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Multidisciplinary care improves surgical outcomes for elderly patients
and were able to leave the hospital after a shorter stay, according to findings from a case-control study of nearly 400 patients.
Data from previous studies suggest that preoperative assessment by geriatric experts can improve outcomes for the elderly, who are more likely than are younger patients to develop preventable postoperative complications, and “this evidence supports the formulation of a different approach to preoperative assessment and postoperative care for this population,” wrote Shelley R. McDonald, DO, of Duke University, Durham, N.C., and colleagues.
The intervention, known as the Perioperative Optimization of Senior Health (POSH), was described as “a quality improvement initiative with prospective data collection.” Patients in a geriatrics clinic within an academic center were selected for the study if they were at high risk for complications linked to elective abdominal surgery. High risk was defined as older than 85 years of age, or older than 65 years of age with conditions including cognitive impairment, recent weight loss, multiple comorbidities, and polypharmacy (JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513).
The POSH intervention patients received preoperative evaluation from a team including a geriatrician, geriatric resource nurse, social worker, program administrator, and nurse practitioner from the preoperative anesthesia testing clinic. Patients and families were advised on risk management and care optimization involving cognition, comorbidities, medications, mobility, functional status, nutrition, hydration, pain, and advanced care planning.
Patients in the POSH group were on average older, had more comorbidities, and were more likely to be smokers. But despite these disadvantaging characteristics, they still had better outcomes in several important variables than did those in the control group.
The POSH group had significantly shorter hospital stays, compared with controls (4 days vs. 6 days), and significantly lower all-cause readmission rates at both 7 days (2.8% vs. 9.9%) and 30 days (7.8% vs. 18.3%). The significance persisted whether the surgeries were laparoscopic or open.
The overall complication rate was lower in the POSH group, compared with the controls, but fell short of statistical significance (44.8% vs. 58.7%, P = .01). However, rates of specific complications were significantly lower in the POSH group, compared with controls, including postoperative cardiogenic or hypovolemic shock (2.2% vs. 8.4%), bleeding, either during or after surgery (6.1% vs. 15.4%), and postoperative ileus (4.9% vs. 20.3%).
“Delirium was identified in POSH patients at higher rates than in the control group, which is not unexpected because higher postoperative delirium rates are known to be identified with increased screening,” the researchers noted. “Collaborative care allows for increasing the recognition of geriatric syndromes like delirium, more focus on symptom management, and proactively anticipating complications,” they said.
The study results were limited by several factors including a long enrollment period for the POSH patients, and potential changes in surgical protocols, the researchers said. However, the findings support the need for further research and more refined analysis to identify the most beneficial aspects of care, and to support better clinical decision making about the timing of interventions and the type of patient who could benefit, they noted.
The researchers had no financial conflicts to disclose. The John A. Hartford Foundation Center of Excellence National Program Award provided salary and database support.
SOURCE: McDonald S et al. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513.
and were able to leave the hospital after a shorter stay, according to findings from a case-control study of nearly 400 patients.
Data from previous studies suggest that preoperative assessment by geriatric experts can improve outcomes for the elderly, who are more likely than are younger patients to develop preventable postoperative complications, and “this evidence supports the formulation of a different approach to preoperative assessment and postoperative care for this population,” wrote Shelley R. McDonald, DO, of Duke University, Durham, N.C., and colleagues.
The intervention, known as the Perioperative Optimization of Senior Health (POSH), was described as “a quality improvement initiative with prospective data collection.” Patients in a geriatrics clinic within an academic center were selected for the study if they were at high risk for complications linked to elective abdominal surgery. High risk was defined as older than 85 years of age, or older than 65 years of age with conditions including cognitive impairment, recent weight loss, multiple comorbidities, and polypharmacy (JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513).
The POSH intervention patients received preoperative evaluation from a team including a geriatrician, geriatric resource nurse, social worker, program administrator, and nurse practitioner from the preoperative anesthesia testing clinic. Patients and families were advised on risk management and care optimization involving cognition, comorbidities, medications, mobility, functional status, nutrition, hydration, pain, and advanced care planning.
Patients in the POSH group were on average older, had more comorbidities, and were more likely to be smokers. But despite these disadvantaging characteristics, they still had better outcomes in several important variables than did those in the control group.
The POSH group had significantly shorter hospital stays, compared with controls (4 days vs. 6 days), and significantly lower all-cause readmission rates at both 7 days (2.8% vs. 9.9%) and 30 days (7.8% vs. 18.3%). The significance persisted whether the surgeries were laparoscopic or open.
The overall complication rate was lower in the POSH group, compared with the controls, but fell short of statistical significance (44.8% vs. 58.7%, P = .01). However, rates of specific complications were significantly lower in the POSH group, compared with controls, including postoperative cardiogenic or hypovolemic shock (2.2% vs. 8.4%), bleeding, either during or after surgery (6.1% vs. 15.4%), and postoperative ileus (4.9% vs. 20.3%).
“Delirium was identified in POSH patients at higher rates than in the control group, which is not unexpected because higher postoperative delirium rates are known to be identified with increased screening,” the researchers noted. “Collaborative care allows for increasing the recognition of geriatric syndromes like delirium, more focus on symptom management, and proactively anticipating complications,” they said.
The study results were limited by several factors including a long enrollment period for the POSH patients, and potential changes in surgical protocols, the researchers said. However, the findings support the need for further research and more refined analysis to identify the most beneficial aspects of care, and to support better clinical decision making about the timing of interventions and the type of patient who could benefit, they noted.
The researchers had no financial conflicts to disclose. The John A. Hartford Foundation Center of Excellence National Program Award provided salary and database support.
SOURCE: McDonald S et al. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513.
and were able to leave the hospital after a shorter stay, according to findings from a case-control study of nearly 400 patients.
Data from previous studies suggest that preoperative assessment by geriatric experts can improve outcomes for the elderly, who are more likely than are younger patients to develop preventable postoperative complications, and “this evidence supports the formulation of a different approach to preoperative assessment and postoperative care for this population,” wrote Shelley R. McDonald, DO, of Duke University, Durham, N.C., and colleagues.
The intervention, known as the Perioperative Optimization of Senior Health (POSH), was described as “a quality improvement initiative with prospective data collection.” Patients in a geriatrics clinic within an academic center were selected for the study if they were at high risk for complications linked to elective abdominal surgery. High risk was defined as older than 85 years of age, or older than 65 years of age with conditions including cognitive impairment, recent weight loss, multiple comorbidities, and polypharmacy (JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513).
The POSH intervention patients received preoperative evaluation from a team including a geriatrician, geriatric resource nurse, social worker, program administrator, and nurse practitioner from the preoperative anesthesia testing clinic. Patients and families were advised on risk management and care optimization involving cognition, comorbidities, medications, mobility, functional status, nutrition, hydration, pain, and advanced care planning.
Patients in the POSH group were on average older, had more comorbidities, and were more likely to be smokers. But despite these disadvantaging characteristics, they still had better outcomes in several important variables than did those in the control group.
The POSH group had significantly shorter hospital stays, compared with controls (4 days vs. 6 days), and significantly lower all-cause readmission rates at both 7 days (2.8% vs. 9.9%) and 30 days (7.8% vs. 18.3%). The significance persisted whether the surgeries were laparoscopic or open.
The overall complication rate was lower in the POSH group, compared with the controls, but fell short of statistical significance (44.8% vs. 58.7%, P = .01). However, rates of specific complications were significantly lower in the POSH group, compared with controls, including postoperative cardiogenic or hypovolemic shock (2.2% vs. 8.4%), bleeding, either during or after surgery (6.1% vs. 15.4%), and postoperative ileus (4.9% vs. 20.3%).
“Delirium was identified in POSH patients at higher rates than in the control group, which is not unexpected because higher postoperative delirium rates are known to be identified with increased screening,” the researchers noted. “Collaborative care allows for increasing the recognition of geriatric syndromes like delirium, more focus on symptom management, and proactively anticipating complications,” they said.
The study results were limited by several factors including a long enrollment period for the POSH patients, and potential changes in surgical protocols, the researchers said. However, the findings support the need for further research and more refined analysis to identify the most beneficial aspects of care, and to support better clinical decision making about the timing of interventions and the type of patient who could benefit, they noted.
The researchers had no financial conflicts to disclose. The John A. Hartford Foundation Center of Excellence National Program Award provided salary and database support.
SOURCE: McDonald S et al. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513.
FROM JAMA SURGERY
Key clinical point: A preoperative surgical intervention improved outcomes and shortened hospital stays for seniors.
Major finding: The POSH group had significantly shorter hospital stays compared with controls (4 days vs. 6 days).
Study details: The data come from a study of 183 surgery patients and 143 controls.
Disclosures: The researchers had no financial conflicts to disclose.
Source: McDonald S JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513
Delayed ileal pouch anal anastomosis creation linked to lower 30-day adverse events
LAS VEGAS – compared with creating the pouch at the time of initial surgery, results from an analysis of national data demonstrated.
“More than 600,000 Americans have UC, and 20%-30% of them require surgical management,” Bharati Kochar, MD, said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “The surgical procedure of choice for many UC patients is total proctocolectomy with ileal pouch anal anastomosis creation.”
According to Dr. Kochar, an advanced fellow in inflammatory bowel diseases at the University of North Carolina at Chapel Hill, existing American medical literature regarding ileal pouch anal anastomosis (IPAA) comes mostly from quaternary care centers and compares one-stage procedures with multistage procedures.
“The risks between two- to three-stage procedures are not described, and there are no prospective national reports of postoperative adverse events after IPAA creation,” she said.
Using data from the National Surgical Quality Improvement Program, Dr. Kochar and her associates conducted an observational cohort analysis of 2,390 adult patients with a postoperative diagnosis of UC who underwent IPAA procedures between 2011 and 2015. Their aims were to evaluate adverse events within 30 days after an IPAA creation and to compare adverse events between pouch creation at the time of colectomy and delayed pouch creation.
They also performed a subanalysis of total abdominal colectomy with ileostomy (TAC), the first stage in the delayed pouch procedures, versus pouch creation at the time of colectomy. Multivariable modified Poisson regression models were used to estimate risk ratios adjusted for age, sex, race, body mass index, smoking status, diabetes, preoperative albumin, and American Society of Anesthesiologists class.
Of the 2,390 patients, 1,571 had pouches created at the time of colectomy (group A), and 819 had delayed pouch creation (group B).
