Examining patient demographics and major adverse cardiac events following noncardiac surgery: Applying a health equity lens.

BACKGROUND: Major adverse cardiac events (MACE) are a major contributor to postoperative complications. This study employed a health equity lens to examine rates of postoperative MACE by race and ethnicity. METHODS: This single-center, retrospective observational cohort study followed patients with and without pre-existing coronary artery stents from 2008 to 2018 who underwent non-cardiac surgery. MACE was the primary outcome (death, acute MI, repeated coronary revascularization, in-stent thrombosis) and self-reported race and ethnicity was the primary predictor. A propensity score model of a 1:1 cohort of non-Hispanic White (NHW) patients and all other racial and ethnic minority populations (Hispanic and Black) was used to compare the rate of perioperative MACE in this cohort. RESULTS: During the study period, 79,686 cases were included in the analytic sample; 950 patients (1.2 %) had pre-existing coronary artery stents. <1 % of patients experienced MACE within 30 days following non-cardiac surgery (0.8 %). After confounder adjustment and propensity score matching, there were no statistically significant differences in MACE among racial and ethnic minority patients compared to NHW patients (OR = 0.77; 95 % CI: 0.48, 1.25). In our sensitivity analyses, stratifying by sex, there were no differences in MACE by race and ethnicity. CONCLUSIONS: The study found no statistically significant differences in MACE by race and ethnicity among patients who underwent non-cardiac surgery. Access to a high-volume, high-quality hospital such as the one studied may reduce the presence of healthcare disparities and may explain why our findings are not consistent with previous studies.

Understanding the complexities of equity within the emergence and utilization of AI in academic medical centers.

This editorial discusses positions for academic medical centers to consider when designing and implementing artificial intelligence (AI) tools.

Urgent Spinal Surgery in a Lateral Decubitus on a Patient with a Left Ventricular Assist Device on Full Anticoagulation: A Case Report.

This case report aims to demonstrate the feasibility of performing spinal surgery in patients with a left ventricular assist device (LVAD), who are traditionally considered unsuitable candidates due to the need for anticoagulation and the challenges associated with the prone position. A case of a patient with an LVAD undergoing microdiscectomy in the left lateral decubitus position is presented. The procedure was carried out by a specialized interdisciplinary team with appropriate monitoring. The patient underwent the procedure safely, demonstrating that spinal surgery can be performed in patients with LVAD without reversing anticoagulation or resorting to the prone position. This approach mitigates the risk of thrombotic events and hemodynamic instability. This case study suggests that spinal surgery, specifically microdiscectomy, can be safely performed in patients with LVAD using the left lateral decubitus position. This finding has significant implications for patients who are unable to ambulate and therefore struggle to qualify for a heart transplant.

The role of methadone in cardiac surgery for management of postoperative pain.

Background: This retrospective study evaluated the efficacy and safety of intraoperative methadone compared with short-acting opioids. Methods: Patients undergoing cardiac surgery with cardiopulmonary bypass (n=11 967) from 2018 to 2023 from a single health system were categorised into groups based on intraoperative opioid administration: no methadone (Group O), methadone plus other opioids (Group M+O), and methadone only (Group M). Results: Patients in Groups M and M+O had lower mean pain scores until postoperative day (POD) 7 compared with Group O after adjusting for covariates (P<0.01). Both Groups M and M+O had lower total opioid administered compared with Group O for all days POD0-POD6 (all P<0.001). The median number of hours until initial postoperative opioid after surgery was 2.55 (inter-quartile range [IQR]=1.07-5.12), 6.82 (IQR=3.52-12.98), and 7.0 (IQR=3.82-12.95) for Group O, Group M+O, and Group M, respectively. The incidence of postoperative complications did not differ between groups. Conclusions: Intraoperative administration of methadone was associated with better pain control without significant side-effects after cardiac surgery.

Differences in the Receipt of Regional Anesthesia Based on Race and Ethnicity in Colorectal Surgery.

