Medication-related quality of life (MRQoL) in ambulatory older adults with multi-morbidity and polypharmacy.

PURPOSE: To assess medication-related quality-of-life (MRQoL) in multi-morbid older adults with polypharmacy and correlations with medications, frailty and health-related QoL. METHODS: With a cross sectional study of multi-morbid geriatric medicine outpatients, we assessed MRQoL (MRQol-LSv1), frailty status, potentially inappropriate medications, Medication Adherence Rating Scale (MARS), health-related-QoL (Short-Form 12, SF12) and medication burden (Living with Medicines Questionnaire, LMQv2). RESULTS: One-in-four (n = 59) of 234 outpatient attendees met inclusion criteria. Almost half (n = 106, 45%) were excluded due to cognition (MMSE < 26). Included participants (n = 27, mean age 80.2 years) experienced a median of 11 (IQR 9-13.5) co-morbidities and were prescribed a median of 10 (IQR 8-12.25) medications. Overall, MRQoL-LS.v.1 scores were low, suggesting good medication-related quality of life (median MRQoL-LS.v.1 score of 14, IQR 14-22). Correlations between MRQoL, number of daily medications, co-morbidity burden, LMQv2 score, SF12 scores and number of PIMs were non-significant. CONCLUSION: MRQoL-LSv.1 is unsuitable for most patients attending geriatric ambulatory services.

Medication review interventions to reduce hospital readmissions in older people.

OBJECTIVE: To assess the efficacy of medication review as an isolated intervention and with several co-interventions for preventing hospital readmissions in older adults. METHODS: Ovid MEDLINE, Embase, The Cochrane Central Register of Controlled Trials and CINAHL were searched for randomized controlled trials evaluating the effectiveness of medication review interventions with or without co-interventions to prevent hospital readmissions in hospitalized or recently discharged adults aged ≥65, until September 13, 2019. Included outcomes were "at least one all-cause hospital readmission within 30 days and at any time after discharge from the index admission." RESULTS: Twenty-five studies met the inclusion criteria. Of these, 11 studies (7,318 participants) contributed to the network meta-analysis (NMA) on all-cause hospital readmission within 30 days. Medication review in combination with (a) medication reconciliation and patient education (risk ratio (RR) 0.45; 95% confidence interval (CI) 0.26-0.80) and (b) medication reconciliation, patient education, professional education and transitional care (RR 0.64; 95% CI 0.49-0.84) were associated with a lower risk of all-cause hospital readmission compared to usual care. Medication review in isolation did not significantly influence hospital readmissions (RR 1.06; 95% CI 0.45-2.51). The NMA on all-cause hospital readmission at any time included 24 studies (11,677 participants). Medication review combined with medication reconciliation, patient education, professional education and transitional care resulted in a reduction of hospital readmissions (RR 0.82; 95% CI 0.74-0.91) compared to usual care. The quality of the studies included in this systematic review raised some concerns, mainly regarding allocation concealment, blinding and contamination. CONCLUSION: Medication review in combination with medication reconciliation, patient education, professional education and transitional care, was associated with a lower risk of hospital readmissions compared to usual care. An effect of medication review without co-interventions was not demonstrated. Trials of higher quality are needed in this field.

In-hospital adverse drug reactions in older adults; prevalence, presentation and associated drugs-a systematic review and meta-analysis.