Compared with patients in group B, those in group A were older (a median age of 40 years vs. 37 years, respectively; P less than .01), were more likely to be on an immunosuppressant (51% vs. 15%; P less than .01), have a lower median preoperative albumin level (3.9 vs. 4.2; P less than .01), and a longer median length of stay (6 days vs. 5 days; P less than .01).
On unadjusted analyses, the researchers also observed that, at 30 days, patients in group A had significantly more major complications, such as mortality and cardiac arrest (12.4% vs. 8.7%; P less than .01); minor complications, such as superficial surgical site infections and pneumonia (11.8% vs. 6.1%; P less than .01); unplanned readmissions (statistically similar at 23.3% vs. 21.3%), and unplanned reoperations (7.7% vs. 3.8%; P less than .01).
After controlling for confounders, patients in group B were significantly less likely to have major complications (relative risk, 0.72), minor complications (RR, 0.48), unplanned readmissions (RR, 0.95), and unplanned reoperations (RR, 0.42).
In the subgroup analysis, Dr. Kochar and her associates observed that patients who underwent TAC were significantly older, compared with patients in group A (a median of 46 years vs. 40 years, respectively; P less than .01), and a higher proportion were on immunosuppressants (69% vs. 51%; P less than .01). “Despite these factors, the risk of adverse events after TAC was lower,” Dr. Kochar said.
She acknowledged certain limitations of the study, including the inability to accurately determine the risk of linked surgeries together and the inability to assess institution and operator factors. Also, data were not collected for the purposes of studying inflammatory bowel disease.
“This is the first prospective assessment of morbidity following IPAA creation in UC patients from a national database,” Dr. Kochar concluded. “Delayed pouch procedures are associated with a lower risk of unplanned reoperations and major and minor complications. Immunosuppression at the time of pouch creation may result in an increased risk of adverse events postoperatively. The findings can be valuable for preoperative risk assessment and postoperative management.”
Dr. Kochar reported having no financial disclosures.
*This story was updated on 3/26.
SOURCE: Kochar et al. Crohn’s & Colitis Congress 2018 Clinical Abstract 11.
LAS VEGAS – compared with creating the pouch at the time of initial surgery, results from an analysis of national data demonstrated.
“More than 600,000 Americans have UC, and 20%-30% of them require surgical management,” Bharati Kochar, MD, said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “The surgical procedure of choice for many UC patients is total proctocolectomy with ileal pouch anal anastomosis creation.”
According to Dr. Kochar, an advanced fellow in inflammatory bowel diseases at the University of North Carolina at Chapel Hill, existing American medical literature regarding ileal pouch anal anastomosis (IPAA) comes mostly from quaternary care centers and compares one-stage procedures with multistage procedures.
“The risks between two- to three-stage procedures are not described, and there are no prospective national reports of postoperative adverse events after IPAA creation,” she said.
Using data from the National Surgical Quality Improvement Program, Dr. Kochar and her associates conducted an observational cohort analysis of 2,390 adult patients with a postoperative diagnosis of UC who underwent IPAA procedures between 2011 and 2015. Their aims were to evaluate adverse events within 30 days after an IPAA creation and to compare adverse events between pouch creation at the time of colectomy and delayed pouch creation.
They also performed a subanalysis of total abdominal colectomy with ileostomy (TAC), the first stage in the delayed pouch procedures, versus pouch creation at the time of colectomy. Multivariable modified Poisson regression models were used to estimate risk ratios adjusted for age, sex, race, body mass index, smoking status, diabetes, preoperative albumin, and American Society of Anesthesiologists class.
Of the 2,390 patients, 1,571 had pouches created at the time of colectomy (group A), and 819 had delayed pouch creation (group B).
Compared with patients in group B, those in group A were older (a median age of 40 years vs. 37 years, respectively; P less than .01), were more likely to be on an immunosuppressant (51% vs. 15%; P less than .01), have a lower median preoperative albumin level (3.9 vs. 4.2; P less than .01), and a longer median length of stay (6 days vs. 5 days; P less than .01).
On unadjusted analyses, the researchers also observed that, at 30 days, patients in group A had significantly more major complications, such as mortality and cardiac arrest (12.4% vs. 8.7%; P less than .01); minor complications, such as superficial surgical site infections and pneumonia (11.8% vs. 6.1%; P less than .01); unplanned readmissions (statistically similar at 23.3% vs. 21.3%), and unplanned reoperations (7.7% vs. 3.8%; P less than .01).
After controlling for confounders, patients in group B were significantly less likely to have major complications (relative risk, 0.72), minor complications (RR, 0.48), unplanned readmissions (RR, 0.95), and unplanned reoperations (RR, 0.42).
In the subgroup analysis, Dr. Kochar and her associates observed that patients who underwent TAC were significantly older, compared with patients in group A (a median of 46 years vs. 40 years, respectively; P less than .01), and a higher proportion were on immunosuppressants (69% vs. 51%; P less than .01). “Despite these factors, the risk of adverse events after TAC was lower,” Dr. Kochar said.
She acknowledged certain limitations of the study, including the inability to accurately determine the risk of linked surgeries together and the inability to assess institution and operator factors. Also, data were not collected for the purposes of studying inflammatory bowel disease.
“This is the first prospective assessment of morbidity following IPAA creation in UC patients from a national database,” Dr. Kochar concluded. “Delayed pouch procedures are associated with a lower risk of unplanned reoperations and major and minor complications. Immunosuppression at the time of pouch creation may result in an increased risk of adverse events postoperatively. The findings can be valuable for preoperative risk assessment and postoperative management.”
Dr. Kochar reported having no financial disclosures.
*This story was updated on 3/26.
SOURCE: Kochar et al. Crohn’s & Colitis Congress 2018 Clinical Abstract 11.
LAS VEGAS – compared with creating the pouch at the time of initial surgery, results from an analysis of national data demonstrated.
“More than 600,000 Americans have UC, and 20%-30% of them require surgical management,” Bharati Kochar, MD, said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “The surgical procedure of choice for many UC patients is total proctocolectomy with ileal pouch anal anastomosis creation.”
According to Dr. Kochar, an advanced fellow in inflammatory bowel diseases at the University of North Carolina at Chapel Hill, existing American medical literature regarding ileal pouch anal anastomosis (IPAA) comes mostly from quaternary care centers and compares one-stage procedures with multistage procedures.
“The risks between two- to three-stage procedures are not described, and there are no prospective national reports of postoperative adverse events after IPAA creation,” she said.
Using data from the National Surgical Quality Improvement Program, Dr. Kochar and her associates conducted an observational cohort analysis of 2,390 adult patients with a postoperative diagnosis of UC who underwent IPAA procedures between 2011 and 2015. Their aims were to evaluate adverse events within 30 days after an IPAA creation and to compare adverse events between pouch creation at the time of colectomy and delayed pouch creation.
They also performed a subanalysis of total abdominal colectomy with ileostomy (TAC), the first stage in the delayed pouch procedures, versus pouch creation at the time of colectomy. Multivariable modified Poisson regression models were used to estimate risk ratios adjusted for age, sex, race, body mass index, smoking status, diabetes, preoperative albumin, and American Society of Anesthesiologists class.
Of the 2,390 patients, 1,571 had pouches created at the time of colectomy (group A), and 819 had delayed pouch creation (group B).
Compared with patients in group B, those in group A were older (a median age of 40 years vs. 37 years, respectively; P less than .01), were more likely to be on an immunosuppressant (51% vs. 15%; P less than .01), have a lower median preoperative albumin level (3.9 vs. 4.2; P less than .01), and a longer median length of stay (6 days vs. 5 days; P less than .01).
On unadjusted analyses, the researchers also observed that, at 30 days, patients in group A had significantly more major complications, such as mortality and cardiac arrest (12.4% vs. 8.7%; P less than .01); minor complications, such as superficial surgical site infections and pneumonia (11.8% vs. 6.1%; P less than .01); unplanned readmissions (statistically similar at 23.3% vs. 21.3%), and unplanned reoperations (7.7% vs. 3.8%; P less than .01).
After controlling for confounders, patients in group B were significantly less likely to have major complications (relative risk, 0.72), minor complications (RR, 0.48), unplanned readmissions (RR, 0.95), and unplanned reoperations (RR, 0.42).
In the subgroup analysis, Dr. Kochar and her associates observed that patients who underwent TAC were significantly older, compared with patients in group A (a median of 46 years vs. 40 years, respectively; P less than .01), and a higher proportion were on immunosuppressants (69% vs. 51%; P less than .01). “Despite these factors, the risk of adverse events after TAC was lower,” Dr. Kochar said.
She acknowledged certain limitations of the study, including the inability to accurately determine the risk of linked surgeries together and the inability to assess institution and operator factors. Also, data were not collected for the purposes of studying inflammatory bowel disease.
“This is the first prospective assessment of morbidity following IPAA creation in UC patients from a national database,” Dr. Kochar concluded. “Delayed pouch procedures are associated with a lower risk of unplanned reoperations and major and minor complications. Immunosuppression at the time of pouch creation may result in an increased risk of adverse events postoperatively. The findings can be valuable for preoperative risk assessment and postoperative management.”
Dr. Kochar reported having no financial disclosures.
*This story was updated on 3/26.
SOURCE: Kochar et al. Crohn’s & Colitis Congress 2018 Clinical Abstract 11.
REPORTING FROM THE CROHN’S & COLITIS CONGRESS
Key clinical point: Delayed ileal pouch anal anastomosis procedures are associated with a lower 30-day adverse-event rate.
Major finding: After controlling for confounders, patients who underwent delayed IPAA procedures were significantly less likely to have major complications (relative risk, 0.72), minor complications (RR, 0.48), unplanned readmissions (RR, 0.95), and unplanned reoperations (RR, 0.42) at 30 days, compared with those who underwent pouch creation at the time of initial surgery.
Study details: An observational cohort analysis of 2,390 adult patients with a postoperative diagnosis of UC.
Disclosures: Dr. Kochar reported having no financial disclosures.
Source: Kochar et al. Crohn’s & Colitis Congress 2018 Clinical Abstract 11. Gastroenterology. 2018;154(1)Suppl:S1-S114.
Medicaid expansion meant earlier presentation, better surgical outcomes
The for five common surgical conditions, according to a Jan. 24 report in JAMA Surgery.
“Given current debate on the ACA [Affordable Care Act] and reforms to the Medicaid program, evidence on the effects of these policies is critical ... As policy makers weigh changes to or a potential repeal of the ACA, these findings provide important new data on the early clinical effects of the law’s coverage expansion,” said investigators led by Andrew Loehrer, MD, of the department of surgical oncology at MD Anderson Cancer Center, Houston.
