Postoperative Respiratory Events in Surgical Patients Exposed to Opioid Analgesic Shortages Compared to Fully Matched Patients Non-exposed to Shortages

Introduction Shortages of opioid analgesics critically disrupt clinical practice and are detrimental to patient safety. There is a dearth of studies assessing the safety implications of drug shortages. Objective We aimed to assess perioperative opioid analgesic use and related postoperative hypoxemia (oxygen saturation less than 90%) in surgical patients exposed to prescription opioid shortages compared to propensity score-matched patients non-exposed to opioid shortages. Methods We conducted a retrospective study including adult patients who underwent elective surgery at The University of California San Francisco in the period August 2018–December 2019. We conducted a Gamma log-link generalized linear model to assess the effect of shortages on perioperative use of opioids and a weighted logistic regression to assess the likelihood of experiencing postoperative hypoxemia. Results There were 1119 patients exposed to opioid shortages and 2787 matched non-exposed patients. After full matching, patients exposed to shortages used a greater mean of morphine milligram equivalents/day (146.94; 95% confidence interval 123.96–174.16) than non-exposed patients (117.92; 95% confidence interval 100.48–138.38; p = 0.0001). The estimated effect was a 1.25 (95% confidence interval 1.12–1.40; p = 0.0001) times greater use of opioids in patients exposed to opioid shortages than non-exposed patients. After full matching, a greater proportion of patients exposed to shortages (19.06%) experienced hypoxemia compared with non-exposed patients (16.91%). In addition, a greater proportion of patients exposed to opioid shortages (1.20%) experienced hypoxemia reversed by intravenous naloxone administration compared with non-exposed patients (0.44%). Conclusions Given the shortage prevalence, reliance on opioid medications, and related risk of respiratory depression, harm prevention measures remain critical to prevent postoperative complications that may compromise patients’ safety

Factors associated with delays in discharge for trauma patients at an urban county hospital.

BackgroundDischarge delays for non-medical reasons put patients at unnecessary risk for hospital-acquired infections, lead to loss of revenue for hospitals and reduce hospital capacity to treat other patients. The objective of this study was to determine prevalence of, and patient characteristics associated with, delays in discharge at an urban county trauma service.MethodsWe performed a retrospective cohort study with data from Zuckerberg San Francisco General Hospital (ZSFGH), a level-1 trauma center and safety net hospital in San Francisco, California. The study included 1720 patients from the trauma surgery service at ZSFGH. A 'delay in discharge' was defined as days in the hospital, including an initial overnight stay, after all medical needs had been met. We used logistic and zero-inflated negative binomial regression models to test whether the following factors were associated with prolonged, non-medical length of stay: age, gender, race/ethnicity, housing, disposition location, type of insurance, having a primary care provider, primary language and zip code.ResultsOf the 1720 patients, 15% experienced a delay in discharge, for a total of 1147 days (median 1.5 days/patient). The following were statistically significant (p<0.05) predictors of delays in discharge in a multivariable logistic regression model: older age, unhoused status or disposition to home health or postacute care (compared with home discharge) were associated with increased likelihood of delays. Having private insurance or Medicare (compared with public insurance) and discharge against medical advice or absent without leave (compared with home discharge) were associated with reduced likelihood of delays in discharge after all medical needs were met.DiscussionThese results suggest that policymakers interested in reducing non-medical hospital stays should focus on addressing structural determinants of health, such as lack of housing, bottlenecks at postacute care disposition destinations and lack of adequate insurance.Level of evidenceEpidemiological, Level III

Is there variation in private payor payments to cancer surgeons? A cross-sectional study in the USA

Objectives Although demand for price transparency in healthcare is growing, variation in private payors’ payments to surgeons for oncologic resection has not been well characterised. Our aim was to assess variation of private payors’ payments to surgeons for cancer resection using data based on fee-for-service allowed amounts, billed by a large mix of commercial payors and third-party administrators.Setting Fair Health (FH), an independent, not-for-profit organisation that collects and compiles claims data from payors nationwide. FH maintains the nation’s largest repository of privately billed medical and dental claims representing over 125 million covered lives in the USA.Participants We performed a cross-sectional study assessing private payer data for five common types of cancer surgery: simple mastectomy (SM), modified radical mastectomy (MRM), open lobectomy, video-assisted thoracoscopic surgery (VATS) lobectomy and radical prostatectomy during 2012 and 2013.Primary and secondary outcome measures To assess variation across regions, we compared regional median allowed payments. To assess intraregion variability, we evaluated the distribution of regional IQRs of allowed payments.Results Median allowed payments varied substantially across regions. For SM, median allowed payments ranged from $550 in the least expensive to$1380 in the costliest region. For MRM, the range was $842–$1760, for lobectomy $326–$3066, for VATS $317–$3307 and for prostatectomy $1716–$4867. There was also substantial variation within geographic areas. For example, the mean IQRs in surgeon payment within regions were: SM $577 (25th percentile) to$1132 (75th percentile); MRM $850–$1620; lobectomy $861–$2767; VATS $1024–$3122; and prostatectomy $2286–$3563.Conclusions There is a wide range of variation both across and within geographic regions in allowed amounts of surgeon payments for common oncologic resections. Transparency about these allowed amounts may have a profound impact on patient and employer choice and facilitate future assessments of value in cancer care

Is there variation in private payor payments to cancer surgeons? A cross-sectional study in the USA.