BACKGROUND: the prevalence of adverse drug reactions (ADRs) in hospitalised older patients, their clinical presentations, causative drugs, severity, preventability and measurable outcomes are unclear, ADRs being an increasing challenge to older patient safety. METHODS: we systematically searched PubMed, Embase, EBSCO-CINAHL, the Cochrane Library, 'rey' literature and relevant systematic review bibliographies, published from database inception to March 2020. We included any study reporting occurrence of in-hospital ADRs as primary or secondary outcomes in hospitalised older adults (mean age ≥ 65 years). Two authors independently extracted relevant information and appraised studies for bias. Study characteristics, ADR clinical presentations, causative drugs, severity, preventability and clinical outcomes were analysed. Study estimates were pooled using random-effects meta-analytic models. RESULTS: from 2,399 abstracts, we undertook full-text screening in 286, identifying 27 studies (29 papers). Final analysis yielded a pooled ADR prevalence of 16% (95%CI 12-22%, I2 98%,τ2 0.8585), in a population of 20,153 hospitalised patients aged ≥65 years of whom 2,479 patients experienced ≥ one ADR. ADR ascertainment was highly heterogeneous. Almost 48.3% of all ADRs involved five presentations: fluid/electrolyte disturbances (17.3%), gastrointestinal motility/defaecation disorders (13.3%), renal disorders (8.2%), hypotension/blood pressure dysregulation disorders/shock (5.5%) and delirium (4.1%). Four drug classes accounted for 57.8% of causative medications i.e. diuretics (19.8%), anti-bacterials (14.8%), antithrombotic agents (12.2%) and analgesics (10.9%). Pooled analysis of severity was not feasible. Four studies reported the majority of ADRs as preventable (55-95%). CONCLUSIONS: on average, 16% of hospitalised older patients experience significant ADRs, varying in severity and mostly preventable, with commonly prescribed drug classes accounting for most ADRs.

Opioid Prescription Consumption Patterns After Total Joint Arthroplasty in Chronic Opioid Users Versus Opioid Naive Patients.

Although chronic preoperative opioid use has been linked to inferior total joint arthroplasty outcomes, little research exists on postoperative prescribing patterns for opioid-naive orthopaedic patients versus chronic opioid users. Method: The New York State Prescription Monitoring Program database, which tracks controlled prescriptions dispensed in-state over the preceding 12 months, was retrospectively queried for 386 patients who underwent primary, elective total hip or knee arthroplasty at a high-volume, urban medical center from May through December 2017. Seventy-four patients were excluded because they did not return prescription monitoring program results, leaving 312 patients. Prescribers, medications, dates prescribed and filled, and quantity dispensed were recorded 3 months preoperatively through 12 months postoperatively. We defined chronic users as ≥2 opioid prescriptions filled in 3 preoperative months and opioid-naive as <2 filled. Opioid use was compared univariately using 2-tailed Student t-tests. Results: Chronic opioid users (n = 49; 15.7%) filled an average of 13,006.64 morphine equivalent doses per patient in the 12-month postoperative period, while opioid-naive users (n = 263; 84.3%) filled an average of 854.48 morphine equivalent doses per patient (P < 0.01). Opioid use in the chronic-user group was significantly higher in each 6-week postoperative interval (P < 0.01). These trends remained significant when stratified by procedure. For opioid-naive patients, 74% of opioid prescriptions were prescribed by our orthopaedic department. For chronic users, only 21% of opioid prescriptions originated from our department. Chronic users were found to cyclically fill opioid prescriptions every 3 to 4 weeks postoperatively as far out as 12 months and were significantly more likely to fill nonopioid controlled substance prescriptions both preoperatively and postoperatively (P < 0.01). Discussion: Chronic opioid users undergoing arthroplasty filled significantly more opioid prescriptions than opioid-naive patients. Chronic users obtained prescriptions from myriad sources, only a minority of which originated from our orthopaedic department. In the current opioid epidemic, vigilance regarding opioid prescribing is critical.

Improved pain control with adductor canal block using liposomal bupivacaine after total knee replacement: a retrospective cohort study.