For a baseline, the team used hospital administrative data from the Vizient Clinical Data Base and Resource Manager to assess outcomes for appendicitis, cholecystitis, diverticulitis, peripheral artery disease, and aortic aneurysm in 42 states during 2010-2013, before the ACA took effect in 2014. They then compared outcomes during 2014-2015 in the 27 states that expanded Medicaid programs under the ACA with 15 states that did not. The study included 225,572 hospital admissions in the Medicaid expansion states and 67,957 in the nonexpansion states at more than 200 academic medical centers and affiliated hospitals.
Medicaid expansion in the 27 states was associated with a 7.5-percentage point decreased probability of patients being uninsured (95% confidence interval, –12.2 to –2.9; P = .002) and an 8.6-percentage point increased probability of having Medicaid (95% CI, 6.1-11.1; P less than .001).
Medicaid expansion was also associated with a 1.8-percentage point increase in the probability of early, uncomplicated presentation (95% CI, 0.7-2.9; P = .001) and a 2.6-percentage point increase in the probability of receiving optimal management after admission, most likely due to the earlier presentation (95% CI, 0.8-4.4; P = .006).
The improvements were concentrated among Medicaid and uninsured patients, who were most likely to benefit from coverage expansion, rather than those with private insurance.
The investigators acknowledged the limitations of their data for tracking changes access and quality of care for surgical patients. “We recognize that the data on improved quality of care are not as clear. Our use of composite outcomes has specific limitations,” they wrote.
“As expected for the conditions studied, our analysis found no significant change in the overall number of individuals treated but rather a change in the timeliness in which individuals received care.” Meanwhile, “our sample revealed an increase in the percentage of surgical patients who were uninsured in nonexpansion states after 2014,” which was associated with “worsening of outcomes ... whereas expansion states had stabilization or improvement,” they said. In Medicaid expansion states, the number of uninsured dropped from 14.% to 6.8%, but in the nonexpansion states, the number of uninsured actually increased slightly from 21.2% to 21.9%.
There was no funding source reported for the study. The authors had no conflicts of interest.
SOURCE: Loehrer AP et. al. JAMA Surg. 2018 Jan 24. doi: 10.1001/jamasurg.2017.5568
The for five common surgical conditions, according to a Jan. 24 report in JAMA Surgery.
“Given current debate on the ACA [Affordable Care Act] and reforms to the Medicaid program, evidence on the effects of these policies is critical ... As policy makers weigh changes to or a potential repeal of the ACA, these findings provide important new data on the early clinical effects of the law’s coverage expansion,” said investigators led by Andrew Loehrer, MD, of the department of surgical oncology at MD Anderson Cancer Center, Houston.
For a baseline, the team used hospital administrative data from the Vizient Clinical Data Base and Resource Manager to assess outcomes for appendicitis, cholecystitis, diverticulitis, peripheral artery disease, and aortic aneurysm in 42 states during 2010-2013, before the ACA took effect in 2014. They then compared outcomes during 2014-2015 in the 27 states that expanded Medicaid programs under the ACA with 15 states that did not. The study included 225,572 hospital admissions in the Medicaid expansion states and 67,957 in the nonexpansion states at more than 200 academic medical centers and affiliated hospitals.
Medicaid expansion in the 27 states was associated with a 7.5-percentage point decreased probability of patients being uninsured (95% confidence interval, –12.2 to –2.9; P = .002) and an 8.6-percentage point increased probability of having Medicaid (95% CI, 6.1-11.1; P less than .001).
Medicaid expansion was also associated with a 1.8-percentage point increase in the probability of early, uncomplicated presentation (95% CI, 0.7-2.9; P = .001) and a 2.6-percentage point increase in the probability of receiving optimal management after admission, most likely due to the earlier presentation (95% CI, 0.8-4.4; P = .006).
The improvements were concentrated among Medicaid and uninsured patients, who were most likely to benefit from coverage expansion, rather than those with private insurance.
The investigators acknowledged the limitations of their data for tracking changes access and quality of care for surgical patients. “We recognize that the data on improved quality of care are not as clear. Our use of composite outcomes has specific limitations,” they wrote.
“As expected for the conditions studied, our analysis found no significant change in the overall number of individuals treated but rather a change in the timeliness in which individuals received care.” Meanwhile, “our sample revealed an increase in the percentage of surgical patients who were uninsured in nonexpansion states after 2014,” which was associated with “worsening of outcomes ... whereas expansion states had stabilization or improvement,” they said. In Medicaid expansion states, the number of uninsured dropped from 14.% to 6.8%, but in the nonexpansion states, the number of uninsured actually increased slightly from 21.2% to 21.9%.
There was no funding source reported for the study. The authors had no conflicts of interest.
SOURCE: Loehrer AP et. al. JAMA Surg. 2018 Jan 24. doi: 10.1001/jamasurg.2017.5568
The for five common surgical conditions, according to a Jan. 24 report in JAMA Surgery.
“Given current debate on the ACA [Affordable Care Act] and reforms to the Medicaid program, evidence on the effects of these policies is critical ... As policy makers weigh changes to or a potential repeal of the ACA, these findings provide important new data on the early clinical effects of the law’s coverage expansion,” said investigators led by Andrew Loehrer, MD, of the department of surgical oncology at MD Anderson Cancer Center, Houston.
For a baseline, the team used hospital administrative data from the Vizient Clinical Data Base and Resource Manager to assess outcomes for appendicitis, cholecystitis, diverticulitis, peripheral artery disease, and aortic aneurysm in 42 states during 2010-2013, before the ACA took effect in 2014. They then compared outcomes during 2014-2015 in the 27 states that expanded Medicaid programs under the ACA with 15 states that did not. The study included 225,572 hospital admissions in the Medicaid expansion states and 67,957 in the nonexpansion states at more than 200 academic medical centers and affiliated hospitals.
Medicaid expansion in the 27 states was associated with a 7.5-percentage point decreased probability of patients being uninsured (95% confidence interval, –12.2 to –2.9; P = .002) and an 8.6-percentage point increased probability of having Medicaid (95% CI, 6.1-11.1; P less than .001).
Medicaid expansion was also associated with a 1.8-percentage point increase in the probability of early, uncomplicated presentation (95% CI, 0.7-2.9; P = .001) and a 2.6-percentage point increase in the probability of receiving optimal management after admission, most likely due to the earlier presentation (95% CI, 0.8-4.4; P = .006).
The improvements were concentrated among Medicaid and uninsured patients, who were most likely to benefit from coverage expansion, rather than those with private insurance.
The investigators acknowledged the limitations of their data for tracking changes access and quality of care for surgical patients. “We recognize that the data on improved quality of care are not as clear. Our use of composite outcomes has specific limitations,” they wrote.
“As expected for the conditions studied, our analysis found no significant change in the overall number of individuals treated but rather a change in the timeliness in which individuals received care.” Meanwhile, “our sample revealed an increase in the percentage of surgical patients who were uninsured in nonexpansion states after 2014,” which was associated with “worsening of outcomes ... whereas expansion states had stabilization or improvement,” they said. In Medicaid expansion states, the number of uninsured dropped from 14.% to 6.8%, but in the nonexpansion states, the number of uninsured actually increased slightly from 21.2% to 21.9%.
There was no funding source reported for the study. The authors had no conflicts of interest.
SOURCE: Loehrer AP et. al. JAMA Surg. 2018 Jan 24. doi: 10.1001/jamasurg.2017.5568
FROM JAMA SURGERY
Key clinical point: The Patient Protection and Affordable Care Act’s Medicaid expansion led to increased coverage of patients, earlier presentation, and improved care for five common surgical conditions.
Major finding: Medicaid expansion was associated with a 2.6 percentage-point increase in the probability of receiving optimal management after admission, most likely due to the earlier presentation.
Study details: Review of more than 200,000 patients, pre- and post-ACA
Disclosures: The authors had no disclosures.
Source: Loehrer AP et. al. JAMA Surg. 2018 Jan 24. doi: 10.1001/jamasurg.2017.5568
Sleeve gastrectomy studied as an option for obese HIV-infected patients
according to the results of a small prospective trial conducted from 2009 to 2015 at a single institution in France.
Ten patients were followed before and after sleeve gastrectomy. Eight were women and half were of African origin. The median patient age was 48.5 years, and the median time since HIV infection was 7.5 years. Patients had a median body mass index of 48.5 kg/m2 at the time of their procedure, according to Guillaume Pourcher, MD, PhD, of Paris-Sud University and his colleagues.
The median postoperative weight loss was 43 kg, while the median percentage of excess weight loss was 82.5% at the latest follow-up. In addition, all comorbidities were resolved with weight loss. With regard to HIV status, there was no significant modification of the CD4 cell count in the patients before and after surgery. Importantly, the pharmacokinetics of the patients’ antiretroviral drugs remained “adequate and efficacious,” according to Dr. Pourcher and his colleagues.
“For HIV-infected patients,we need to choose a safe procedure, with no disruption of intestinal continuity, without implanted foreign material, resulting in less malabsorption, and with long-term weight loss efficacy,” the authors stated.
Taking this into account, optimal management of HIV-infected patients with morbid obesity may include classical surgical procedures such as sleeve gastrectomy as with non-HIV obese patients, as long as close drug monitoring and immunovirologic follow-up are maintained, they suggested.
Sleeve gastrectomy “appears to be a good therapeutic option in morbidly obese HIV-infected patients, because it avoids malabsorption and possible modification of antiretroviral drug absorption,” the researchers concluded.
The authors reported that they had no commercial conflicts of interest relative to their study.
SOURCE: Pourcher G et al. Surgery for Obesity and Related Diseases. 2017;13:1990-6.
according to the results of a small prospective trial conducted from 2009 to 2015 at a single institution in France.
Ten patients were followed before and after sleeve gastrectomy. Eight were women and half were of African origin. The median patient age was 48.5 years, and the median time since HIV infection was 7.5 years. Patients had a median body mass index of 48.5 kg/m2 at the time of their procedure, according to Guillaume Pourcher, MD, PhD, of Paris-Sud University and his colleagues.
The median postoperative weight loss was 43 kg, while the median percentage of excess weight loss was 82.5% at the latest follow-up. In addition, all comorbidities were resolved with weight loss. With regard to HIV status, there was no significant modification of the CD4 cell count in the patients before and after surgery. Importantly, the pharmacokinetics of the patients’ antiretroviral drugs remained “adequate and efficacious,” according to Dr. Pourcher and his colleagues.
