee arthroplasty (THA/TKA) patients given neuraxial versus general anesthesia. As the use of neuraxial anesthesia has increased and anesthesia practices evolve, updated analyses are critical to ensure if previously found differences still persist.MethodsThis retrospective cohort study included elective THA/TKAs from 2006 to 2021 as recorded in the all-payor Premier Healthcare Database. Multivariable regression models measured the association between anesthesia type (neuraxial, general, combined) and several adverse outcomes (pulmonary embolism, cerebrovascular events, pulmonary compromise, cardiac complications, acute myocardial infarction, pneumonia, all infections, acute renal failure, gastrointestinal complications, postoperative mechanical ventilation, intensive care unit admissions, and blood transfusions); models were run separately by period (2006–2015 and 2016–2021) and THA/TKA.ResultsWe identified 587,919 and 499,484 THAs for 2006–2015 and 2016–2021, respectively; this was 1,186,483 and 803,324 for TKAs. Among THAs, neuraxial anesthesia use increased from 10.7% in 2006 to 25.7% in 2021; during both time periods, specifically neuraxial versus general anesthesia was associated with lower odds for most adverse outcomes, with sometimes stronger (protective) effect estimates observed for 2016–2021 versus 2006–2015 (eg, acute renal failure OR 0.72 CI 0.65 to 0.80 vs OR 0.56 CI 0.50 to 0.63 and blood transfusion OR 0.91 CI 0.89 to 0.94 vs OR 0.44 CI 0.41 to 0.47, respectively; all p<0.001). Similar patterns existed for TKAs.ConclusionThese findings re-confirm our study group’s decade-old study using more recent data and offer additional evidence toward the sustained benefit of neuraxial anesthesia in major orthopedic surgery.

To analyze the use of neuraxial techniques in total hip or knee arthroplasty patients who previously underwent lumbar spine surgeries. Retrospective analysis of a national database. U.S. hospitals. Patients undergoing a total hip or knee arthroplasty, stratified by those with a previous lumbar fusion or decompression procedure. Our primary outcome was the use of neuraxial anesthesia; secondary outcomes included combined complications, cardio-pulmonary complications, and prolonged length of stay. Patients with and without a history of a lumbar procedure were compared using mixed-effects regression. Among 758,857 THAs 8961 had a history of lumbar fusion and 8599 of decompression. Among 1,387,335 TKAs 15,827 had a history of lumbar fusion and 13,652 of decompression. History of a lumbar fusion was associated with lower odds of neuraxial anesthesia use in THA (OR: 0.74 CI: 0.70–0.79, p ≤0.0001) and TKA (OR: 0.80 CI: 0.77–0.84, p ≤0.0001). Previous lumbar fusion -but not decompression- surgery is associated with lower neuraxial anesthesia in THA/TKA patients, despite its use being universally associated with decreased length of stay. More research is needed to address the importance of neuraxial techniques in patients with prior spine surgery. •Lumbar procedures are common in the U.S. and are expected to increase in practice.•We analyzed more than 2.1 million patients undergoing total joint arthroplasty.•Only 15.6% of patients with previous lumbar fusion received neuraxial anesthesia.•History of a lumbar fusion was associated with lower odds of neuraxial anesthesia use.

Acetaminophen (APAP) and intravenous acetaminophen (IVAPAP) has been proposed as a part of many opioid-sparing multimodal analgesic pathways. The aim of this analysis was to compare the effectiveness of IVAPAP with oral APAP on opioid utilization and opioid-related adverse effects. Retrospective study of population-based database. The Premier Healthcare database was queried patients undergoing surgery for a primary diagnosis of hip fracture from 2011 to 2019 yielding 245,976 patients. Primary exposure was use of IVAPAP or oral APAP on the day of surgery. None. The primary outcome of interest was opioid utilization over the hospital stay, secondary outcomes included opioid-related adverse effects, length, and costs of hospital stay. Mixed effect models measured the association of IVPAP and APAP and outcomes. In the study population 30.67% (75,445) received at least 1 dose of IVAPAP on the day of surgery. Upon adjusting for relevant covariates, patients who received IVPAP on the day of surgery had slightly higher opioid use standardized by length of hospital stay (2.8% CI: 2%, 3.6%; p < .001), higher hospital cost (2.7% CI: 2.1%, 3.4%), and higher odds of naloxone use (1.18, CI: 1.1, 1.27; p < .001) when compared with patients who received oral APAP. In this population, IVAPAP use on the day of surgery failed to reduce opioid use or associated opioid related adverse effects when compared with oral APAP. IVAPAP was associated with increased overall costs, opioid requirements, and naloxone use. These results do not support the use of IV over oral APAP routinely for hip fracture surgery patients. •IVAPAP use on the day of surgery failed to reduce opioid related adverse effects when compared with oral APAP.•IVAPAP was associated with increased overall costs, opioid requirements, and naloxone use when compared with oral APAP.•These results do not support the use of IV over oral APAP routinely for hip fracture surgery patients.