BACKGROUND: Health equity in pain management during the perioperative period continues to be a topic of interest. The authors evaluated the association of race and ethnicity with regional anesthesia in patients who underwent colorectal surgery and characterized trends in regional anesthesia. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2020, the research team identified patients who underwent open or laparoscopic colorectal surgery. Associations between race and ethnicity and use of regional anesthesia were estimated using logistic regression models. RESULTS: The final sample size was 292,797, of which 15.6% (n = 45,784) received regional anesthesia. The unadjusted rates of regional anesthesia for race and ethnicity were 15.7% white, 15.1% Black, 12.8% Asian, 29.6% American Indian or Alaska Native, 16.3% Native Hawaiian or Pacific Islander, and 12.4% Hispanic. Black (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.96, p < 0.001) and Asian (OR 0.76, 95% CI 0.71-0.80, p < 0.001) patients had lower odds of regional anesthesia compared to white patients. Hispanic patients had lower odds of regional anesthesia compared to non-Hispanic patients (OR 0.72, 95% CI 0.68-0.75, p < 0.001). There was a significant annual increase in regional anesthesia from 2015 to 2020 for all racial and ethnic cohorts (p < 0.05). CONCLUSION: There was an annual increase in the use of regional anesthesia, yet Black and Asian patients (compared to whites) and Hispanics (compared to non-Hispanics) were less likely to receive regional anesthesia for colorectal surgery. These differences suggest that there are racial and ethnic differences in regional anesthesia use for colorectal surgery.

Postanesthesia Care Unit and Anesthetic Management Outcomes Among Patients Undergoing Noncardiac Surgery: Differences by Race and Ethnicity.

PURPOSE: To investigate the association of patient race and ethnicity with postanesthesia care unit (PACU) outcomes in common, noncardiac surgeries requiring general anesthesia. DESIGN: Single tertiary care academic medical center retrospective matched cohort. METHODS: We matched 1:1 1836 adult patients by race and/or ethnicity undergoing common surgeries. We compared racial and ethnic minority populations (62 American Indian, 250 Asian, 315 Black or African American, 281 Hispanic, and 10 Pacific Islander patients) to 918 non-Hispanic White patients. The primary outcomes were: the use of an appropriate number of postoperative nausea and vomiting (PONV) prophylactics; the incidence of PONV; and the use of a propofol infusion as part of the anesthetic (PROP). Secondary outcomes were: the use of opioid-sparing multimodal analgesia, including the use of regional anesthesia for postoperative pain control; the use of any local anesthetic, including the use of liposomal bupivacaine; the duration until readiness for discharge from the PACU; the time between arrival to PACU and first pain score; and the time between the first PACU pain score of ≥4 and administration of an analgesic. Logistic and linear regression were used for relevant outcomes of interest. FINDINGS: Overall, there were no differences in the appropriate number of PONV prophylactics, nor the incidence of PONV between the two groups. There was, however, a decreased use of PROP (OR = 0.80; 95% CI: 0.69, 0.94; P = .005), PACU length of stay was 9.56 minutes longer (95% CI: 2.62, 16.49; P = .007), and time between arrival to PACU and first pain score was 2.30 minutes longer in patients from racial and ethnic minority populations (95% CI: 0.99, 3.61; P = .001). There were no statistically significant differences in the other secondary outcomes. CONCLUSIONS: The rate of appropriate number of PONV prophylactic medications as well as the incidence of PONV were similar in patients from racial and ethnic minority populations compared to non-Hispanic White patients. However, there was a lower use of PROP in racial and ethnic minority patients. It is important to have a health equity lens to identify differences in management that may contribute to disparities within each phase of perioperative care.

Racial and Ethnic Disparities in Perioperative Health Care Among Patients Undergoing Cardiac Surgery: JACC State-of-the-Art Review.