“For HIV-infected patients,we need to choose a safe procedure, with no disruption of intestinal continuity, without implanted foreign material, resulting in less malabsorption, and with long-term weight loss efficacy,” the authors stated.
Taking this into account, optimal management of HIV-infected patients with morbid obesity may include classical surgical procedures such as sleeve gastrectomy as with non-HIV obese patients, as long as close drug monitoring and immunovirologic follow-up are maintained, they suggested.
Sleeve gastrectomy “appears to be a good therapeutic option in morbidly obese HIV-infected patients, because it avoids malabsorption and possible modification of antiretroviral drug absorption,” the researchers concluded.
The authors reported that they had no commercial conflicts of interest relative to their study.
SOURCE: Pourcher G et al. Surgery for Obesity and Related Diseases. 2017;13:1990-6.
according to the results of a small prospective trial conducted from 2009 to 2015 at a single institution in France.
Ten patients were followed before and after sleeve gastrectomy. Eight were women and half were of African origin. The median patient age was 48.5 years, and the median time since HIV infection was 7.5 years. Patients had a median body mass index of 48.5 kg/m2 at the time of their procedure, according to Guillaume Pourcher, MD, PhD, of Paris-Sud University and his colleagues.
The median postoperative weight loss was 43 kg, while the median percentage of excess weight loss was 82.5% at the latest follow-up. In addition, all comorbidities were resolved with weight loss. With regard to HIV status, there was no significant modification of the CD4 cell count in the patients before and after surgery. Importantly, the pharmacokinetics of the patients’ antiretroviral drugs remained “adequate and efficacious,” according to Dr. Pourcher and his colleagues.
“For HIV-infected patients,we need to choose a safe procedure, with no disruption of intestinal continuity, without implanted foreign material, resulting in less malabsorption, and with long-term weight loss efficacy,” the authors stated.
Taking this into account, optimal management of HIV-infected patients with morbid obesity may include classical surgical procedures such as sleeve gastrectomy as with non-HIV obese patients, as long as close drug monitoring and immunovirologic follow-up are maintained, they suggested.
Sleeve gastrectomy “appears to be a good therapeutic option in morbidly obese HIV-infected patients, because it avoids malabsorption and possible modification of antiretroviral drug absorption,” the researchers concluded.
The authors reported that they had no commercial conflicts of interest relative to their study.
SOURCE: Pourcher G et al. Surgery for Obesity and Related Diseases. 2017;13:1990-6.
FROM SURGERY FOR OBESITY AND RELATED DISEASES
Key clinical point: HIV-infected patients lost weight after sleeve gastrectomy and maintained their viral status.
Major finding: Median postoperative weight loss was 43 kg and median percentage of excess weight loss was 82.5%.
Study details: Ten HIV-infected patients were prospectively followed before and after sleeve gastrectomy.
Disclosures: The authors reported that they had no commercial conflicts of interest relative to their study.
Source: Pourcher G et al. Surg Obes Relat Dis. 2017;13:1990-6.
Elderly trauma patients at high risk for post-discharge mortality
LAKE BUENA VISTA, FLA. – Nearly one-quarter of discharge, according to a study presented at the Eastern Association for the Surgery of Trauma Scientific Assembly.
These findings emphasize a need to know more about geriatric patient outcomes, especially as a tide of elderly trauma patients has begun to sweep through trauma centers, according to presenter Ciara Huntington, MD, a surgical resident at the Carolinas Healthcare System, Charlotte, N.C.
Investigators studied 6,285 geriatric patients in the ACS-verified Level 1 trauma registry between 2009 and 2015, and cross-referenced those files with the Social Security Death Index.
Patients were an average of 78.6 years, and the majority were female (57%) and white (85.7%). Average length of stay of was 6.7 days with an average injury severity score of 11, with a median time to death of 225 days.
While 5,780 patients were alive at discharge, 1,519 (24.2%) were dead within 1 year of hospitalization.
In a comparison of geriatric trauma patients against those of similar age in the general population, geriatric patients within the trauma population had a significantly lower life expectancy across all ages.
For trauma patients aged 65-70 years, life expectancy was estimated at 1.52 years, compared with 18.79 years for those in the general population.
Discharge location may have an impact on mortality, according to Dr. Huntington and her colleagues, who found geriatric patients discharged to their homes had a 1-year mortality rate of 13.5%, compared with 22.6% of those discharged to acute inpatient rehab centers, and 53.7% of those sent to skilled nursing facilities.
Another factor may be mechanism of injury, as the 1-year mortality of trauma patients who had fallen (27%) was nearly double the rate of those in motor vehicle crashes (15%).
Falls also were the most common injury, accounting for around 75% of the hospitalizations in the study.
In a question-and-answer session after the presentation, audience members asked about how these findings will help improve palliative care for geriatric trauma patients.
“The goal of this research is to have better predictive models and also to have better conversations” with families about the potential outcomes of trauma in these elderly patients, Dr. Huntington responded. Knowing the risk of 1-year mortality can change “how families can plan to spend time with their loved ones and how to make more appropriate medical decisions by incorporating quantitative data into the conversation.”
Dr. Huntington and her colleagues reported no relevant financial disclosures.
SOURCE: EAST 2018, Abstract #47.
LAKE BUENA VISTA, FLA. – Nearly one-quarter of discharge, according to a study presented at the Eastern Association for the Surgery of Trauma Scientific Assembly.
These findings emphasize a need to know more about geriatric patient outcomes, especially as a tide of elderly trauma patients has begun to sweep through trauma centers, according to presenter Ciara Huntington, MD, a surgical resident at the Carolinas Healthcare System, Charlotte, N.C.
Investigators studied 6,285 geriatric patients in the ACS-verified Level 1 trauma registry between 2009 and 2015, and cross-referenced those files with the Social Security Death Index.
Patients were an average of 78.6 years, and the majority were female (57%) and white (85.7%). Average length of stay of was 6.7 days with an average injury severity score of 11, with a median time to death of 225 days.
While 5,780 patients were alive at discharge, 1,519 (24.2%) were dead within 1 year of hospitalization.
In a comparison of geriatric trauma patients against those of similar age in the general population, geriatric patients within the trauma population had a significantly lower life expectancy across all ages.
For trauma patients aged 65-70 years, life expectancy was estimated at 1.52 years, compared with 18.79 years for those in the general population.
Discharge location may have an impact on mortality, according to Dr. Huntington and her colleagues, who found geriatric patients discharged to their homes had a 1-year mortality rate of 13.5%, compared with 22.6% of those discharged to acute inpatient rehab centers, and 53.7% of those sent to skilled nursing facilities.
Another factor may be mechanism of injury, as the 1-year mortality of trauma patients who had fallen (27%) was nearly double the rate of those in motor vehicle crashes (15%).
Falls also were the most common injury, accounting for around 75% of the hospitalizations in the study.
In a question-and-answer session after the presentation, audience members asked about how these findings will help improve palliative care for geriatric trauma patients.
“The goal of this research is to have better predictive models and also to have better conversations” with families about the potential outcomes of trauma in these elderly patients, Dr. Huntington responded. Knowing the risk of 1-year mortality can change “how families can plan to spend time with their loved ones and how to make more appropriate medical decisions by incorporating quantitative data into the conversation.”
Dr. Huntington and her colleagues reported no relevant financial disclosures.
SOURCE: EAST 2018, Abstract #47.
LAKE BUENA VISTA, FLA. – Nearly one-quarter of discharge, according to a study presented at the Eastern Association for the Surgery of Trauma Scientific Assembly.
These findings emphasize a need to know more about geriatric patient outcomes, especially as a tide of elderly trauma patients has begun to sweep through trauma centers, according to presenter Ciara Huntington, MD, a surgical resident at the Carolinas Healthcare System, Charlotte, N.C.
Investigators studied 6,285 geriatric patients in the ACS-verified Level 1 trauma registry between 2009 and 2015, and cross-referenced those files with the Social Security Death Index.
Patients were an average of 78.6 years, and the majority were female (57%) and white (85.7%). Average length of stay of was 6.7 days with an average injury severity score of 11, with a median time to death of 225 days.
While 5,780 patients were alive at discharge, 1,519 (24.2%) were dead within 1 year of hospitalization.
In a comparison of geriatric trauma patients against those of similar age in the general population, geriatric patients within the trauma population had a significantly lower life expectancy across all ages.
For trauma patients aged 65-70 years, life expectancy was estimated at 1.52 years, compared with 18.79 years for those in the general population.
Discharge location may have an impact on mortality, according to Dr. Huntington and her colleagues, who found geriatric patients discharged to their homes had a 1-year mortality rate of 13.5%, compared with 22.6% of those discharged to acute inpatient rehab centers, and 53.7% of those sent to skilled nursing facilities.
Another factor may be mechanism of injury, as the 1-year mortality of trauma patients who had fallen (27%) was nearly double the rate of those in motor vehicle crashes (15%).
Falls also were the most common injury, accounting for around 75% of the hospitalizations in the study.
In a question-and-answer session after the presentation, audience members asked about how these findings will help improve palliative care for geriatric trauma patients.
“The goal of this research is to have better predictive models and also to have better conversations” with families about the potential outcomes of trauma in these elderly patients, Dr. Huntington responded. Knowing the risk of 1-year mortality can change “how families can plan to spend time with their loved ones and how to make more appropriate medical decisions by incorporating quantitative data into the conversation.”
Dr. Huntington and her colleagues reported no relevant financial disclosures.
SOURCE: EAST 2018, Abstract #47.
REPORTING FROM EAST 2018
Key clinical point: Short-term mortality rates do not show a full picture of the burden of trauma on elderly patients.
Major finding: While 92% of patients survived to discharge, 24.1% of patients died within 1 year after injury, and 41.9% died within 8 years of injury.
Data source: Study of 6,285 geriatric trauma patients collected from an ACS-verified Level 1 trauma center registry database during 2009-2015.
Disclosures: Presenters reported no relevant financial disclosures.
Source: EAST Scientific Assembly abstract #47.
Emergent colectomies for ulcerative colitis declining
LAS VEGAS – , a large database analysis has shown.
“Despite advances in medical therapy for ulcerative colitis (UC), many patients still need surgery,” Ryan C. Ungaro, MD, said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “Prior epidemiologic studies have demonstrated a decline in colectomy rates over time, particularly comparing the pre- and postbiologic eras, but less is known about rates of emergent colectomy over time,” he said. In particular, he continued, data on UC colectomy and ileal pouch anal anastomosis (IPAA) surgery rates in the United States are limited.
