Clinical Focus

  • Anesthesia

Academic Appointments

Boards, Advisory Committees, Professional Organizations

  • Committee on Evidence- Based Clinical Practice Guidelines to Prescribing Opioids for Acute Pain, National Academies of Science, Engineering, and Medicine (2018 - 2019)
  • Senior Economist, Council of Economic Advisers, Executive Office of the President (2019 - 2020)
  • Member, Committee on Health and Public Policy, American Society of Anesthesiologists (2015 - 2017)
  • Member, Committee on Anesthesia Workforce Trends, American Society of Anesthesiologists (2018 - Present)
  • Associate Editor, Anesthesiology (2019 - Present)
  • Associate Editor, Anesthesia and Analgesia (2015 - Present)

Professional Education

  • Residency: Stanford University Anesthesiology Residency (2014) CA
  • Internship: Santa Clara Valley Medical Center (2011) CA United States of America
  • Medical Education: Pritzker School of Medicine University of Chicago Registrar (2010) IL
  • Board Certification: American Board of Anesthesiology, Anesthesia (2016)
  • PhD, University of Chicago Booth Graduate School of Business, Business Economics (2006)

Current Research and Scholarly Interests

My research examines questions of health economics and health policy, with a focus on economics and policy in the perioperative setting. Current research topics include the economics of treatments for chronic pain, as well as how physician practice organization affects outcomes and costs.

2023-24 Courses

Stanford Advisees

All Publications

  • Preoperative GLP-1 Receptor Agonist Use and Risk of Postoperative Respiratory Complications. JAMA Dixit, A. A., Bateman, B. T., Hawn, M. T., Odden, M. C., Sun, E. C. 2024

    View details for DOI 10.1001/jama.2024.5003

    View details for PubMedID 38648036

    View details for PubMedCentralID PMC11036309

  • Assessment of Perioperative Outcomes Among Surgeons Who Operated the Night Before. JAMA internal medicine Sun, E. C., Mello, M. M., Vaughn, M. T., Kheterpal, S., Hawn, M. T., Dimick, J. B., Jena, A. B. 2022


    Importance: The association between physician fatigue and patient outcomes is important to understand but has been difficult to examine given methodological and data limitations. Surgeons frequently perform urgent procedures overnight and perform additional procedures the following day, which could adversely affect outcomes for those daytime operations.Objective: To examine the association between an attending surgeon operating overnight and outcomes for operations performed by that surgeon the next day.Design, Setting, and Participants: In this cross-sectional study, a retrospective analysis of a large multicenter registry of surgical procedures was done using a within-surgeon analysis to address confounding, with data from 20 high-volume US institutions. This study included 498 234 patients who underwent a surgical procedure during the day (between 7 am and 5 pm) between January 1, 2010, and August 30, 2020.Exposures: Whether the attending surgeon for the current day's procedures operated between 11 pm and 7 am the previous night. Two exposure measures were examined: whether the surgeon operated at all the previous night and the number of hours spent operating the previous night (including having performed no work at all).Main Outcomes and Measures: The primary composite outcome was in-hospital death or major complication (sepsis, pneumonia, myocardial infarction, thromboembolic event, or stroke). Secondary outcomes included operation length and individual outcomes of death, major complications, and minor complications (surgical site infection or urinary tract infection).Results: Among 498 234 daytime operations performed by 1131 surgeons, 13 098 (2.6%) involved an attending surgeon who operated the night before. The mean (SD) age of the patients who underwent an operation was 55.3 (16.4) years, and 264 740 (53.1%) were female. After adjusting for operation type, surgeon fixed effects, and observable patient characteristics (ie, age and comorbidities), the adjusted incidence of in-hospital death or major complications was 5.89% (95% CI, 5.41%-6.36%) among daytime operations when the attending surgeon operated the night before compared with 5.87% (95% CI, 5.85%-5.89%) among daytime operations when the same surgeon did not (absolute adjusted difference, 0.02%; 95% CI, -0.47% to 0.51%; P=.93). No significant associations were found between overnight work and secondary outcomes except for operation length. Operating the previous night was associated with a statistically significant decrease in length of daytime operations (adjusted length, 112.7 vs 117.4 minutes; adjusted difference, -4.7 minutes; 95% CI, -8.7 to -0.8, P=.02), although this difference is unlikely to be meaningful.Conclusions and Relevance: The findings of this cross-sectional study suggest that operating overnight was not associated with worse outcomes for operations performed by surgeons the subsequent day. These results provide reassurance concerning the practice of having attending surgeons take overnight call and still perform operations the following morning.