BACKGROUND: Adductor canal blocks (ACBs), typically administered with a local anesthetic such as bupivacaine, help control perioperative pain after total knee arthroplasty. Recently, liposomal bupivacaine (LB) was introduced in an attempt to extend the duration of analgesia, used primarily in periarticular injections (PAIs). The purpose of this study was to compare pain control and early perioperative outcomes with ACB using LB vs standard bupivacaine (SB). METHODS: We retrospectively compared pain control in a group of 75 patients with ACB and PAI with SB to that of a cohort of 75 patients who received ACB and PAI with LB. The primary outcome measure was pain measured using the visual analog score. The secondary outcome measures were morphine equivalents of pain medication (ME), physical therapy distance ambulated, disposition status, and length of stay. RESULTS: There were no significant differences between the two cohorts for age, gender, body mass index, preoperative diagnosis, or American Society of Anesthesiologists. Visual analog scores were significantly lower in the LB group for postoperative day (POD) 0 (2.1 vs 2.8, P = .046), POD 1 (2.2 vs 3.3, P < .001), and POD 2 (2.1 vs 3.7, P = .001) than those in the SB group. The LB group consumed significantly fewer ME on the POD 0 (18.7 vs 25.2, P = .02) and POD 1 (23.4 vs 37.8, P = .003), as well as overall ME/day (24.6 vs 41.7, P < .001). The LB group walked more on POD 0 (261.6 vs 108.2, P < .001) and POD 1 (761.5 vs 372.0, P < .001). CONCLUSIONS: We report improved outcomes across all measures for the LB group. There were no adverse events. This study supports the use of LB for ACBs in total knee arthroplasty.

The Impact of Running, Monofilament Barbed Suture for Subcutaneous Tissue Closure on Infection Rates in Total Hip Arthroplasty: A Retrospective Cohort Analysis.

BACKGROUND: Recently, running, monofilament barbed suture has become more popular as an efficient and economical alternative to traditional braided interrupted suture for wound closure following total joint arthroplasty. Its overall association with wound complications following surgery remains unknown at this time. Several studies have investigated its use in total knee arthroplasty (TKA), but there is limited literature surrounding use in total hip arthroplasty (THA). In this retrospective cohort study, our primary objective was to determine whether the use of monofilament barbed suture in THA was associated with reduced rates of postoperative infection when compared to traditional braided suture. METHODS: Patients who underwent primary unilateral THA between November 2011 and December 2017 by a single senior surgeon with closure using either monofilament barbed suture (162 patients) or braided interrupted suture (429 patients) were retrospectively reviewed for postoperative wound complications during the first 90 days after surgery. Demographics, comorbidities, and perioperative data were also included to assess for risk factors for infection. RESULTS: There was no difference between braided and barbed suture in overall rates of major complication, including periprosthetic joint infection (PJI) (0.47% vs 0.62%, P = .82) or revisions (1.86% vs 1.23%, P = .60). The overall rate of minor, superficial wound complications was also similar between both groups (6.1% vs 3.1%, P = .15). However, when superficial complications were categorized by type (dehiscence vs infection), the use of barbed suture was associated with a decreased rate of superficial wound infection (0% vs 5.4%, P = .003) and an increased rate of wound dehiscence (3.1% vs 0.7%, P = .04). CONCLUSION: The use of monofilament barbed suture for superficial skin closure in THA leads to similar overall rates of both major and minor wound complications when compared to traditional interrupted braided suture. However, while barbed suture was associated with fewer superficial infections, there was an increased incidence of wound dehiscence. Overall, barbed suture demonstrated a cumulatively equivalent rate of superficial wound complications compared to braided suture. Based on this investigation, barbed suture appears safe to use in THA and may represent an efficient and effective alternative to braided suture for wound closure. LEVEL OF EVIDENCE: Level IV; retrospective cohort study.