In an effort to examine UC emergent colectomy rates and IPAA over time, Dr. Ungaro, of the division of gastroenterology at the Icahn School of Medicine at Mount Sinai, New York, and his associates analyzed data from the U.S. Nationwide Inpatient Sample from 2000 through 2014. They defined emergent colectomy cases as admission through the emergency department and used the ICD-9-CM code for subtotal colectomy (45.8) as the outcome variable, and defined a second cohort of UC patients admitted electively with an outcome variable of ICD-9-CM code for IPAA (45.95). To evaluate temporal trends of colectomy and IPAA, the researchers used joinpoint regression analysis with calculation of annual percentage change.
They also observed disparities in IPAA surgery rates based on race and insurance type. Specifically, whites had higher rates of elective IPAA during the study period, compared with black or Hispanic patients (P less than .01), while patients with private insurance had higher rates of elective IPAA, compared with those insured by Medicare or Medicaid (P less than .01). Dr. Ungaro acknowledged certain limitations of the study, including the fact that the Nationwide Inpatient Sample relies on administrative codes, “which may increase risk of misclassification bias,” he said. They were also unable to track individual patients across time and lacked data on medication use and disease severity.
“There has been a significant decline in emergency colectomy for ulcerative colitis in the United States,” Dr. Ungaro concluded. “We expect that this is due to more effective inpatient care. However, the overall need for surgery in UC appears to be stable given unchanged IPAA rates. This suggests a limited impact on overall surgery rates with a shift from emergent to elective procedures.” He reported having no relevant financial disclosures.
*This story was updated on 3/26.
SOURCE: Ungaro RC et al. Crohn’s & Colitis Congress, Clinical Abstract 23.
LAS VEGAS – , a large database analysis has shown.
“Despite advances in medical therapy for ulcerative colitis (UC), many patients still need surgery,” Ryan C. Ungaro, MD, said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “Prior epidemiologic studies have demonstrated a decline in colectomy rates over time, particularly comparing the pre- and postbiologic eras, but less is known about rates of emergent colectomy over time,” he said. In particular, he continued, data on UC colectomy and ileal pouch anal anastomosis (IPAA) surgery rates in the United States are limited.
In an effort to examine UC emergent colectomy rates and IPAA over time, Dr. Ungaro, of the division of gastroenterology at the Icahn School of Medicine at Mount Sinai, New York, and his associates analyzed data from the U.S. Nationwide Inpatient Sample from 2000 through 2014. They defined emergent colectomy cases as admission through the emergency department and used the ICD-9-CM code for subtotal colectomy (45.8) as the outcome variable, and defined a second cohort of UC patients admitted electively with an outcome variable of ICD-9-CM code for IPAA (45.95). To evaluate temporal trends of colectomy and IPAA, the researchers used joinpoint regression analysis with calculation of annual percentage change.
They also observed disparities in IPAA surgery rates based on race and insurance type. Specifically, whites had higher rates of elective IPAA during the study period, compared with black or Hispanic patients (P less than .01), while patients with private insurance had higher rates of elective IPAA, compared with those insured by Medicare or Medicaid (P less than .01). Dr. Ungaro acknowledged certain limitations of the study, including the fact that the Nationwide Inpatient Sample relies on administrative codes, “which may increase risk of misclassification bias,” he said. They were also unable to track individual patients across time and lacked data on medication use and disease severity.
“There has been a significant decline in emergency colectomy for ulcerative colitis in the United States,” Dr. Ungaro concluded. “We expect that this is due to more effective inpatient care. However, the overall need for surgery in UC appears to be stable given unchanged IPAA rates. This suggests a limited impact on overall surgery rates with a shift from emergent to elective procedures.” He reported having no relevant financial disclosures.
*This story was updated on 3/26.
SOURCE: Ungaro RC et al. Crohn’s & Colitis Congress, Clinical Abstract 23.
LAS VEGAS – , a large database analysis has shown.
“Despite advances in medical therapy for ulcerative colitis (UC), many patients still need surgery,” Ryan C. Ungaro, MD, said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “Prior epidemiologic studies have demonstrated a decline in colectomy rates over time, particularly comparing the pre- and postbiologic eras, but less is known about rates of emergent colectomy over time,” he said. In particular, he continued, data on UC colectomy and ileal pouch anal anastomosis (IPAA) surgery rates in the United States are limited.
In an effort to examine UC emergent colectomy rates and IPAA over time, Dr. Ungaro, of the division of gastroenterology at the Icahn School of Medicine at Mount Sinai, New York, and his associates analyzed data from the U.S. Nationwide Inpatient Sample from 2000 through 2014. They defined emergent colectomy cases as admission through the emergency department and used the ICD-9-CM code for subtotal colectomy (45.8) as the outcome variable, and defined a second cohort of UC patients admitted electively with an outcome variable of ICD-9-CM code for IPAA (45.95). To evaluate temporal trends of colectomy and IPAA, the researchers used joinpoint regression analysis with calculation of annual percentage change.
They also observed disparities in IPAA surgery rates based on race and insurance type. Specifically, whites had higher rates of elective IPAA during the study period, compared with black or Hispanic patients (P less than .01), while patients with private insurance had higher rates of elective IPAA, compared with those insured by Medicare or Medicaid (P less than .01). Dr. Ungaro acknowledged certain limitations of the study, including the fact that the Nationwide Inpatient Sample relies on administrative codes, “which may increase risk of misclassification bias,” he said. They were also unable to track individual patients across time and lacked data on medication use and disease severity.
“There has been a significant decline in emergency colectomy for ulcerative colitis in the United States,” Dr. Ungaro concluded. “We expect that this is due to more effective inpatient care. However, the overall need for surgery in UC appears to be stable given unchanged IPAA rates. This suggests a limited impact on overall surgery rates with a shift from emergent to elective procedures.” He reported having no relevant financial disclosures.
*This story was updated on 3/26.
SOURCE: Ungaro RC et al. Crohn’s & Colitis Congress, Clinical Abstract 23.
REPORTING FROM THE CROHN’S & COLITIS CONGRESS
Key clinical point: There has been a significant decline in emergent ulcerative colitis colectomies in the United States.
Major finding: Between 2000 and 2014, the colectomy rate among patients emergently admitted to the hospital declined more than 7% annually (P less than .05).
Study details: An analysis of 470,720 hospital admissions from the Nationwide Inpatient Sample.
Disclosures: Dr. Ungaro reported having no financial disclosures.
Source: Ungaro RC et al. Crohn’s & Colitis Congress, Clinical Abstract 23.
VIDEO: New stroke guideline embraces imaging-guided thrombectomy
LOS ANGELES – When a panel organized by the American Heart Association’s Stroke Council recently revised the group’s guideline for early management of acute ischemic stroke, they were clear on the overarching change they had to make: Incorporate recent evidence collected in two trials that established brain imaging as the way to identify patients eligible for clot removal treatment by thrombectomy, a change in practice that has made this outcome-altering intervention available to more patients.
“The major take-home message [of the new guideline] is the extension of the time window for treating acute ischemic stroke,” said William J. Powers, MD, chair of the guideline group (Stroke. 2018 Jan 24. doi: 10.1161/STR.0000000000000158).
Based on recently reported results from the DAWN (N Engl J Med. 2018;378[1]:11-21) and DEFUSE 3 (N Engl J Med. 2018 Jan 24. doi: 10.1056/NEJMoa1713973) trials “we know that there are patients out to 24 hours from their stroke onset who may benefit” from thrombectomy. “This is a major, major change in how we view care for patients with stroke,” Dr. Powers said in a video interview. “Now there’s much more time. Ideally, we’ll see smaller hospitals develop the ability to do the imaging” that makes it possible to select acute ischemic stroke patients eligible for thrombectomy despite a delay of up to 24 hours from their stroke onset to the time of thrombectomy, said Dr. Powers, professor and chair of neurology at the University of North Carolina, Chapel Hill.
The big priority for the stroke community now that this major change in patient selection was incorporated into a U.S. practice guideline will be acting quickly to implement the steps needed to make this change happen, Dr. Powers and others said.
The new guideline will mean “changes in process and systems of care,” agreed Jeffrey L. Saver, MD, professor of neurology and director of the stroke unit at the University of California, Los Angeles. The imaging called for “will be practical at some primary stroke centers but not others,” he said, although most hospitals certified to provide stroke care as primary stroke centers or acute stroke–ready hospitals have a CT scanner that could provide the basic imaging needed to assess many patients. (CT angiography and perfusion CT are more informative for determining thrombectomy eligibility.) But interpretation of the brain images to distinguish patients eligible for thrombectomy from those who aren’t will likely happen at comprehensive stroke centers that perform thrombectomy or by experts using remote image reading.
Dr. Saver expects that the new guideline will translate most quickly into changes in the imaging and transfer protocols that the Joint Commission may now require from hospitals certified as primary stroke centers or acute stroke-ready hospitals, changes that could be in place sometime later in 2018, he predicted. These are steps “that would really help drive system change.”
Dr. Powers and Dr. Furie had no disclosures. Dr. Saver has received research support and personal fees from Medtronic-Abbott and Neuravia.
LOS ANGELES – When a panel organized by the American Heart Association’s Stroke Council recently revised the group’s guideline for early management of acute ischemic stroke, they were clear on the overarching change they had to make: Incorporate recent evidence collected in two trials that established brain imaging as the way to identify patients eligible for clot removal treatment by thrombectomy, a change in practice that has made this outcome-altering intervention available to more patients.
“The major take-home message [of the new guideline] is the extension of the time window for treating acute ischemic stroke,” said William J. Powers, MD, chair of the guideline group (Stroke. 2018 Jan 24. doi: 10.1161/STR.0000000000000158).
Based on recently reported results from the DAWN (N Engl J Med. 2018;378[1]:11-21) and DEFUSE 3 (N Engl J Med. 2018 Jan 24. doi: 10.1056/NEJMoa1713973) trials “we know that there are patients out to 24 hours from their stroke onset who may benefit” from thrombectomy. “This is a major, major change in how we view care for patients with stroke,” Dr. Powers said in a video interview. “Now there’s much more time. Ideally, we’ll see smaller hospitals develop the ability to do the imaging” that makes it possible to select acute ischemic stroke patients eligible for thrombectomy despite a delay of up to 24 hours from their stroke onset to the time of thrombectomy, said Dr. Powers, professor and chair of neurology at the University of North Carolina, Chapel Hill.
The big priority for the stroke community now that this major change in patient selection was incorporated into a U.S. practice guideline will be acting quickly to implement the steps needed to make this change happen, Dr. Powers and others said.