    View details for DOI 10.1001/jamainternmed.2022.1563

    View details for PubMedID 35604661

  • Assessment of Out-of-Network Billing for Privately Insured Patients Receiving Care in In-Network Hospitals. JAMA internal medicine Sun, E. C., Mello, M. M., Moshfegh, J., Baker, L. C. 2019


    Importance: Although surprise medical bills are receiving considerable attention from lawmakers and the news media, to date there has been little systematic study of the incidence and financial consequences of out-of-network billing.Objective: To examine out-of-network billing among privately insured patients with an inpatient admission or emergency department (ED) visit at in-network hospitals.Design, Setting, and Participants: A retrospective analysis using data from the Clinformatics Data Mart database (Optum), which includes health insurance claims for individuals from all 50 US states receiving private health insurance from a large commercial insurer was conducted of all inpatient admissions (n=5 457 981) and ED visits (n=13 579 006) at in-network hospitals between January 1, 2010, and December 31, 2016. Data were collected and analyzed in March 2019.Exposures: Receipt of a bill for care from at least 1 out-of-network physician or medical transport service associated with patient admission or ED visit.Main Outcomes and Measures: The incidence of out-of-network billing and the potential amount of patients' financial liability associated with out-of-network bills from the admission or visit.Results: Of 5 457 981 inpatient admissions and 13 579 006 ED admissions between 2010 and 2016, the percentage of ED visits with an out-of-network bill increased from 32.3% to 42.8% (P<.001) during the study period, and the mean (SD) potential financial responsibility for these bills increased from $220 ($420) to $628 ($865) (P<.001; all dollar values in 2018 US$). Similarly, the percentage of inpatient admissions with an out-of-network bill increased from 26.3% to 42.0% (P<.001), and the mean (SD) potential financial responsibility increased from $804 ($2456) to $2040 ($4967) (P<.001).Conclusions and Relevance: Out-of-network billing appears to have become common for privately insured patients even when they seek treatment at in-network hospitals. The mean amounts billed appear to be sufficiently large that they may create financial strain for a substantial proportion of patients.

    View details for DOI 10.1001/jamainternmed.2019.3451

    View details for PubMedID 31403651

  • Association of Overlapping Surgery With Perioperative Outcomes JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Sun, E., Mello, M. M., Rishel, C. A., Vaughn, M. T., Kheterpal, S., Saager, L., Fleisher, L. A., Damrose, E. J., Kadry, B., Jena, A. B., Kooij, F., Wilczak, J., Soto, R., Berris, J., Price, Z., Urman, R. D., Lins, S., Harris, J. M., Cummings, K. C., Berman, M. F., Nanamori, M., Adelman, B. T., Wedeven, C., Bittner, E. A., LaGorio, J., McCormick, P. J., Tom, S., Aziz, M. F., Coffman, T., Ellis, T. A., Molina, S., Peterson, W., Mackey, S. C., van Klei, W. A., Mahajan, A., Geffen, D., Jameson, L. C., Biggs, D. A., Craft, R., Pace, N. L., Paganelli, W. C., Durieux, M. E., Nair, B. J., Wanderer, J. P., Miller, S. A., Helsten, D. L., Turnbull, Z. A., Schonberger, R. B., MPOG 2019; 321 (8): 762–72
  • Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis BMJ-BRITISH MEDICAL JOURNAL Sun, E. C., Dixit, A., Humphreys, K., Darnall, B. D., Baker, L. C., Mackey, S. 2017; 356


    Objectives To identify trends in concurrent use of a benzodiazepine and an opioid and to identify the impact of these trends on admissions to hospital and emergency room visits for opioid overdose.Design Retrospective analysis of claims data, 2001-13.Setting Administrative health claims database.Participants 315 428 privately insured people aged 18-64 who were continuously enrolled in a health plan with medical and pharmacy benefits during the study period and who also filled at least one prescription for an opioid.Interventions Concurrent benzodiazepine/opioid use, defined as an overlap of at least one day in the time periods covered by prescriptions for each drug. Main outcome measures Annual percentage of opioid users with concurrent benzodiazepine use; annual incidence of visits to emergency room and inpatient admissions for opioid overdose.Results 9% of opioid users also used a benzodiazepine in 2001, increasing to 17% in 2013 (80% relative increase). This increase was driven mainly by increases among intermittent, as opposed to chronic, opioid users. Compared with opioid users who did not use benzodiazepines, concurrent use of both drugs was associated with an increased risk of an emergency room visit or inpatient admission for opioid overdose (adjusted odds ratio 2.14, 95% confidence interval 2.05 to 2.24; P<0.001) among all opioid users. The adjusted odds ratio for an emergency room visit or inpatient admission for opioid overdose was 1.42 (1.33 to 1.51; P<0.001) for intermittent opioid users and 1.81 (1.67 to 1.96; P<0.001) chronic opioid users. If this association is causal, elimination of concurrent benzodiazepine/opioid use could reduce the risk of emergency room visits related to opioid use and inpatient admissions for opioid overdose by an estimated 15% (95% confidence interval 14 to 16).Conclusions From 2001 to 2013, concurrent benzodiazepine/opioid use sharply increased in a large sample of privately insured patients in the US and significantly contributed to the overall population risk of opioid overdose.