There has been little progress in reducing health care disparities since the 2003 landmark Institute of Medicine's report Unequal Treatment. Despite the higher burden of cardiovascular disease in underrepresented racial and ethnic groups, they have less access to cardiologists and cardiothoracic surgeons, and have higher rates of morbidity and mortality with cardiac surgical interventions. This review summarizes existing literature and highlights disparities in cardiovascular perioperative health care. We propose actionable solutions utilizing multidisciplinary perspectives from cardiology, cardiac surgery, cardiothoracic anesthesiology, critical care, medical ethics, and health disparity experts. Applying a health equity lens to multipronged interventions is necessary to eliminate the disparities in perioperative health care among patients undergoing cardiac surgery.

Arterial Hyperoxemia During Cardiopulmonary Bypass Was Not Associated With Worse Postoperative Pulmonary Function: A Retrospective Cohort Study.

BACKGROUND: Arterial hyperoxemia may cause end-organ damage secondary to the increased formation of free oxygen radicals. The clinical evidence on postoperative lung toxicity from arterial hyperoxemia during cardiopulmonary bypass (CPB) is scarce, and the effect of arterial partial pressure of oxygen (Pa o2 ) during cardiac surgery on lung injury has been underinvestigated. Thus, we aimed to examine the relationship between Pa o2 during CPB and postoperative lung injury. Secondarily, we examined the relationship between Pa o2 and global (lactate), and regional tissue malperfusion (acute kidney injury). We further explored the association with regional tissue malperfusion by examining markers of cardiac (troponin) and liver injury (bilirubin). METHODS: This was a retrospective cohort study including patients who underwent elective cardiac surgeries (coronary artery bypass, valve, aortic, or combined) requiring CPB between April 2015 and December 2021 at a large quaternary medical center. The primary outcome was postoperative lung function defined as the ratio of Pa o2 to fractional inspired oxygen concentration (F io2 ); P/F ratio 6 hours following surgery or before extubation. The association between CPB in-line sample monitor Pa o2 and primary, secondary, and exploratory outcomes was evaluated using linear or logistic regression models adjusting for available baseline confounders. RESULTS: A total of 9141 patients met inclusion and exclusion criteria, and 8429 (92.2%) patients had complete baseline variables available and were included in the analysis. The mean age of the sample was 64 (SD = 13), and 68% were men (n = 6208). The time-weighted average (TWA) of in-line sample monitor Pa o2 during CPB was weakly positively associated with the postoperative P/F ratio. With a 100-unit increase in Pa o2 , the estimated increase in postoperative P/F ratio was 4.61 (95% CI, 0.71-8.50; P = .02). Our secondary analysis showed no significant association between Pa o2 with peak lactate 6 hours post CPB (geometric mean ratio [GMR], 1.01; 98.3% CI, 0.98-1.03; P = .55), average lactate 6 hours post CPB (GMR, 1.00; 98.3% CI, 0.97-1.03; P = .93), or acute kidney injury by Kidney Disease Improving Global Outcomes (KDIGO) criteria (odds ratio, 0.91; 98.3% CI, 0.75-1.10; P = .23). CONCLUSIONS: Our investigation found no clinically significant association between Pa o2 during CPB and postoperative lung function. Similarly, there was no association between Pa o2 during CPB and lactate levels, postoperative renal function, or other exploratory outcomes.

Individual- and Community-Level Socioeconomic Status and Deceased Donor Renal Transplant Outcomes.