The new guideline will mean “changes in process and systems of care,” agreed Jeffrey L. Saver, MD, professor of neurology and director of the stroke unit at the University of California, Los Angeles. The imaging called for “will be practical at some primary stroke centers but not others,” he said, although most hospitals certified to provide stroke care as primary stroke centers or acute stroke–ready hospitals have a CT scanner that could provide the basic imaging needed to assess many patients. (CT angiography and perfusion CT are more informative for determining thrombectomy eligibility.) But interpretation of the brain images to distinguish patients eligible for thrombectomy from those who aren’t will likely happen at comprehensive stroke centers that perform thrombectomy or by experts using remote image reading.
Dr. Saver expects that the new guideline will translate most quickly into changes in the imaging and transfer protocols that the Joint Commission may now require from hospitals certified as primary stroke centers or acute stroke-ready hospitals, changes that could be in place sometime later in 2018, he predicted. These are steps “that would really help drive system change.”
Dr. Powers and Dr. Furie had no disclosures. Dr. Saver has received research support and personal fees from Medtronic-Abbott and Neuravia.
LOS ANGELES – When a panel organized by the American Heart Association’s Stroke Council recently revised the group’s guideline for early management of acute ischemic stroke, they were clear on the overarching change they had to make: Incorporate recent evidence collected in two trials that established brain imaging as the way to identify patients eligible for clot removal treatment by thrombectomy, a change in practice that has made this outcome-altering intervention available to more patients.
“The major take-home message [of the new guideline] is the extension of the time window for treating acute ischemic stroke,” said William J. Powers, MD, chair of the guideline group (Stroke. 2018 Jan 24. doi: 10.1161/STR.0000000000000158).
Based on recently reported results from the DAWN (N Engl J Med. 2018;378[1]:11-21) and DEFUSE 3 (N Engl J Med. 2018 Jan 24. doi: 10.1056/NEJMoa1713973) trials “we know that there are patients out to 24 hours from their stroke onset who may benefit” from thrombectomy. “This is a major, major change in how we view care for patients with stroke,” Dr. Powers said in a video interview. “Now there’s much more time. Ideally, we’ll see smaller hospitals develop the ability to do the imaging” that makes it possible to select acute ischemic stroke patients eligible for thrombectomy despite a delay of up to 24 hours from their stroke onset to the time of thrombectomy, said Dr. Powers, professor and chair of neurology at the University of North Carolina, Chapel Hill.
The big priority for the stroke community now that this major change in patient selection was incorporated into a U.S. practice guideline will be acting quickly to implement the steps needed to make this change happen, Dr. Powers and others said.
The new guideline will mean “changes in process and systems of care,” agreed Jeffrey L. Saver, MD, professor of neurology and director of the stroke unit at the University of California, Los Angeles. The imaging called for “will be practical at some primary stroke centers but not others,” he said, although most hospitals certified to provide stroke care as primary stroke centers or acute stroke–ready hospitals have a CT scanner that could provide the basic imaging needed to assess many patients. (CT angiography and perfusion CT are more informative for determining thrombectomy eligibility.) But interpretation of the brain images to distinguish patients eligible for thrombectomy from those who aren’t will likely happen at comprehensive stroke centers that perform thrombectomy or by experts using remote image reading.
Dr. Saver expects that the new guideline will translate most quickly into changes in the imaging and transfer protocols that the Joint Commission may now require from hospitals certified as primary stroke centers or acute stroke-ready hospitals, changes that could be in place sometime later in 2018, he predicted. These are steps “that would really help drive system change.”
Dr. Powers and Dr. Furie had no disclosures. Dr. Saver has received research support and personal fees from Medtronic-Abbott and Neuravia.
EXPERT ANALYSIS FROM ISC 2018
DEFUSE 3: Thrombectomy time window broadens
LOS ANGELES – The final results of the DEFUSE 3 trial are in, and the results are unequivocal: Thrombectomy performed 6-16 hours after the stroke patient was last known to be well was associated with dramatically improved outcomes in 90-day death and disability.
It has long been said that time is brain. Time is still vital, but some strokes progress at a slower rate. “We have the opportunity to treat these patients in a time window that we never thought was possible,” Gregory W. Albers, MD, said in presenting the findings at the International Stroke Conference sponsored by the American Heart Association.
The subjects included those with proximal middle-cerebral artery or internal-carotid artery occlusion and infarcts of 70 mL or less in size, and a ratio of the volume of ischemic tissue on perfusion imaging to infarct tissue of 1.8 or higher. Both DAWN and DEFUSE 3 used the RAPID software from iSchemaView to assess infarct volume.
The DEFUSE 3 results aren’t a surprise, as the trial was stopped early after an interim analysis showed efficacy. But they are immediately practice changing. “This will perhaps be a once in a lifetime situation where a study gets published and within 2 hours gets incorporated into new guidelines,” said Dr. Albers, lead author of the study, who is the Coyote Foundation Professor, neurology and neurological sciences, and professor, by courtesy, of neurosurgery at the Stanford (Calif.) University Medical Center. Minutes later at the press conference, it was announced that the results of both DEFUSE 3 and DAWN had indeed been included in the guidelines.
The DEFUSE (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) 3 trial included 182 patients from 38 U.S. centers who were recruited during May 2016–May 2017. Of these, 92 were randomized to thrombectomy and standard medical therapy, and 90 to standard medical therapy only.
Patients who underwent thrombectomy were more likely to have a favorable distribution of disability scores on the modified Rankin scale at 90 days (unadjusted odds ratio, 2.77; adjusted OR, 3.36; both P less than .001). “The odds ratio [of 2.77] was the largest ever reported for a thrombectomy study,” Dr. Albers said, and the ISC audience erupted into spontaneous applause. “We couldn’t be happier,” he responded.
Nearly half (45%) of patients in the thrombectomy group scored as functionally independent at 90 days (Rankin score 0-2), compared with 17% in the medical-therapy group (risk ratio, 2.67; P less than .001). Mortality was also lower in the intervention group (14% vs. 26%; P = .05).
The rates of symptomatic intracranial hemorrhage (7% thrombectomy, 4% medical therapy only) did not differ significantly between the two groups. Serious complications occurred in 43% of patients in the thrombectomy group, compared with 53% in the medical therapy–only group (P = .018).
A subanalysis showed consistent benefit of thrombectomy, even in patients with a longer elapsed time between stroke onset and randomization, while the patients who received medical therapy had worse outcomes as more time passed. In 50 patients in the under 9-hour group, 40% of those who received thrombectomy were functionally independent at 9 weeks, compared with 28% in the medical therapy–only group. Among 72 patients in the 9- to 12-hour group, 50% were functionally independent (vs. 17%), and in the greater than 12-hour group, 42% (7%).
The study filled up rapidly, at about twice the rate that the researchers anticipated, and that suggests that the procedure could find broad use. “It shows that these patients are not difficult to find,” said Dr. Albers.
The National Institutes of Health funded the study. Dr. Albers has a financial stake in iSchemaView and is on the scientific advisory board for iSchemaView and Medtronic.
The DEFUSE 3 results were published online concurrently with Dr. Albers’s presentation (N Engl J Med. 2018 Jan 24; doi: 10.1056/nejmoa1713973).
SOURCE: Albers G et al. ISC 2018
LOS ANGELES – The final results of the DEFUSE 3 trial are in, and the results are unequivocal: Thrombectomy performed 6-16 hours after the stroke patient was last known to be well was associated with dramatically improved outcomes in 90-day death and disability.
It has long been said that time is brain. Time is still vital, but some strokes progress at a slower rate. “We have the opportunity to treat these patients in a time window that we never thought was possible,” Gregory W. Albers, MD, said in presenting the findings at the International Stroke Conference sponsored by the American Heart Association.
The subjects included those with proximal middle-cerebral artery or internal-carotid artery occlusion and infarcts of 70 mL or less in size, and a ratio of the volume of ischemic tissue on perfusion imaging to infarct tissue of 1.8 or higher. Both DAWN and DEFUSE 3 used the RAPID software from iSchemaView to assess infarct volume.
The DEFUSE 3 results aren’t a surprise, as the trial was stopped early after an interim analysis showed efficacy. But they are immediately practice changing. “This will perhaps be a once in a lifetime situation where a study gets published and within 2 hours gets incorporated into new guidelines,” said Dr. Albers, lead author of the study, who is the Coyote Foundation Professor, neurology and neurological sciences, and professor, by courtesy, of neurosurgery at the Stanford (Calif.) University Medical Center. Minutes later at the press conference, it was announced that the results of both DEFUSE 3 and DAWN had indeed been included in the guidelines.
The DEFUSE (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) 3 trial included 182 patients from 38 U.S. centers who were recruited during May 2016–May 2017. Of these, 92 were randomized to thrombectomy and standard medical therapy, and 90 to standard medical therapy only.
Patients who underwent thrombectomy were more likely to have a favorable distribution of disability scores on the modified Rankin scale at 90 days (unadjusted odds ratio, 2.77; adjusted OR, 3.36; both P less than .001). “The odds ratio [of 2.77] was the largest ever reported for a thrombectomy study,” Dr. Albers said, and the ISC audience erupted into spontaneous applause. “We couldn’t be happier,” he responded.
Nearly half (45%) of patients in the thrombectomy group scored as functionally independent at 90 days (Rankin score 0-2), compared with 17% in the medical-therapy group (risk ratio, 2.67; P less than .001). Mortality was also lower in the intervention group (14% vs. 26%; P = .05).
The rates of symptomatic intracranial hemorrhage (7% thrombectomy, 4% medical therapy only) did not differ significantly between the two groups. Serious complications occurred in 43% of patients in the thrombectomy group, compared with 53% in the medical therapy–only group (P = .018).
A subanalysis showed consistent benefit of thrombectomy, even in patients with a longer elapsed time between stroke onset and randomization, while the patients who received medical therapy had worse outcomes as more time passed. In 50 patients in the under 9-hour group, 40% of those who received thrombectomy were functionally independent at 9 weeks, compared with 28% in the medical therapy–only group. Among 72 patients in the 9- to 12-hour group, 50% were functionally independent (vs. 17%), and in the greater than 12-hour group, 42% (7%).
The study filled up rapidly, at about twice the rate that the researchers anticipated, and that suggests that the procedure could find broad use. “It shows that these patients are not difficult to find,” said Dr. Albers.
The National Institutes of Health funded the study. Dr. Albers has a financial stake in iSchemaView and is on the scientific advisory board for iSchemaView and Medtronic.