    View details for DOI 10.1136/bmj.j760

    View details for Web of Science ID 000397014900002

    View details for PubMedID 28292769

  • Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period. JAMA internal medicine Sun, E. C., Darnall, B. D., Baker, L. C., Mackey, S. 2016; 176 (9): 1286-1293


    Chronic opioid use imposes a substantial burden in terms of morbidity and economic costs. Whether opioid-naive patients undergoing surgery are at increased risk for chronic opioid use is unknown, as are the potential risk factors for chronic opioid use following surgery.To characterize the risk of chronic opioid use among opioid-naive patients following 1 of 11 surgical procedures compared with nonsurgical patients.Retrospective analysis of administrative health claims to determine the association between chronic opioid use and surgery among privately insured patients between January 1, 2001, and December 31, 2013. The data concluded 11 surgical procedures (total knee arthroplasty [TKA], total hip arthroplasty, laparoscopic cholecystectomy, open cholecystectomy, laparoscopic appendectomy, open appendectomy, cesarean delivery, functional endoscopic sinus surgery [FESS], cataract surgery, transurethral prostate resection [TURP], and simple mastectomy). Multivariable logistic regression analysis was performed to control for possible confounders, including sex, age, preoperative history of depression, psychosis, drug or alcohol abuse, and preoperatice use of benzodiazepines, antipsychotics, and antidepressants.One of the 11 study surgical procedures.Chronic opioid use, defined as having filled 10 or more prescriptions or more than 120 days' supply of an opioid in the first year after surgery, excluding the first 90 postoperative days. For nonsurgical patients, chronic opioid use was defined as having filled 10 or more prescriptions or more than 120 days' supply following a randomly assigned "surgery date."The study included 641 941 opioid-naive surgical patients (169 666 men; mean [SD] age, 44.0 [12.8] years), and 18 011 137 opioid-naive nonsurgical patients (8 849 107 men; mean [SD] age, 42.4 [12.6] years). Among the surgical patients, the incidence of chronic opioid in the first preoperative year ranged from 0.119% for Cesarean delivery (95% CI, 0.104%-0.134%) to 1.41% for TKA (95% CI, 1.29%-1.53%) The baseline incidence of chronic opioid use among the nonsurgical patients was 0.136% (95% CI, 0.134%-0.137%). Except for cataract surgery, laparoscopic appendectomy, FESS, and TURP, all of the surgical procedures were associated with an increased risk of chronic opioid use, with odds ratios ranging from 1.28 (95% CI, 1.12-1.46) for cesarean delivery to 5.10 (95% CI, 4.67-5.58) for TKA. Male sex, age older than 50 years, and preoperative history of drug abuse, alcohol abuse, depression, benzodiazepine use, or antidepressant use were associated with chronic opioid use among surgical patients.In opioid-naive patients, many surgical procedures are associated with an increased risk of chronic opioid use in the postoperative period. A certain subset of patients (eg, men, elderly patients) may be particularly vulnerable.

    View details for DOI 10.1001/jamainternmed.2016.3298

    View details for PubMedID 27400458

  • Association between Anesthesia Group Size and Merit-Based Incentive Payment System Scores. Anesthesiology Sekeres, G., Miller, T. R., Mariano, E. R., Glance, L. G., Sun, E. C. 2024; 140 (4): 853-855

    View details for DOI 10.1097/ALN.0000000000004887

    View details for PubMedID 38470114

  • Variability in Intraoperative Opioid and Nonopioid Utilization During Intracranial Surgery: A Multicenter, Retrospective Cohort Study. Journal of neurosurgical anesthesiology Naik, B. I., Lele, A. V., Sharma, D., Akkermans, A., Vlisides, P. E., Colquhoun, D. A., Domino, K. B., Tsang, S., Sun, E., Dunn, L. K. 2024


    Key goals during intracranial surgery are to facilitate rapid emergence and extubation for early neurologic evaluation. Longer-acting opioids are often avoided or administered at subtherapeutic doses due to their perceived risk of sedation and delayed emergence. However, inadequate analgesia and increased postoperative pain are common after intracranial surgery. In this multicenter study, we describe variability in opioid and nonopioid administration patterns in patients undergoing intracranial surgery.This was a multicenter, retrospective observational cohort study using the Multicenter Perioperative Outcomes Group database. Opioid and nonopioid practice patterns in 31,217 cases undergoing intracranial surgery across 11 institutions in the United States are described.Across all 11 institutions, total median [interquartile range] oral morphine equivalents, normalized to weight and anesthesia duration was 0.17 (0.08 to 0.3) There was a 7-fold difference in oral morphine equivalents between the lowest (0.05 [0.02 to 0.13] and highest (0.36 [0.18 to 0.54] prescribing institutions. Patients undergoing supratentorial surgery had higher normalized oral morphine equivalents compared with those having infratentorial surgery [0.17 [0.08-0.31] vs. 0.15 [0.07-0.27] mg/kg/min-1; P<0.001); however, this difference is clinically small. Nonopioid analgesics were not administered in 20% to 96.8% of cases across institutions.This study found wide variability for both opioid and nonopioid utilization at an institutional level. Future work on practitioner-level opioid and nonopioid use and its impact on outcomes after intracranial surgery should be conducted.

    View details for DOI 10.1097/ANA.0000000000000960

    View details for PubMedID 38546217

  • A Cost and Waste-Savings Comparison Between Single-Use and Reusable Pulse Oximetry Sensors Across US Operating Rooms. Anesthesia and analgesia Stockert, E. W., Carvalho, B., Sun, E. C. 2024