ObjectivesAlthough demand for price transparency in healthcare is growing, variation in private payors' payments to surgeons for oncologic resection has not been well characterised. Our aim was to assess variation of private payors' payments to surgeons for cancer resection using data based on fee-for-service allowed amounts, billed by a large mix of commercial payors and third-party administrators.SettingFair Health (FH), an independent, not-for-profit organisation that collects and compiles claims data from payors nationwide. FH maintains the nation's largest repository of privately billed medical and dental claims representing over 125 million covered lives in the USA.ParticipantsWe performed a cross-sectional study assessing private payer data for five common types of cancer surgery: simple mastectomy (SM), modified radical mastectomy (MRM), open lobectomy, video-assisted thoracoscopic surgery (VATS) lobectomy and radical prostatectomy during 2012 and 2013.Primary and secondary outcome measuresTo assess variation across regions, we compared regional median allowed payments. To assess intraregion variability, we evaluated the distribution of regional IQRs of allowed payments.ResultsMedian allowed payments varied substantially across regions. For SM, median allowed payments ranged from $550 in the least expensive to$1380 in the costliest region. For MRM, the range was $842-$1760, for lobectomy $326-$3066, for VATS $317-$3307 and for prostatectomy $1716-$4867. There was also substantial variation within geographic areas. For example, the mean IQRs in surgeon payment within regions were: SM $577 (25th percentile) to$1132 (75th percentile); MRM $850-$1620; lobectomy $861-$2767; VATS $1024-$3122; and prostatectomy $2286-$3563.ConclusionsThere is a wide range of variation both across and within geographic regions in allowed amounts of surgeon payments for common oncologic resections. Transparency about these allowed amounts may have a profound impact on patient and employer choice and facilitate future assessments of value in cancer care

Is there variation in private payor payments to cancer surgeons? A cross-sectional study in the USA.

ObjectivesAlthough demand for price transparency in healthcare is growing, variation in private payors' payments to surgeons for oncologic resection has not been well characterised. Our aim was to assess variation of private payors' payments to surgeons for cancer resection using data based on fee-for-service allowed amounts, billed by a large mix of commercial payors and third-party administrators.SettingFair Health (FH), an independent, not-for-profit organisation that collects and compiles claims data from payors nationwide. FH maintains the nation's largest repository of privately billed medical and dental claims representing over 125 million covered lives in the USA.ParticipantsWe performed a cross-sectional study assessing private payer data for five common types of cancer surgery: simple mastectomy (SM), modified radical mastectomy (MRM), open lobectomy, video-assisted thoracoscopic surgery (VATS) lobectomy and radical prostatectomy during 2012 and 2013.Primary and secondary outcome measuresTo assess variation across regions, we compared regional median allowed payments. To assess intraregion variability, we evaluated the distribution of regional IQRs of allowed payments.ResultsMedian allowed payments varied substantially across regions. For SM, median allowed payments ranged from $550 in the least expensive to$1380 in the costliest region. For MRM, the range was $842-$1760, for lobectomy $326-$3066, for VATS $317-$3307 and for prostatectomy $1716-$4867. There was also substantial variation within geographic areas. For example, the mean IQRs in surgeon payment within regions were: SM $577 (25th percentile) to$1132 (75th percentile); MRM $850-$1620; lobectomy $861-$2767; VATS $1024-$3122; and prostatectomy $2286-$3563.ConclusionsThere is a wide range of variation both across and within geographic regions in allowed amounts of surgeon payments for common oncologic resections. Transparency about these allowed amounts may have a profound impact on patient and employer choice and facilitate future assessments of value in cancer care

Unplanned hospital visits after ambulatory surgical care.

ObjectivesWe sought to assess the rate of unplanned hospital visits among patients undergoing ambulatory surgery.Summary background dataThe majority of surgeries performed in the United States now take place in outpatient settings. Post-discharge hospital visit rates have been shown to vary widely, suggesting variation in surgical or discharge care quality. Complicating efforts to address quality, most facilities and surgeons are unaware of their patients' hospital visits after surgery since patients may present to a different hospital.MethodsWe used state-level, administrative data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project from California to assess unplanned hospital visits after ambulatory surgery. To compare rates across centers, we determined the age, sex, and procedure-adjusted rates of hospital visits for each facility using 2-level, hierarchical, generalized linear models using methods similar to existing Centers for Medicare and Medicaid Services measures.ResultsAmong a total of 1,260,619 ambulatory same-day surgeries from 440 surgical facilities, the risk adjusted 30-day rate of unplanned hospital visits was 4.8%, with emergency department visits of 3.1% and hospital admissions of 1.7%. Several patient characteristics were associated with increased risk of unplanned hospitals visits, including increased age, increased number of comorbidities (using the Elixhauser score), and type of procedure (p<0.001).ConclusionsThe overall rate unplanned hospital visits within 30 days after same-day surgery is low but variable, suggesting a difference in the quality of care provided. Further, these rates are higher among specific patient populations and procedure types, suggesting areas for targeted improvement