The DEFUSE 3 results were published online concurrently with Dr. Albers’s presentation (N Engl J Med. 2018 Jan 24; doi: 10.1056/nejmoa1713973).
SOURCE: Albers G et al. ISC 2018
LOS ANGELES – The final results of the DEFUSE 3 trial are in, and the results are unequivocal: Thrombectomy performed 6-16 hours after the stroke patient was last known to be well was associated with dramatically improved outcomes in 90-day death and disability.
It has long been said that time is brain. Time is still vital, but some strokes progress at a slower rate. “We have the opportunity to treat these patients in a time window that we never thought was possible,” Gregory W. Albers, MD, said in presenting the findings at the International Stroke Conference sponsored by the American Heart Association.
The subjects included those with proximal middle-cerebral artery or internal-carotid artery occlusion and infarcts of 70 mL or less in size, and a ratio of the volume of ischemic tissue on perfusion imaging to infarct tissue of 1.8 or higher. Both DAWN and DEFUSE 3 used the RAPID software from iSchemaView to assess infarct volume.
The DEFUSE 3 results aren’t a surprise, as the trial was stopped early after an interim analysis showed efficacy. But they are immediately practice changing. “This will perhaps be a once in a lifetime situation where a study gets published and within 2 hours gets incorporated into new guidelines,” said Dr. Albers, lead author of the study, who is the Coyote Foundation Professor, neurology and neurological sciences, and professor, by courtesy, of neurosurgery at the Stanford (Calif.) University Medical Center. Minutes later at the press conference, it was announced that the results of both DEFUSE 3 and DAWN had indeed been included in the guidelines.
The DEFUSE (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) 3 trial included 182 patients from 38 U.S. centers who were recruited during May 2016–May 2017. Of these, 92 were randomized to thrombectomy and standard medical therapy, and 90 to standard medical therapy only.
Patients who underwent thrombectomy were more likely to have a favorable distribution of disability scores on the modified Rankin scale at 90 days (unadjusted odds ratio, 2.77; adjusted OR, 3.36; both P less than .001). “The odds ratio [of 2.77] was the largest ever reported for a thrombectomy study,” Dr. Albers said, and the ISC audience erupted into spontaneous applause. “We couldn’t be happier,” he responded.
Nearly half (45%) of patients in the thrombectomy group scored as functionally independent at 90 days (Rankin score 0-2), compared with 17% in the medical-therapy group (risk ratio, 2.67; P less than .001). Mortality was also lower in the intervention group (14% vs. 26%; P = .05).
The rates of symptomatic intracranial hemorrhage (7% thrombectomy, 4% medical therapy only) did not differ significantly between the two groups. Serious complications occurred in 43% of patients in the thrombectomy group, compared with 53% in the medical therapy–only group (P = .018).
A subanalysis showed consistent benefit of thrombectomy, even in patients with a longer elapsed time between stroke onset and randomization, while the patients who received medical therapy had worse outcomes as more time passed. In 50 patients in the under 9-hour group, 40% of those who received thrombectomy were functionally independent at 9 weeks, compared with 28% in the medical therapy–only group. Among 72 patients in the 9- to 12-hour group, 50% were functionally independent (vs. 17%), and in the greater than 12-hour group, 42% (7%).
The study filled up rapidly, at about twice the rate that the researchers anticipated, and that suggests that the procedure could find broad use. “It shows that these patients are not difficult to find,” said Dr. Albers.
The National Institutes of Health funded the study. Dr. Albers has a financial stake in iSchemaView and is on the scientific advisory board for iSchemaView and Medtronic.
The DEFUSE 3 results were published online concurrently with Dr. Albers’s presentation (N Engl J Med. 2018 Jan 24; doi: 10.1056/nejmoa1713973).
SOURCE: Albers G et al. ISC 2018
REPORTING FROM ISC 2018
Key clinical point: Stroke patients with clinical imaging mismatch had significantly better 90-day disability outcomes with thrombectomy.
Major finding: The odds ratio of a favorable outcome at 90 days was 2.77.
Data source: DEFUSE 3, a multicenter, randomized, controlled trial in 182 stroke patients.
Disclosures: The National Institutes of Health funded the study. Dr. Albers has a financial stake in iSchemaView and is on the scientific advisor board for iSchemaView and Medtronic.
Source: Albers G. et al. ISC 2018
Alex Azar confirmed as HHS Secretary
Alex M. Azar II has been confirmed as secretary of the Department of Health & Human Services following a Jan. 24 vote in the U.S. Senate.
His nomination passed by a vote of 55-43.
Mr. Azar has previously been confirmed to two posts at HHS, first as general counsel and later as deputy HHS secretary during the administration of President George W. Bush between 2001 and 2007. Both appointments were confirmed by unanimous consent in the Senate.
Democrats on the Senate Finance Committee challenged Mr. Azar on drug prices and other issues, but their objections to his pharmaceutical industry past were not enough to stop his confirmation.
“Mr. Azar was part of this broken system [of high drug pricing], and despite the cheerful overtures that he has made to senators on the other side of the aisle over the last few weeks on how he wants to work on the issue, he has not given a single concrete example of how he would actually change the system, change the system that he said is broken,” Senate Finance Committee Ranking Member Ron Wyden (D-Ore.) said on the Senate floor. “He won’t give us an example of how he would change it to make it better.”
In a statement, Senate Health, Education, Labor, and Pensions Chairman Lamar Alexander (R-Tenn.) said that Mr. Azar “has the broad perspective necessary to address the opioid crisis.”
However, Sen. Maggie Hassan (D-N.H.) expressed concern about whether he could effectively address the opioid epidemic.
“I was disappointed that Mr. Azar would not commit to advocating for new funding during his confirmation hearing. Considering his tenure as a top executive at a major pharmaceutical company, I also continue to have serious doubts that Mr. Azar can be a leader in addressing the skyrocketing cost of prescription drugs,” she said.
Alex M. Azar II has been confirmed as secretary of the Department of Health & Human Services following a Jan. 24 vote in the U.S. Senate.
His nomination passed by a vote of 55-43.
Mr. Azar has previously been confirmed to two posts at HHS, first as general counsel and later as deputy HHS secretary during the administration of President George W. Bush between 2001 and 2007. Both appointments were confirmed by unanimous consent in the Senate.
Democrats on the Senate Finance Committee challenged Mr. Azar on drug prices and other issues, but their objections to his pharmaceutical industry past were not enough to stop his confirmation.
“Mr. Azar was part of this broken system [of high drug pricing], and despite the cheerful overtures that he has made to senators on the other side of the aisle over the last few weeks on how he wants to work on the issue, he has not given a single concrete example of how he would actually change the system, change the system that he said is broken,” Senate Finance Committee Ranking Member Ron Wyden (D-Ore.) said on the Senate floor. “He won’t give us an example of how he would change it to make it better.”
In a statement, Senate Health, Education, Labor, and Pensions Chairman Lamar Alexander (R-Tenn.) said that Mr. Azar “has the broad perspective necessary to address the opioid crisis.”
However, Sen. Maggie Hassan (D-N.H.) expressed concern about whether he could effectively address the opioid epidemic.
“I was disappointed that Mr. Azar would not commit to advocating for new funding during his confirmation hearing. Considering his tenure as a top executive at a major pharmaceutical company, I also continue to have serious doubts that Mr. Azar can be a leader in addressing the skyrocketing cost of prescription drugs,” she said.
Alex M. Azar II has been confirmed as secretary of the Department of Health & Human Services following a Jan. 24 vote in the U.S. Senate.
His nomination passed by a vote of 55-43.
Mr. Azar has previously been confirmed to two posts at HHS, first as general counsel and later as deputy HHS secretary during the administration of President George W. Bush between 2001 and 2007. Both appointments were confirmed by unanimous consent in the Senate.
Democrats on the Senate Finance Committee challenged Mr. Azar on drug prices and other issues, but their objections to his pharmaceutical industry past were not enough to stop his confirmation.
“Mr. Azar was part of this broken system [of high drug pricing], and despite the cheerful overtures that he has made to senators on the other side of the aisle over the last few weeks on how he wants to work on the issue, he has not given a single concrete example of how he would actually change the system, change the system that he said is broken,” Senate Finance Committee Ranking Member Ron Wyden (D-Ore.) said on the Senate floor. “He won’t give us an example of how he would change it to make it better.”
In a statement, Senate Health, Education, Labor, and Pensions Chairman Lamar Alexander (R-Tenn.) said that Mr. Azar “has the broad perspective necessary to address the opioid crisis.”
However, Sen. Maggie Hassan (D-N.H.) expressed concern about whether he could effectively address the opioid epidemic.
“I was disappointed that Mr. Azar would not commit to advocating for new funding during his confirmation hearing. Considering his tenure as a top executive at a major pharmaceutical company, I also continue to have serious doubts that Mr. Azar can be a leader in addressing the skyrocketing cost of prescription drugs,” she said.
Persistent opioid use a risk after surgery in teens and young adults
For a subset of opioid-naive adolescents and young adults who received perioperative opioid scripts, those prescriptions were filled for months after the surgery, raising concerns about long-term risk for substance use disorder.
To get an idea of the teen opioid problem, from 1997 to 2012 for adolescents aged 15-19 years, the incidence of hospitalizations for opioid poisonings per 100,000 teens increased from 3.69 to 10.17, an increase of 176%, according to a study in JAMA Pediatrics (2016;170[12]:1195-201). Adolescents are at a three to five time higher risk for serious medical outcomes when hospitalized with opioid poisoning, such as life-threatening symptoms or death, compared with younger children, according to a study reporting prescription drug exposures among children (Pediatrics. 2017;139[4]:e20163382).
These figures are concerning in part because “a significant association between medical use of prescription opioids alone in adolescence and subsequent nonmedical use of prescription opioids was observed at age 35 years” in a national longitudinal study reported in the journal Pain (2016 Oct;157[10]:2173-8), said Calista M. Harbaugh, MD, of the University of Michigan, Ann Arbor, and her study coauthors.
The study in Pediatrics, which drew from a large national insurance claims database, found some patient characteristics had independent associations with increased risk of persistent opioid use. These included being female or older, as well as having a prior history of substance use disorder, chronic pain, or filling an opioid prescription preoperatively.
Dr. Harbaugh and her collaborators used a large national research database to select opioid-naive patients aged 13-21 years who received 1 of 13 surgical procedures. A total of 88,637 opioid-naive surgical patients were included in the study, with 110,432 control nonsurgical patients. The control group consisted of 3% of the database’s nonsurgical patients who met age and opioid-naivete criteria. Patients in both groups also had to have continuous insurance for the prior 12 months, not have had an opioid prescription filled within the prior year, and not have received any subsequent surgical procedures during the study period.