    BACKGROUND: Operating room (OR) expenditures and waste generation are a priority, with several professional societies recommending the use of reprocessed or reusable equipment where feasible. The aim of this analysis was to compare single-use pulse oximetry sensor stickers ("single-use stickers") versus reusable pulse oximetry sensor clips ("reusable clips") in terms of annual cost savings and waste generation across all ORs nationally.METHODS: This study did not involve patient data or research on human subjects. As such, it did not meet the requirements for institutional review board approval. An economic model was used to compare the relative costs and waste generation from using single-use stickers versus reusable clips. This model took into account: (1) the relative prices of single-use stickers and reusable clips, (2) the number of surgeries and ORs nationwide, (3) the workload burden of cleaning the reusable clips, and (4) the costs of capital for single-use stickers and reusable clips. In addition, we also estimated differences in waste production based on the raw weight plus unit packaging of single-use stickers and reusable clips that would be disposed of over the course of the year, without any recycling interventions. Estimated savings were rounded to the nearest $0.1 million.RESULTS: The national net annual savings of transitioning from single-use stickers to reusable clips in all ORs ranged from $510.5 million (conservative state) to $519.3 million (favorable state). Variability in savings estimates is driven by scenario planning for replacement rate of reusable clips, workload burden of cleaning (ranging from an additional expense of $618k versus a cost savings of $309k), and cost of capital-interest gained on investment of capital that is freed up by the monetary savings of a transition to reusable clips contributes between $541k (low-interest rates of 2.85%) and $1.3 million (high-interest rates of 7.08%). The annual waste that could be diverted from landfill by transitioning to reusable clips was found to be between 587 tons (conservative state) up to 589 tons (favorable state). If institutions need to purchase new vendor monitors or cables to make the transition, that may increase the 1-time capital disbursement.CONCLUSIONS: Using reusable clips versus single-use stickers across all ORs nationally would result in appreciable annual cost savings and waste generation reduction impact. As both single-use stickers and reusable clips are equally accurate and reliable, this cost and waste savings could be instituted without a compromise in clinical care.

    View details for DOI 10.1213/ANE.0000000000006778

    View details for PubMedID 38195082

  • Association of Patient Race and Hospital with Utilization of Regional Anesthesia for Treatment of Post-Operative Pain in Total Knee Arthroplasty: A Retrospective Analysis Using Medicare Claims. Anesthesiology Dixit, A. A., Sekeres, G., Mariano, E. R., Memtsoudis, S. G., Sun, E. C. 2023


    Regional anesthesia for total knee arthroplasty has been deemed high priority by national and international societies and its use can serve as a measure of healthcare equity. We estimated the association between utilization of regional anesthesia for postoperative pain and 1) race and 2) hospital in patients undergoing total knee arthroplasty. We hypothesized that Black patients would be less likely than White patients to receive regional anesthesia, and that variability in regional anesthesia would more likely be attributable to the hospital where surgery occurred than race.We used Medicare fee-for-service claims for patients aged 65 or older who underwent primary total knee arthroplasty between 1/1/2011 and 12/31/2016. Our primary outcome was administration of regional anesthesia for postoperative pain, defined as any peripheral (femoral, lumbar plexus, or other) or neuraxial (spinal or epidural) block. Our primary exposure was self-reported race (Black, White, or Other). We defined clinical significance as a relative difference of 10% in regional anesthesia administration.Data from 733,406 cases across 2,507 hospitals were analyzed: 90.7% of patients were identified as White, 4.7% as Black, and 4.6% as Other. Median hospital-level prevalence of use of regional anesthesia was 51% (interquartile range 18-79%). Black patients did not have a statistically different probability of receiving a regional anesthetic compared to White patients (adjusted estimates: Black 53.3%, 95% CI 52.5-54.1%; White 52.7%, 95% CI 52.4-54.1%, p=0.132). Findings were robust to alternate specifications of the exposure and outcome. Analysis-of-variance revealed that 42.0% of the variation in block administration was attributable to hospital, compared to less than 0.01% to race, after adjusting for other patient-level confounders.Race was not associated with administration of regional anesthesia in Medicare patients undergoing primary total knee arthroplasty. Variation in the use of regional anesthesia was primarily associated with the hospital where surgery occurred.

    View details for DOI 10.1097/ALN.0000000000004827

    View details for PubMedID 37910860

  • Association Between "Balance Billing" Legislation and Anesthesia Payments in California: A Retrospective Analysis. Anesthesiology Dixit, A., Heavner, D. L., Baker, L. C., Sun, E. C. 2023


    Insured patients who receive out-of-network care may receive a "balance bill" for the difference between the practitioner's charge and their insurer's contracted rate. In 2017, California banned balance billing for anesthesia care. We examined the association between California's law and subsequent payments for anesthesia care. We hypothesized that following the law's implementation, there would be no change in-network payment amounts, and that out-of-network payment amounts and the portion of claims occurring out-of-network would decline.We used average, quarterly, California county-level payment data (2013-2020) derived from a claims database of commercially-insured patients. Using a difference-in-differences approach, we estimated the change in payment amounts for intraoperative/intrapartum anesthesia care, along with the portion of claims occurring out-of-network, following the law's implementation. The comparison group was office visit payments, expected to be unaffected by the law. We prespecified that we would refer to differences of ≥10% as policy significant.Our sample consisted of 43,728 procedure code-county-quarter-network combinations aggregated from 4,599,936 claims. The law's implementation was associated with a significant 13.6% decline in payments for out-of-network anesthesia care (95%CI -16.5 to -10.6%; p<0.001), translating to an average $108 decrease across all procedures (95%CI -$149 to -$64). There was a statistically significant 3.0% increase in payments for in-network anesthesia care (95%CI 0.9 to 5.1%; p=0.007), translating to an average $87 increase (95%CI $64 to $110), which may be notable in some circumstances but did not meet our threshold for identifying a change as policy significant. There was a non-statistically significant increase in the portion of claims occurring out-of-network (10.0%, 95%CI -4.1 to 24.2%, p=0.155).California's balance billing law was associated with significant declines in out-of-network anesthesia payments in the first three years following implementation. There were mixed statistical and policy significant results for in-network payments and the proportion of out-of-network claims.