BACKGROUND: This study examined the relationship between socioeconomic status (SES), race, and ethnicity and clinical outcomes following deceased donor kidney transplant (DDKT) at a high-volume transplant center. METHODS: This retrospective cohort study used regression models and survival analyses to examine the relationship between individual- and community-level SES, race, and ethnicity and DDKT outcomes (i.e., delayed graft function, graft failure, mortality) adjusting for potential confounders. RESULTS: The analytic sample included 3366 patients; 40.7% (n = 1370) were female, the mean age was 54.7 (SD = 13.3) years, 49.3% were non-Hispanic White, and the median follow-up time was 39.5 months (IQR = 24.2-68.1). Patients living in the most disadvantaged communities (using the US Census data) had a higher likelihood of delayed graft function (adjusted relative risk [RR] = 1.12, p = 0.042) and a higher hazard of mortality (adjusted hazard ratio [HR] = 1.32, p = 0.025) compared to patients living in the least disadvantaged communities. Patients without a high school diploma had a higher risk of delayed graft function compared to patients with an associate degree or more (RR = 1.37, p < 0.001). Patients with public insurance coverage had a higher risk of delayed graft function (RR = 1.24, p < 0.001) and a higher hazard of mortality (HR = 1.37, p < 0.001) and graft failure (HR = 1.71, p < 0.001) compared to patients without public insurance. There were no differences in graft failure or mortality by race and ethnicity. CONCLUSIONS: SES was not consistently associated with outcomes following DDKT; however, many of the predictors were associated with delayed graft function. With a large and diverse sample size, these findings further the heterogeneity of the present renal transplant research suggesting the need for further investigation to guide implementation of innovative strategies and interventions.

Development of a systematic social observation tool for monitoring use of harm reduction supplies.

BACKGROUND: Harm reduction services such as safer injection supply distribution are essential to reducing morbidity and mortality among people who use drugs (PWUD); however, local use of harm reduction supplies (e.g., tourniquets, saline solution) is difficult to routinely and systematically monitor. The purpose of this study was to develop and validate a systematic social observation tool designed to assess use of harm reduction supplies at the street block level. METHODS: Data collection took place on a random sample of 150 blocks located throughout the Kensington neighborhood of North Philadelphia from November 2021 to January 2022. We measured inter-rater reliability by two-way mixed-effects intra-class correlation coefficients (ICC) with the consistency agreement definition and internal consistency reliability using Cronbach's alpha and McDonald's omega. Exploratory factor analysis with principal component extraction and promax rotation assessed internal consistency. We validated scales against locations of public syringe disposal boxes, a proxy measure for areas of concentrated drug use, using logistic regression. RESULTS: Naloxone canisters, syringe caps, saline and sterile water solution bottles showed the highest reliability (ICC≥0.7). Items also showed high internal consistency (alpha, omega>0.7). Exploratory factor analysis identified one, three-item scale with high internal consistency: syringe caps, vials, and baggies (alpha = 0.85; omega = 0.85)-all supplies used concurrently with drug injection but not discarded in syringe disposal boxes. Drug use (OR = 1.78, 95 % CI = (1.48, 2.23)), harm reduction (OR = 3.53, 95 % CI = (2.20, 6.12)), and EFA scales (OR = 1.85, 95 %CI = (1.51, 2.34)) were significantly and positively associated with being within walking distance (≤0.25 miles or 0.4 km) of a syringe disposal box. CONCLUSION: This study provides an efficient tool with high reliability and validity metrics to assess community uptake of harm reduction supplies designed for use by community organizations, policy makers, or other groups providing resources to PWUD.

Interventional Pain Physician Burnout During the COVID-19 Pandemic: A Survey from the American Society of Pain and Neuroscience.