To be able to compare medication use among patients receiving different types of opioids, the opioid component of all prescriptions was converted to milligrams, and then used to calculate oral morphine equivalents (OMEs) for each prescription.
Although the most common procedures were tonsillectomy and/or adenoidectomy (35.9% of patients), arthroscopic knee repair (25.3%), and appendectomy, (18.6%), these were not the procedures that were most associated with persistent opioid use.
Overall, 7.1% of patients had an initial daily dosage greater than 100 OMEs for their first postoperative prescription. These high opioid doses were likely to be seen in patients undergoing three procedures known to have considerable postoperative pain: pectus repair, posterior arthrodesis, and supracondylar fracture fixation. However, patients undergoing these procedures weren’t more likely to have persistent opioid use than other surgical patients in the study, the researchers said.
Rather, cholecystectomy and colectomy had the highest risk for persistent opioid use, with adjusted odds ratios of 1.13 and 2.33, respectively. Dr. Harbaugh and her collaborators, in discussing the study’s findings, noted that these two conditions involve high levels of preoperative inflammation and are characterized by visceral pain. This scenario, they said, may set these patients up for visceral and central sensitization and present an increased risk for chronic pain.
Dr. Harbaugh and her colleagues called for preoperative screening for risk factors for persistent opioid use, so that at-risk patients can receive closer monitoring and attention. “We are not suggesting that … pain should be underappreciated or undertreated,” or that at-risk patients should not be prescribed opioids.
The investigators said that their work “points toward the multifactorial etiology of postoperative pain and its complex nature in both the short and long term.” They called for more work to “elucidate the mechanism that underlies new persistent opioid use after certain procedures,” as well as more efforts to better understand how best to use multimodal pharmacologic and nonpharmacologic pain control measures in the adolescent and young adult population.
The study was funded by the Michigan Department of Health and Human Services. Dr. Harbaugh reported that she had no relevant financial disclosures. Some of the other investigators received grants from various agencies.
SOURCE: Harbaugh CM et al. Pediatrics 2018 Jan 1;141(1):e20172439
For a subset of opioid-naive adolescents and young adults who received perioperative opioid scripts, those prescriptions were filled for months after the surgery, raising concerns about long-term risk for substance use disorder.
To get an idea of the teen opioid problem, from 1997 to 2012 for adolescents aged 15-19 years, the incidence of hospitalizations for opioid poisonings per 100,000 teens increased from 3.69 to 10.17, an increase of 176%, according to a study in JAMA Pediatrics (2016;170[12]:1195-201). Adolescents are at a three to five time higher risk for serious medical outcomes when hospitalized with opioid poisoning, such as life-threatening symptoms or death, compared with younger children, according to a study reporting prescription drug exposures among children (Pediatrics. 2017;139[4]:e20163382).
These figures are concerning in part because “a significant association between medical use of prescription opioids alone in adolescence and subsequent nonmedical use of prescription opioids was observed at age 35 years” in a national longitudinal study reported in the journal Pain (2016 Oct;157[10]:2173-8), said Calista M. Harbaugh, MD, of the University of Michigan, Ann Arbor, and her study coauthors.
The study in Pediatrics, which drew from a large national insurance claims database, found some patient characteristics had independent associations with increased risk of persistent opioid use. These included being female or older, as well as having a prior history of substance use disorder, chronic pain, or filling an opioid prescription preoperatively.
Dr. Harbaugh and her collaborators used a large national research database to select opioid-naive patients aged 13-21 years who received 1 of 13 surgical procedures. A total of 88,637 opioid-naive surgical patients were included in the study, with 110,432 control nonsurgical patients. The control group consisted of 3% of the database’s nonsurgical patients who met age and opioid-naivete criteria. Patients in both groups also had to have continuous insurance for the prior 12 months, not have had an opioid prescription filled within the prior year, and not have received any subsequent surgical procedures during the study period.
To be able to compare medication use among patients receiving different types of opioids, the opioid component of all prescriptions was converted to milligrams, and then used to calculate oral morphine equivalents (OMEs) for each prescription.
Although the most common procedures were tonsillectomy and/or adenoidectomy (35.9% of patients), arthroscopic knee repair (25.3%), and appendectomy, (18.6%), these were not the procedures that were most associated with persistent opioid use.
Overall, 7.1% of patients had an initial daily dosage greater than 100 OMEs for their first postoperative prescription. These high opioid doses were likely to be seen in patients undergoing three procedures known to have considerable postoperative pain: pectus repair, posterior arthrodesis, and supracondylar fracture fixation. However, patients undergoing these procedures weren’t more likely to have persistent opioid use than other surgical patients in the study, the researchers said.
Rather, cholecystectomy and colectomy had the highest risk for persistent opioid use, with adjusted odds ratios of 1.13 and 2.33, respectively. Dr. Harbaugh and her collaborators, in discussing the study’s findings, noted that these two conditions involve high levels of preoperative inflammation and are characterized by visceral pain. This scenario, they said, may set these patients up for visceral and central sensitization and present an increased risk for chronic pain.
Dr. Harbaugh and her colleagues called for preoperative screening for risk factors for persistent opioid use, so that at-risk patients can receive closer monitoring and attention. “We are not suggesting that … pain should be underappreciated or undertreated,” or that at-risk patients should not be prescribed opioids.
The investigators said that their work “points toward the multifactorial etiology of postoperative pain and its complex nature in both the short and long term.” They called for more work to “elucidate the mechanism that underlies new persistent opioid use after certain procedures,” as well as more efforts to better understand how best to use multimodal pharmacologic and nonpharmacologic pain control measures in the adolescent and young adult population.
The study was funded by the Michigan Department of Health and Human Services. Dr. Harbaugh reported that she had no relevant financial disclosures. Some of the other investigators received grants from various agencies.
SOURCE: Harbaugh CM et al. Pediatrics 2018 Jan 1;141(1):e20172439
For a subset of opioid-naive adolescents and young adults who received perioperative opioid scripts, those prescriptions were filled for months after the surgery, raising concerns about long-term risk for substance use disorder.
To get an idea of the teen opioid problem, from 1997 to 2012 for adolescents aged 15-19 years, the incidence of hospitalizations for opioid poisonings per 100,000 teens increased from 3.69 to 10.17, an increase of 176%, according to a study in JAMA Pediatrics (2016;170[12]:1195-201). Adolescents are at a three to five time higher risk for serious medical outcomes when hospitalized with opioid poisoning, such as life-threatening symptoms or death, compared with younger children, according to a study reporting prescription drug exposures among children (Pediatrics. 2017;139[4]:e20163382).
These figures are concerning in part because “a significant association between medical use of prescription opioids alone in adolescence and subsequent nonmedical use of prescription opioids was observed at age 35 years” in a national longitudinal study reported in the journal Pain (2016 Oct;157[10]:2173-8), said Calista M. Harbaugh, MD, of the University of Michigan, Ann Arbor, and her study coauthors.
The study in Pediatrics, which drew from a large national insurance claims database, found some patient characteristics had independent associations with increased risk of persistent opioid use. These included being female or older, as well as having a prior history of substance use disorder, chronic pain, or filling an opioid prescription preoperatively.
Dr. Harbaugh and her collaborators used a large national research database to select opioid-naive patients aged 13-21 years who received 1 of 13 surgical procedures. A total of 88,637 opioid-naive surgical patients were included in the study, with 110,432 control nonsurgical patients. The control group consisted of 3% of the database’s nonsurgical patients who met age and opioid-naivete criteria. Patients in both groups also had to have continuous insurance for the prior 12 months, not have had an opioid prescription filled within the prior year, and not have received any subsequent surgical procedures during the study period.
To be able to compare medication use among patients receiving different types of opioids, the opioid component of all prescriptions was converted to milligrams, and then used to calculate oral morphine equivalents (OMEs) for each prescription.
Although the most common procedures were tonsillectomy and/or adenoidectomy (35.9% of patients), arthroscopic knee repair (25.3%), and appendectomy, (18.6%), these were not the procedures that were most associated with persistent opioid use.
Overall, 7.1% of patients had an initial daily dosage greater than 100 OMEs for their first postoperative prescription. These high opioid doses were likely to be seen in patients undergoing three procedures known to have considerable postoperative pain: pectus repair, posterior arthrodesis, and supracondylar fracture fixation. However, patients undergoing these procedures weren’t more likely to have persistent opioid use than other surgical patients in the study, the researchers said.
Rather, cholecystectomy and colectomy had the highest risk for persistent opioid use, with adjusted odds ratios of 1.13 and 2.33, respectively. Dr. Harbaugh and her collaborators, in discussing the study’s findings, noted that these two conditions involve high levels of preoperative inflammation and are characterized by visceral pain. This scenario, they said, may set these patients up for visceral and central sensitization and present an increased risk for chronic pain.
Dr. Harbaugh and her colleagues called for preoperative screening for risk factors for persistent opioid use, so that at-risk patients can receive closer monitoring and attention. “We are not suggesting that … pain should be underappreciated or undertreated,” or that at-risk patients should not be prescribed opioids.
The investigators said that their work “points toward the multifactorial etiology of postoperative pain and its complex nature in both the short and long term.” They called for more work to “elucidate the mechanism that underlies new persistent opioid use after certain procedures,” as well as more efforts to better understand how best to use multimodal pharmacologic and nonpharmacologic pain control measures in the adolescent and young adult population.
The study was funded by the Michigan Department of Health and Human Services. Dr. Harbaugh reported that she had no relevant financial disclosures. Some of the other investigators received grants from various agencies.
SOURCE: Harbaugh CM et al. Pediatrics 2018 Jan 1;141(1):e20172439
FROM PEDIATRICS
Key clinical point: Especially for females, older teens, and young adults, there’s a risk for persistent postsurgical opioid use.
Major finding: Opioid use persisted for 4.8% of patients undergoing surgery, compared with 0.1% of patients who did not have surgery.
Study details: Retrospective review of claims database including 88,637 adolescent and young adult patients undergoing surgery, and 110,432 controls who did not have surgery.
Disclosures: The study was funded by the Michigan Department of Health and Human Services. Dr. Harbaugh reported that she had no conflicts of interest. Some of the other investigators received grants from various agencies.
Source: Harbaugh CM et al. Pediatrics. 2018 Jan 1;141(1):e20172439