    View details for DOI 10.1097/ALN.0000000000004675

    View details for PubMedID 37406154

  • Association Between Naloxone Co-Prescription Mandates and Post-Operative Outcomes. Annals of surgery Du, A. L., Rishel, C. A., Sun, E. C. 2023


    INTRODUCTION: The opioid epidemic is a public health issue in the United States. The objective of this study was to evaluate the association between naloxone co-prescription mandates and postoperative outcomes.SUMMARY BACKGROUND DATA: Data on naloxone co-prescription mandates show mixed evidence for fatal overdoses in the broader population. How these mandates have impacted surgical patients has not been fully explored.METHODS: Healthcare claims data were used to identify all patients undergoing 1 of 50 common procedures between January 1, 2004 and June 30, 2019 and categorized as high-risk for opioid overdose. The primary outcomes were an emergency department visit or hospital admission within 30 postoperative days. To reduce confounding, the association between this outcome and the implementation of naloxone co-prescription mandates was estimated using a difference-in-differences approach.RESULTS: The study included 429,878 surgical patients with an average age of 54.8 years (s.d. 15.9y) and with 257,728 females (60.0%). There was no significant association between naloxone prescribing mandates and the primary outcomes. After adjustment for potential confounders, the incidence of a hospital admission was 3.26% after implementation of a naloxone co-prescription mandate compared to 3.33% before (difference change -0.08%, 95% CI -0.44% to 0.29%, P=0.68). The incidence of an emergency department visit was 7.06% after implementation of a naloxone co-prescription mandate compared to 7.73% before (difference -0.67%, 95% CI -1.39% to 0.05%, P=0.07). These results were robust to a variety of sensitivity and subgroup analyses.CONCLUSION: Naloxone co-prescription mandates were not associated with statistically or clinically significant change in emergency department visits or hospital admissions within 30 postoperative days.

    View details for DOI 10.1097/SLA.0000000000005821

    View details for PubMedID 36805578

  • Meeting Report: First Cardiovascular Outcomes Research in Perioperative Medicine Conference. Anesthesia and analgesia Bartels, K., Howard-Quijano, K., Prin, M., Shaefi, S., Steppan, J., Sun, E. C., Williams, B., Fox, A. A., Namuyonga, J., Shaw, A. D., Vavilala, M. S., Sessler, D. I. 2023; 136 (2): 418-420


    The first Cardiovascular Outcomes Research in Perioperative Medicine (COR-PM) conference took place on May 13, 2022, in Palm Springs, CA, and online. Here, we: (1) summarize the background, objective, and aims of the COR-PM meeting; (2) describe the conduct of the meeting; and (3) outline future directions for scientific meetings aimed at fostering high-quality clinical research in the broader perioperative medicine community.

    View details for DOI 10.1213/ANE.0000000000006248

    View details for PubMedID 36638519

  • Variations in operating room staff compliance with mandatory daily electronic COVID-19 symptom screening. British journal of anaesthesia Gessner, D. M., Sun, E., Fielding-Singh, V. 2023; 130 (1): e10-e12

    View details for DOI 10.1016/j.bja.2022.09.014

    View details for PubMedID 36939494

  • Hospital-level variability in regional nerve block administration by race for total knee arthroplasty. Regional anesthesia and pain medicine Dixit, A. A., Kim, C. Y., Mariano, E. R., Krishnamoorthy, V., Ohnuma, T., Raghunathan, K., Bryan, W. E., Bartels, K., Sun, E. C. 2022

    View details for DOI 10.1136/rapm-2022-104028

    View details for PubMedID 36598069

  • Hospital-level variability in regional nerve block administration by race for total knee arthroplasty REGIONAL ANESTHESIA AND PAIN MEDICINE Dixit, A. A., Kim, C. Y., Mariano, E. R., Krishnamoorthy, V., Ohnuma, T., Raghunathan, K., Bryan, W. E., Bartels, K., Sun, E. C. 2022
  • The Opioid Crisis, Centers for Disease Control Opioid Guideline, and Naloxone Coprescription for Patients at Risk for Opioid Overdose. Anesthesia and analgesia Benzon, H. T., Sun, E. C., Chou, R. 2022; 135 (1): 21-25

    View details for DOI 10.1213/ANE.0000000000006029

    View details for PubMedID 35709441

  • Surgeon Variation in Perioperative Opioid Prescribing and Medium or Long Term Opioid Utilization After Total Knee Arthroplasty: A Cross-Sectional Analysis. Anesthesiology Cen, X., Jena, A. B., Mackey, S., Sun, E. C. 2022


