Racial and Ethnic Differences in the Prevalence of Do-Not-Resuscitate Orders among Older Adults with Severe Traumatic Brain Injury.

BACKGROUND: Older adults suffering from traumatic brain injury (TBI) are subject to higher injury burden and mortality. Do Not Resuscitate (DNR) orders are used to provide care aligned with patient wishes, but they may not be equitably distributed across racial/ethnic groups. We examined racial/ethnic differences in the prevalence of DNR orders at hospital admission in older patients with severe TBI. METHODS: We conducted a retrospective cohort study using the National Trauma Databank (NTDB) between 2007 to 2016. We examined patients ≥ 65 years with severe TBI. For our primary aim, the exposure was race/ethnicity and outcome was the presence of a documented DNR at hospital admission. We conducted an exploratory analysis of hospital outcomes including hospital mortality, discharge to hospice, and healthcare utilization (intracranial pressure monitor placement, hospital LOS, and duration of mechanical ventilation). RESULTS: Compared to White patients, Black patients (OR 0.48, 95% CI 0.35-0.64), Hispanic patients (OR 0.54, 95% CI 0.40-0.70), and Asian patients (OR 0.63, 95% CI 0.44-0.90) had decreased odds of having a DNR order at hospital admission. Patients with DNRs had increased odds of hospital mortality (OR 2.16, 95% CI 1.94-2.42), discharge to hospice (OR 2.08, 95% CI 1.75-2.46), shorter hospital LOS (-2.07 days, 95% CI -3.07 to -1.08) and duration of mechanical ventilation (-1.09 days, 95% CI -1.52 to -0.67). There was no significant difference in the utilization of ICP monitoring (OR 0.94, 95% CI 0.78-1.12). CONCLUSIONS: We found significant racial and ethnic differences in the utilization of DNR orders among older patients with severe TBI. Additionally. DNR orders at hospital admission were associated with increased in-hospital mortality, increased hospice utilization, and decreased healthcare utilization. Future studies should examine mechanisms underlying race-based differences in DNR utilization.

Interscalene block with liposomal bupivacaine versus continuous interscalene catheter in primary total shoulder arthroplasty.

BACKGROUND: Multimodal pain regimens in total shoulder arthroplasty (TSA) now include regional anesthetic techniques. Historically, regional anesthesia for extended postoperative pain control in TSA was administered using a continuous interscalene catheter (CIC). Liposomal bupivacaine (LB) is used for its potential for similar pain control and fewer complications compared with indwelling catheters. We evaluated the efficacy of interscalene LB compared with a CIC in postoperative pain control for patients undergoing TSA. METHODS: This was a retrospective cohort study at a tertiary-care academic medical center including consecutive patients undergoing primary anatomic or reverse TSA from 2016 to 2020 who received either single-shot LB or a CIC for perioperative pain control. Perioperative and outcome variables were collected. The primary outcome was postoperative pain control, whereas the secondary outcome was health care utilization. RESULTS: The study included 565 patients, with 242 in the CIC cohort and 323 in the LB cohort. Demographic characteristics including sex (P = .99) and race (P = .81) were similar between the cohorts. The LB cohort had significantly lower mean pain scores at 24 hours (3 vs. 2, P < .001) and 36 hours (3 vs. 2, P < .001) postoperatively. The CIC cohort showed a higher percentage of patients experiencing a pain score of 9 or 10 postoperatively (29% vs. 17%, P = .001), whereas the LB cohort had a significantly greater proportion of opioid-free patients (32% vs. 10%, P < .001). Additionally, a greater proportion of CIC patients required opioid escalation to patient-controlled analgesia (7% vs. 2%, P = .002). The CIC cohort experienced a greater length of stay (2.3 days vs. 2.1 days, P = .01) and more 30-day emergency department visits (5% vs. 2%, P = .038). CONCLUSIONS: LB demonstrated lower mean pain scores at 24 and 36 hours postoperatively and lower rates of severe postoperative pain. Additionally, LB patients showed significantly higher rates of opioid-free pain regimens. These results suggest that as part of a multimodal pain regimen in primary shoulder arthroplasty, LB may provide greater reductions in pain and opioid use when compared with CICs.

Predicting Postoperative Course After Total Shoulder Arthroplasty Using a Medical-Social Evaluation Model.

INTRODUCTION: The ability to predict successful outcomes is important for patient satisfaction and optimal results after shoulder arthroplasty. We hypothesize that a medical-social scoring tool will predict resource requirements in doing total shoulder arthroplasty (TSA). METHODS: A retrospective analysis of 453 patients undergoing TSA was undertaken. Preoperatively, medical and social surveys were completed by each patient. Demographics, comorbidity scores, hospital course, postdischarge disposition, and readmissions were collected. RESULTS: The average length of stay was 1.6 days (0 to 7). There was an association with utilization of home care or inpatient rehabilitation and both the medical (7.3 versus 3.9; P = 0.0002) and social (7.1 versus 3.4; P < 0.0001) components of the survey. There was a weak correlation between hospital length of stay and the social component of the survey (R = 0.29; P < 0.001), but not the medical component (R = 0.04; P = 0.38). No variable was predictive of readmission. Social score of eight was found to be predictive of postoperative requirement of home care or rehabilitation. CONCLUSION: This study found that Medical and Social Survey Scores can stratify patients who are at risk of requiring more advanced postdischarge care and/or a longer hospital stay. With this, we can match patients to the most appropriate level of postoperative care.

The Characteristics of Surgeons Performing Total Shoulder Arthroplasty: Volume Consistency, Training, and Specialization.

Total shoulder arthroplasty (TSA) has proved a cost-effective, reproducible procedure for multiple shoulder pathologies. As utilization of TSA continues to grow, it is important to investigate procedure diversity, training, and other characteristics of surgeons performing TSA. To identify surgeons performing TSA in the Medicare population, the Medicare Provider Utilization and Payment Databases from 2012 through 2014 were used. This dataset includes any provider who bills Medicare >10 times with a single billing code. A web-based search was performed for each physician performing >10 TSA in all years of the study to identify their surgical training characteristics. Between 2012 and 2014, 1374 surgeons (39 females [2.8%]) performed >10 TSA in Medicare patients in at least 1 year (71,973 TSA). Only 44.3% (609/1374) of surgeons met this threshold for all 3 years (55,538 TSA). Of these 609 surgeons, 191 (31.3%) were shoulder and elbow fellowship trained (21,444 TSA). Shoulder and elbow fellowship-trained surgeons were at earlier points in their careers and practiced in large referral-based centers with other surgeons performing TSA. In addition to TSA, surgeons performed other non-arthroplasty shoulder procedures (80.2% of surgeons), total knee arthroplasty (46.3%), repairs of traumatic injuries (29.8%), total hip arthroplasty (27.8%), non-arthroplasty knee surgeries (27.2%), elbow procedures (19.6%), and hand surgery (15.4%) during the study period. With less than one-third of TSA performed by shoulder and elbow fellowship-trained surgeons with consistent moderate-volume practices, the impact of consistent high-volume practices and targeted fellowship training on quality must be determined.