Value-based care initiatives require accurate quantification of resource utilization. This study explores hospital resource documentation performance for total knee and hip arthroplasty (TKA, THA) implants and how this may differ between hospitals. This retrospective study utilized the Premier discharge database, years 2006 to 2020. TKA/THA cases were categorized into 5 tiers based upon the completeness of implant component documentation: Platinum, Gold, Silver, Bronze, Poor. Correlation between TKA and THA documentation performance (per-hospital percentage of Platinum cases) was assessed. Logistic regression analyses measured the association between hospital characteristics (region, teaching status, bed size, urban/rural) and satisfactory documentation. TKA/THA implant documentation performance was compared to documentation for endovascular stent procedures. Individual hospitals tended to have very complete (Platinum) or very incomplete (Poor) documentation for both TKA and THA. TKA and THA documentation performance were correlated (correlation coefficient = .70). Teaching hospitals were less likely to have satisfactory documentation for both TKA (P = .002) and THA (P = .029). Documentation for endovascular stent procedures was superior compared to TKA/THA. Hospitals’ TKA and THA-related implant documentation performance is generally either very proficient or very poor, in contrast with often well-documented endovascular stent procedures. Hospital characteristics, other than teaching status, do not appear to impact TKA/THA documentation completeness.

Background and Aims The onset of the coronavirus 2019 (COVID‐19) pandemic brought together the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the European Society of Regional Anaesthesia and Pain Therapy (ESRA) to release a joint statement on anesthesia use. Their statement included a recommendation to use regional anesthesia whenever possible to mitigate the risk associated with aerosolizing procedures. We sought to examine the utilization of anesthesia in pediatric patients undergoing a surgical procedure for fractures or ligament repairs before and during COVID‐19. Methods Using the Premier Health Database, we retrospectively analyzed pediatric patients undergoing a surgical intervention for fractures or ligament repair before and during COVID‐19. We sought to determine if there were differences in anesthesia use among this cohort during the two time periods. Fracture groups included shoulder and clavicle, humerus and elbow, forearm and wrist, hand and finger, pelvis and hip, femur and knee, leg and ankles, and foot and toes. Ligament procedures included surgical intervention for the anterior cruciate ligament and ulnar collateral ligament repair. Results We identified a total of 5935 patients undergoing a surgical procedure for fractures or ligament repairs before and during COVID‐19. After exclusion for unknown anesthesia use, 2,807 patients were included in our cohort with 81.5% (n = 2288) of patients undergoing a procedure under general anesthesia, 6.4% (n = 181) under regional anesthesia, and 12.0% (n = 338) under combined general‐regional anesthesia. There did not appear to be a significant difference in the type of anesthesia used before and during COVID‐19 (p = 0.052). Conclusions Our study did not identify a difference in anesthesia use before and during COVID‐19 among pediatric patients undergoing a surgical procedure. Further studies should estimate the change in anesthesia used during the time period when elective procedures were resumed.

IntroductionThe benzodiazepine midazolam is the main sedative used in the perioperative setting, resulting in anxiolysis and a reduction in anesthetic dose requirements. However, benzodiazepine use is also associated with potentially serious side effects including respiratory complications, and postoperative delirium (POD). A paucity of population level data exists on current perioperative midazolam use in adult orthopedic surgery and its effects on complications. Using a large national dataset, we aimed to determine perioperative midazolam utilization patterns and to analyze its effect on postoperative outcomes.MethodsPatients who underwent total knee and hip arthroplasty (TKA/THA) were identified from Premier database (2006–2019). Primary exposure of interest was midazolam use on the day of surgery. Multivariable logistic regression models were run to determine if midazolam was associated with postoperative cardiac and pulmonary complications, delirium, and in-hospital falls.ResultsAmong 2,848,897 patients, more than 75% received midazolam perioperatively. This was associated with increased adjusted odds for in-hospital falls in TKA/THA (OR 1.1, 95% CI 1.07 to 1.14)/(OR 1.1, 95% CI 1.06 to 1.16), while a decrease in the adjusted odds for cardiac complications in TKA/THA (OR 0.94, 95% CI 0.91 to 0.97)/(OR 0.93, 95% CI 0.89 to 0.97), and pulmonary complications (OR 0.92, 95% CI 0.87 to 0.96) (all p<0.001) was seen. Most notably, the concurrent use of midazolam and gabapentinoids significantly increased the adjusted odds for postoperative complications, including pulmonary complications (OR 1.22, 95% CI 1.18 to 1.27)/(OR 1.29, 95% CI 1.22 to 1.37), naloxone utilization (OR 1.56, 95% CI 1.51 to 1.60)/(OR 1.49, 95% CI 1.42 to 1.56), and POD (OR 1.45, 95% CI 1.38 to 1.52)/(OR 1.32, 95% CI 1.23 to 1.34) in THA/TKA.ConclusionPerioperative midazolam use was associated with an increase in postoperative patient falls, and a decrease in cardiac complications. Notably, the combined use of midazolam and gabapentinoids was associated with a substantial increase in the odds for respiratory failure and delirium. Given the high prevalence of benzodiazepines perioperatively, the risk benefit profile should be more clearly established to inform perioperative decision making.