    BACKGROUND: Whether a particular surgeon's opioid prescribing behavior is associated with prolonged postoperative opioid use is unknown. We tested the hypothesis that the patients of surgeons with a higher propensity to prescribe opioids are more likely to utilize opioids long-term postoperatively.METHODS: We identified 612,378 Medicare fee-for-service patients undergoing total knee arthroplasty between January 1, 2011 and December 31, 2016. We then defined "high-intensity" surgeons as those whose patients were, on average, in the upper quartile of opioid utilization in the immediate perioperative period (preoperative day 7 to postoperative day 7), We then estimated whether patients of "high-intensity" surgeons had higher opioid utilization in the mid-term (postoperative days 8-90) and long-term (postoperative days 91-365), utilizing an instrumental variables approach to minimize confounding from unobservable factors.RESULTS: In the final sample of 604,093 patients, the average age was 74 years (SD 5) and there were 413,121 (68.4%) females. 180,926 patients (30%) were treated by "high-intensity" surgeons. On average, patients receiving treatment from a "high-intensity" surgeon received 36.1 (SD 35.0) oral morphine equivalents (MME)/day during the immediate perioperative period compared to 17.3 MME (SD 23.1) per day for all other patients (+18.9 MME/day difference; 95%CI 18.7 to 19.0; p<0.001). After adjusting for confounders, receiving treatment from a "high-intensity" surgeon was associated with higher opioid utilization in the mid-term opioid postoperative period (+2.4 MME/day difference, 95%CI 1.7 to 3.2, p<0.001, [11.4 MME/day vs 9.0]), and lower opioid utilization in the long-term postoperative period (-1.0 MME/day difference, 95%CI -1.4 to -0.6, p<0.001, [2.8 MME/day vs 3.8]). While statistically significant, these differences were clinically small.CONCLUSIONS: Among Medicare fee-for-service patients undergoing total knee arthroplasty, surgeon-level variation in opioid utilization in the immediate perioperative period was associated with statistically significant but clinically insignificant differences in opioid utilization in the medium- and long-term postoperative periods.

    View details for DOI 10.1097/ALN.0000000000004259

    View details for PubMedID 35503990

  • Association of Medicaid Expansion With Neuraxial Labor Analgesia Use in the United States: A Retrospective Cross-Sectional Analysis. Anesthesia and analgesia Xiao, M. Z., Whitney, D., Guo, N., Sun, E. C., Wong, C. A., Bentley, J., Butwick, A. J. 2022; 134 (3): 505-514


    BACKGROUND: The Affordable Care Act has been associated with increased Medicaid coverage for childbirth among low-income US women. We hypothesized that Medicaid expansion was associated with increased use of labor neuraxial analgesia.METHODS: We performed a cross-sectional analysis of US women with singleton live births who underwent vaginal delivery or intrapartum cesarean delivery between 2009 and 2017. Data were sourced from births in 26 US states that used the 2003 Revised US Birth Certificate. Difference-in-difference linear probability models were used to compare changes in the prevalence of neuraxial labor analgesia in 15 expansion and 11 nonexpansion states before and after Medicaid expansion. Models were adjusted for potential maternal and obstetric confounders with standard errors clustered at the state level.RESULTS: The study sample included 5,703,371 births from 15 expansion states and 5,582,689 births from 11 nonexpansion states. In the preexpansion period, the overall rate of neuraxial analgesia in expansion and nonexpansion states was 73.2% vs 76.3%. Compared with the preexpansion period, the rate of neuraxial analgesia increased in the postexpansion period by 1.7% in expansion states (95% CI, 1.6-1.8) and 0.9% (95% CI, 0.9-1.0) in nonexpansion states. The adjusted difference-in-difference estimate comparing expansion and nonexpansion states was 0.47% points (95% CI, -0.63 to 1.57; P = .39).CONCLUSIONS: Medicaid expansion was not associated with an increase in the rate of neuraxial labor analgesia in expansion states compared to the change in nonexpansion states over the same time period. Increasing Medicaid eligibility alone may be insufficient to increase the rate of neuraxial labor analgesia.

    View details for DOI 10.1213/ANE.0000000000005878

    View details for PubMedID 35180167

  • Association Between Changes in Postoperative Opioid Utilization and Long-Term Health Care Spending Among Surgical Patients With Chronic Opioid Utilization. Anesthesia and analgesia Sun, E. C., Rishel, C. A., Jena, A. B. 2022; 134 (3): 515-523