Transdermal Scopolamine as an Adjunct to Multimodal Pain Management in Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: Postoperative nausea and vomiting (PONV) after surgery degrades patient experience, tolerance of pain medication, rehabilitation progress, and functional outcomes. Given the importance of early rehabilitation following total joint arthroplasty (TJA), we asked whether transdermal scopolamine is effective in reducing rates of PONV and improving functional outcomes following TJA. METHODS: We retrospectively reviewed the charts of 1580 consecutive patients who underwent TJA between 2014 and 2017 and compared patients before the addition of the scopolamine patch (control group) to those after the addition (study group). Patients were given the scopolamine patch in the holding area unless contraindicated. A total of 495 patients were excluded. Charts were reviewed for PONV, demographic information, surgical time, length of stay, distance walked with physical therapy, and Visual Analog Scale pain scores. Student t-test was used to compare continuous data and chi-square was used for categorical variables. RESULTS: The incidence of PONV was significantly lower in the study group compared to the control group (14.4% vs 29.3%, P < .0001). Patients who were given scopolamine had lower Visual Analog Scale pain scores on postoperative days (POD) 0 through 2 (P < .01), were able to walk further distances on POD 0 through 3 (P < .001), and received fewer morphine equivalents on POD 1 and 2 (P < .001). Greater morphine equivalents were received by the study group on POD 0. CONCLUSION: Use of a scopolamine patch was associated with significant reduction in PONV and improvement in functional outcomes following TJA. These data support the use of transdermal scopolamine as part of a multimodal, perioperative pain protocol in patients undergoing TJA.

The Learning Curve by Operative Time for Soft Tissue Balancing in Total Knee Arthroplasty Using Electronic Sensor Technology.

BACKGROUND: Electronic sensor devices can provide an objective assessment of soft tissue balancing in total knee arthroplasty (TKA) which may potentially decrease postoperative pain. We aim to quantify the learning curve for operative time (OT) for this technology. METHODS: Consecutive TKA cases balanced with an electronic sensor balancing device by one senior surgeon from 2013 to 2017 were included in this study. The OT (in minutes) was analyzed using the cumulative sum analysis to evaluate the learning curve for this technology. Further analysis was done by splitting the 287 patients into 7 cohorts, 41 patients each. RESULTS: Two hundred eighty-seven patients balanced with sensor technology were available for analysis. The cumulative sum OT learning curve estimated that this technology's learning curve was 41 cases. This curve consisted of 2 phases: phase 1 which includes the first 41 cases and phase 2 which includes the remaining 246 patients. The mean OT for the first and last sensor-assisted cohorts was 120.4 and 108.9 minutes (P = .021). The mean OT for the first sensor-assisted cohort and the control cohort was 120.4 versus 109 minutes (P = .023). The mean OT for the last sensor-assisted cohort and the control cohort was 108.9 versus 109 minutes (P = .94). CONCLUSION: Our findings suggest that it takes approximately 41 cases of sensor-assisted TKA cases to achieve OTs identical to manually balanced TKA cases. This is a relatively shallow learning curve for the sensor technology, and allows arthroplasty surgeons to objectively achieve soft tissue balancing without adding OT to the surgery.

A risk-stratification algorithm to reduce superficial surgical site complications in primary hip and knee arthroplasty.

BACKGROUND: Surgical site complications (SSCs) are the most common cause for readmission after total joint arthroplasty (TJA), increasing costs while predisposing to inferior long-term outcomes. Prophylactic use of closed-incision negative pressure therapy (ciNPT) may lower the risk of these complications, especially in high-risk populations, but appropriate-use guidelines are lacking for patients undergoing primary TJA. We sought to develop a risk-stratification algorithm to guide use of ciNPT dressings and test its use in normalizing the rate of superficial SSCs among high-risk groups. METHODS: We reviewed 323 consecutive primary TJAs, where 38% of those patients considered at elevated risk were risk-stratified to receive ciNPT dressings. An individual risk score was developed, assigning points based on patient-specific risk factors. We identified a historical control population of 643 patients who all received the same postoperative dressing to test the impact of this risk score. RESULTS: Compared with historical controls, we observed a modest but significant improvement in superficial SSCs after implementation of risk-stratification (12.0% vs 6.8%; P = .013). Among high-risk patients, there was a marked improvement in SSCs when treated prophylactically with ciNPT dressings as compared with historical controls (26.2% vs 7.3%; P < .001). Low-risk patients, who continued to be treated with standard postoperative dressings, demonstrated no significant improvement (8.6% vs 6.5%; P = .344). CONCLUSIONS: ciNPT dressings are effective at reducing and normalizing risks of superficial SSCs among high-risk primary arthroplasty patients. The proposed risk-stratification algorithm may help identify those patients who benefit most from these dressings.