Background and AimsPosterior spine instrumentation and fusion (PSF) is a painful surgery undertaken to treat adolescent idiopathic scoliosis (AIS). Ultrasound-guided Erector Spinae Plane Block (ESPB) may present a new opportunity to apply regional analgesia to pediatric patients undergoing this surgery. To date, there exist limited applications of regional anesthesia for PSF in a comprehensive enhanced recovery pathway. We assessed the feasibility of performing ESPB in patients with AIS undergoing PSF.MethodsThis randomized control trial was approved by the institutional review board of the Hospital for Special Surgery (IRB# 2019-2131). A total of 24 patients were enrolled; 12 patients were randomized to receive the bilateral ESPB with local anesthesia and 12 did not receive the bilateral ESPB. Patients in both the ESPB group and no block group received the same standard anesthetic/analgesic regimen.Abstract EP020 Figure 1CONSORT patient flow diagram[Figure omitted. See PDF]Abstract EP020 Table 1Characteristics of patients successfully enrolledResultsTo reach our enrollment target of 24 participants, we approached 57 eligible patients. Out of the 12 patients randomized to the ESPB group, 9 (75.0%) successfully received the allocated intervention. Completion of the block in two patients was unsuccessful. In addition, one case was cancelled due to an unrelated intraoperative complication. Patients and their parents in the ESPB group were on average more satisfied with their pain management postoperatively than the control group.ConclusionsWithin our cohort, we successfully administered ESPB to 75% of the patients in the treatment group. Further studies are needed to investigate the potential benefits of ESPB improving postoperative analgesia and decreasing patient opioid requirements in patients with AIS undergoing PSF.

Background and AimsExparelTM, a liposomal bupivacaine formulation, is a long-acting local anesthetic that can provide pain relief after total hip or knee arthroplasty (THA/TKA) when used for local wound infiltration or peripheral nerve blocks. At the same time, Exparel is a relatively expensive medication, and its use can increase healthcare costs. As population-level trend data remain rare, we aimed to investigate nationwide trends of Exparel use in the United States for THA/TKA.MethodsThis study was approved by the institutional review board of the Hospital for Special Surgery (IRB#2012-050). We identified patients from the Premier Healthcare database who underwent elective THA/TKA using a standard set of International Classification of Diseases -ninth/tenth revision codes from 2012 to 2021. We examined the use of Exparel over time at both the patient and hospital levels.ResultsAmong 103,165 cases, Exparel use increased from 2012 to 2015 (0.36% to 22.8%), and decreased afterward (15.7% in 2021) (table 1). At the hospital level, 599 hospitals (59.7%) ever used Exparel during the study period. In 2013, 30% of hospitals started to initiate Exparel use, and the rate has been decreasing over time (compared to 3.1% hospital initiated Exparel use in 2021). In 2014, hospitals started to terminate Exparel (1.1%); this termination rate increased and peaked in 2019 (9.5%). (figure 1)Abstract EP115 Figure 1Exparel use trends on hospital level[Figure omitted. See PDF]Abstract EP115 Table 1Exparel use trends on patient levelConclusionsThe use of Exparel peaked around the year 2014-2015 and has been decreasing afterward. The reason for hospitals stopping Exparel use may be related to recent evidence for its modest efficacy and should be studied further.Stundner_NoticeOfIRBApproval

Background and AimsHip fracture is a common and serious injury, particularly in older adults, which can lead to significant morbidity, mortality, and decreased quality of life. Surgery is the standard treatment for hip fractures, and its timing is crucial for optimal outcomes. Studying the time from hip fracture to surgery can help identify best practices for timely surgery and improve patient outcomes.MethodsThis study was approved by the Institutional Review Board at our hospital review board (IRB#2012-050). From the Premier Healthcare database (Premier Healthcare Solutions, Inc., Charlotte, NC; 2006-2021) we identified patients who had a primary diagnosis of hip fracture and underwent surgical procedures. The primary exposure of interest was time from hip fracture diagnosis to surgery (categorized as 0-1 day, 2 days, and 3 days). Outcomes of interest included any major complications, length of stay, ICU admission (identified by billing code), and total opioid consumption during hospitalization.ResultsWe identified 65,111 patients who underwent surgical treatment within 3 days of hip fracture onsite, with 29.1 of patients receiving the surgery within 1 day, and 53.8% of patients receiving the surgery within 2 days. Prolonged wait time to have surgery increased the risk of having major complications, mortality, ICU admission, and longer hospitalization (table 1).Abstract EP003 Table 1Mixed modeling outcomes comparing different time between surgery and fracture onsiteConclusionsDelayed surgery after hip fracture is associated with increased morbidity and mortality, increased length of hospital stay, and increased use of resources. It is recommended that healthcare providers prioritize timely surgical intervention for patients with hip fractures to optimize their chances of a successful recovery.