    BACKGROUND: There is growing interest in identifying and developing interventions aimed at reducing the risk of increased, long-term opioid use among surgical patients. While understanding how these interventions impact health care spending has important policy implications and may facilitate the widespread adoption of these interventions, the extent to which they may impact health care spending among surgical patients who utilize opioids chronically is unknown.METHODS: This study was a retrospective analysis of administrative health care claims data for privately insured patients. We identified 53,847 patients undergoing 1 of 10 procedures between January 1, 2004, and September 30, 2018 (total knee arthroplasty, total hip arthroplasty, laparoscopic cholecystectomy, open cholecystectomy, laparoscopic appendectomy, open appendectomy, cesarean delivery, functional endoscopic sinus surgery, transurethral resection of the prostate, or simple mastectomy) who had chronic opioid utilization (≥10 prescriptions or ≥120-day supply in the year before surgery). Patients were classified into 3 groups based on differences in opioid utilization, measured in average daily oral morphine milligram equivalents (MMEs), between the first postoperative year and the year before surgery: "stable" (<20% change), "increasing" (≥20% increase), or "decreasing" (≥20% decrease). We then examined the association between these 3 groups and health care spending during the first postoperative year, using a multivariable regression to adjust for observable confounders, such as patient demographics, medical comorbidities, and preoperative health care utilization.RESULTS: The average age of the sample was 62.0 (standard deviation [SD] 13.1) years, and there were 35,715 (66.3%) women. Based on the change in average daily MME between the first postoperative year and the year before surgery, 16,961 (31.5%) patients were classified as "stable," 15,463 (28.7%) were classified as "increasing," and 21,423 (39.8%) patients were classified as "decreasing." After adjusting for potential confounders, "increasing" patients had higher health care spending ($37,437) than "stable" patients ($31,061), a difference that was statistically significant ($6377; 95% confidence interval [CI], $5669-$7084; P < .001), while "decreasing" patients had lower health care spending ($29,990), a difference (-$1070) that was also statistically significant (95% CI, -$1679 to -$462; P = .001). These results were generally consistent across an array of subgroup and sensitivity analyses.CONCLUSIONS: Among patients with chronic opioid utilization before surgery, subsequent increases in opioid utilization during the first postoperative year were associated with increased health care spending during that timeframe, while subsequent decreases in opioid utilization were associated with decreased health care spending.

    View details for DOI 10.1213/ANE.0000000000005865

    View details for PubMedID 35180168

  • Preoperative Opioid Utilization Patterns and Postoperative Opioid Utilization: A Retrospective Cohort Study. Anesthesiology Rishel, C. A., Angst, M. S., Sun, E. C. 2021; 135 (6): 1015-1026


    BACKGROUND: Among chronic opioid users, the association between decreasing or increasing preoperative opioid utilization and postoperative outcomes is unknown. The authors hypothesized that decreasing utilization would be associated with improved outcomes and increasing utilization with worsened outcomes.METHODS: Using commercial insurance claims, the authors identified 57,019 chronic opioid users (10 or more prescriptions or 120 or more days supplied during the preoperative year), age 18 to 89 yr, undergoing one of 10 surgeries between 2004 and 2018. Patients with a 20% or greater decrease or increase in opioid utilization between preoperative days 7 to 90 and 91 to 365 were compared to patients with less than 20% change (stable utilization). The primary outcome was opioid utilization during postoperative days 91 to 365. Secondary outcomes included alternative measures of postoperative opioid utilization (filling a minimum number of prescriptions during this period), postoperative adverse events, and healthcare utilization.RESULTS: The average age was 63 ± 13 yr, with 38,045 (66.7%) female patients. Preoperative opioid utilization was decreasing for 12,347 (21.7%) patients, increasing for 21,330 (37.4%) patients, and stable for 23,342 (40.9%) patients. Patients with decreasing utilization were slightly less likely to fill an opioid prescription during postoperative days 91 to 365 compared to stable patients (89.2% vs. 96.4%; odds ratio, 0.323; 95% CI, 0.296 to 0.352; P < 0.001), though the average daily doses were similar among patients who continued to utilize opioids during this timeframe (46.7 vs. 46.5 morphine milligram equivalents; difference, 0.2; 95% CI, -0.8 to 1.2; P = 0.684). Of patients with increasing utilization, 93.6% filled opioid prescriptions during this period (odds ratio, 0.57; 95% CI, 0.52 to 0.62; P < 0.001), with slightly lower average daily doses (44.3 morphine milligram equivalents; difference, -2.2; 95% CI, -3.1 to -1.3; P < 0.001). Except for alternative measures of persistent postoperative opioid utilization, there were no clinically significant differences for the secondary outcomes.CONCLUSIONS: Changes in preoperative opioid utilization were not associated with clinically significant differences for several postoperative outcomes including postoperative opioid utilization.EDITORS PERSPECTIVE:

    View details for DOI 10.1097/ALN.0000000000004026

    View details for PubMedID 34731242

  • Association Between State Limits on Opioid Prescribing and the Incidence of Persistent Postoperative Opioid Use Among Surgical Patients. Annals of surgery Sun, E. C., Rishel, C. A., Waljee, J. F., Brummett, C. M., Jena, A. B. 2021


    OBJECTIVE: To examine whether laws limiting opioid prescribing have been associated with reductions in the incidence of persistent postoperative opioid use.SUMMARY BACKGROUND DATA: In an effort to address the opioid epidemic, 26 states (as of 2018) have passed laws limiting opioid prescribing for acute pain. However, it is unknown whether these laws have achieved their reduced the risk of persistent postoperative opioid use.METHODS: We identified 957,639 privately insured patients undergoing one of 10 procedures between January 1, 2004 and September 30, 2018. We then estimated the association between persistent postoperative opioid use, defined as having filled ≥10 prescriptions or ≥120 days supply of opioids during postoperative days 91-365, and whether opioid prescribing limits were in effect on the day of surgery. States were classified as having: no limits, a limit of ≤7 days supply, or a limit of >7 days supply. The regression models adjusted for observable confounders such as patient comorbidities and also utilized a difference-in-differences approach, which relied on variation in state laws over time, to further minimize confounding.RESULTS: The adjusted incidence of persistent postoperative opioid use was 3.5% (95%CI 3.3%-3.7%) for patients facing a limit of ≤7 days supply, compared with 3.3% (95%CI 3.3%-3.3%) for patients facing no prescribing limits (p=0.13 for difference compared to no prescribing limits) and 3.4%, (95%CI 3.2%-3.6%) for patients facing a limit of >7 days supply (p=0.43 for difference compared to no prescribing limits).CONCLUSIONS: Laws limiting opioid prescriptions were not associated with subsequent reductions in persistent postoperative opioid use.