PURPOSE OF REVIEW: The study sought to assess the prevalence of physician burnout among interventional pain physicians in 2022. RECENT FINDINGS: Physician burnout is major psychosocial and occupational health issue. Prior to the coronavirus disease of 2019 (COVID-19) pandemic, over 60% of physicians reported emotional exhaustion and burnout. Physician burnout was reported to become more prevalent in multiple medical specialties during the COVID-19 pandemic. An 18-question survey was distributed electronically to all ASPN members (n = 7809) in the summer of 2022 to assess demographics, burnout characteristics (e.g., Have you felt burned out due to COVID?), and strategies to cope with burnout and stress (e.g., reached out for mental health assistance). Members were able to complete the survey once and were unable to make changes to their responses once submitted. Descriptive statistics were used to assess the prevalence and severity of physician burnout within the ASPN community. Chi-square tests were used to examine differences in burnout by provider characteristics (age, gender, years practicing, and practice type) with p-values less than 0.05 indicating statistical significance. There were 7809 ASPN members that received the survey email, 164 of those members completed the survey, a response rate of 2.1%. The majority of respondents were male (74.1%, n = 120), 94% were attending physicians (n = 152), and 26% (n = 43) have been in practice for twenty years or longer. Most respondents expressed having experienced burnout during the COVID pandemic (73.5%, n = 119), 21.6% of the sample reported reduced hours and responsibilities during the pandemic, and 6.2% of surveyed physicians quit or retired due to burnout. Nearly half of responders reported negative impacts to their family and social lives as well as personal physical and mental health. A variety of negative (e.g., changes in diet, smoking/vaping) and positive coping strategies (e.g., exercise and training, spiritual enrichment) were employed in response to stress and burnout; 33.5% felt they should or had reached out for mental health assistance and suicidal ideations were expressed in 6.2% due to burnout. A high percentage of interventional pain physicians continue to experience mental symptoms that may lead to risk for significant issues going forward. Our findings should be interpreted with caution based on the low response rate. Evaluation of burnout should be incorporated into annual assessments given issues of survey fatigue and low survey response rates. Interventions and strategies to address burnout are warranted.

Influence of Social Media on Applicant Perceptions of Anesthesiology Residency Programs During the COVID-19 Pandemic: Quantitative Survey.

BACKGROUND: Social media may be an effective tool in residency recruitment, given its ability to engage a broad audience; however, there are limited data regarding the influence of social media on applicants' evaluation of anesthesiology residency programs. OBJECTIVE: This study evaluates the influence of social media on applicants' perceptions of anesthesiology residency programs during the COVID-19 pandemic to allow programs to evaluate the importance of a social media presence for residency recruitment. The study also sought to understand if there were differences in the use of social media by applicant demographic characteristics (eg, race, ethnicity, gender, and age). We hypothesized that given the COVID-19 pandemic restrictions on visiting rotations and the interview process, the social media presence of anesthesiology residency programs would have a positive impact on the recruitment process and be an effective form of communication about program characteristics. METHODS: All anesthesiology residency applicants who applied to Mayo Clinic Arizona were emailed a survey in October 2020 along with statements regarding the anonymity and optional nature of the survey. The 20-item Qualtrics survey included questions regarding subinternship rotation completion, social media resource use and impact (eg, "residency-based social media accounts positively impacted my opinion of the program"), and applicant demographic characteristics. Descriptive statistics were examined, and perceptions of social media were stratified by gender, race, and ethnicity; a factor analysis was performed, and the resulting scale was regressed on race, ethnicity, age, and gender. RESULTS: The survey was emailed to 1091 individuals who applied to the Mayo Clinic Arizona anesthesiology residency program; there were 640 unique responses recorded (response rate=58.6%). Nearly 65% of applicants reported an inability to complete 2 or more planned subinternships due to COVID-19 restrictions (n=361, 55.9%), with 25% of applicants reporting inability to do any visiting student rotations (n=167). Official program websites (91.5%), Doximity (47.6%), Instagram (38.5%), and Twitter (19.4%) were reported as the most used resources by applicants. The majority of applicants (n=385, 67.3%) agreed that social media was an effective means to inform applicants, and 57.5% (n=328) of them indicated that social media positively impacted their perception of the program. An 8-item scale with good reliability was created, representing the importance of social media (Cronbach α=.838). There was a positive and statistically significant relationship such that male applicants (standardized ß=.151; P=.002) and older applicants (ß=.159; P<.001) had less trust and reliance in social media for information regarding anesthesiology residency programs. The applicants' race and ethnicity were not associated with the social media scale (ß=-.089; P=.08). CONCLUSIONS: Social media was an effective means to inform applicants, and generally positively impacted applicants' perception of programs. Thus, residency programs should consider investing time and resources toward building a social media presence to improve resident recruitment.