    View details for DOI 10.1097/SLA.0000000000005283

    View details for PubMedID 35129496

  • Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature. Regional anesthesia and pain medicine Memtsoudis, S. G., Cozowicz, C., Bekeris, J., Bekere, D., Liu, J., Soffin, E. M., Mariano, E. R., Johnson, R. L., Go, G., Hargett, M. J., Lee, B. H., Wendel, P., Brouillette, M., Kim, S. J., Baaklini, L., Wetmore, D. S., Hong, G., Goto, R., Jivanelli, B., Athanassoglou, V., Argyra, E., Barrington, M. J., Borgeat, A., De Andres, J., El-Boghdadly, K., Elkassabany, N. M., Gautier, P., Gerner, P., Gonzalez Della Valle, A., Goytizolo, E., Guo, Z., Hogg, R., Kehlet, H., Kessler, P., Kopp, S., Lavand'homme, P., Macfarlane, A., MacLean, C., Mantilla, C., McIsaac, D., McLawhorn, A., Neal, J. M., Parks, M., Parvizi, J., Peng, P., Pichler, L., Poeran, J., Poultsides, L., Schwenk, E. S., Sites, B. D., Stundner, O., Sun, E. C., Viscusi, E., Votta-Velis, E. G., Wu, C. L., YaDeau, J., Sharrock, N. E. 2021


    BACKGROUND: Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.METHODS: A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations.RESULTS: Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95%CI 0.17 to 0.53/OR 0.52, 95%CI 0.34 to 0.80), respiratory failure (OR 0.36, 95%CI 0.17 to 0.74/OR 0.37, 95%CI 0.18 to 0.75), cardiac complications (OR 0.84, 95%CI 0.76 to 0.93/OR 0.83, 95%CI 0.79 to 0.86), surgical site infections (OR 0.55 95%CI 0.47 to 0.64/OR 0.86 95%CI 0.80 to 0.91), thromboembolism (OR 0.74, 95%CI 0.58 to 0.96/OR 0.90, 95%CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95%CI 0.83 to 0.86/OR 0.91, 95%CI 0.90 to 0.92).CONCLUSIONS: Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes.RECOMMENDATION: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

    View details for DOI 10.1136/rapm-2021-102750

    View details for PubMedID 34433647

  • How Can Anesthesiologists Influence Policymaking? Reflections from a Year at the Council of Economic Advisers ANESTHESIOLOGY Sun, E. C. 2021; 134 (6): 841-844


    From September 2019 to August 2020, the author served as a senior economist on the Council of Economic Advisers, a government agency charged with providing economic analysis and advice to the President of the United States and senior government officials. Working with the Council yielded many useful lessons on how anesthesiologists can influence healthcare policy. First, because the President has wide latitude over many areas of health policy that directly impact patient care and anesthesiologists' working environment, anesthesiologists should focus their efforts on influencing policymakers within the executive branch of government in addition to influencing lawmakers. Second, policymakers are busy and typically do not have a technical background, so anesthesiologists must learn how to communicate with them succinctly and at an appropriate level. Finally, because policymakers often need analysis quickly, anesthesiologists must meet these needs even if the underlying analysis is rougher and less precise that what would normally be needed for peer review.

    View details for DOI 10.1097/ALN.0000000000003756

    View details for Web of Science ID 000648691100007

    View details for PubMedID 33791750

  • Increased health care costs associated with new persistent opioid use after major surgery in opioid-naive patients. Journal of managed care & specialty pharmacy Brummett, C. M., Evans-Shields, J., England, C., Kong, A. M., Lew, C. R., Henriques, C., Zimmerman, N. M., Sun, E. C. 2021: 1–12


    BACKGROUND: Opioid use after surgery is associated with increased health care utilization and costs. Although some studies show that surgical patients may later become persistent opioid users, data on the association between new persistent opioid use after surgery and health care utilization and costs are lacking. OBJECTIVE: To compare health care utilization and costs after major inpatient or METHODS: The IBM MarketScan Research databases were used to identify opioid-naive patients with major inpatient or outpatient surgeries and at least 1 year of continuous enrollment before and after this index surgery. Cohorts were stratified by new persistent opioid utilization status, setting of surgery (inpatient, outpatient), and payer (commercial, Medicare, Medicaid). Patients were considered new persistent opioid users if they had at least 1 opioid claim 4-90 days after index surgery and at least 1 opioid claim 91-180 days after index surgery. Patients with opioid prescription claims between 1 year and 15 days before their index event were excluded. Health care utilization and costs (excluding index surgery) were measured in the 1-year period after surgery. Predicted costs and cost ratios were estimated using multivariable log-linked gamma-family generalized linear models. RESULTS: In the inpatient cohorts, 827,583 commercial, 186,154 Medicare, and 104,734 Medicaid patients were included in the study, and the incidence of new persistent opioid use in these cohorts was 4.1%, 5.6%, and 7.1%, respectively. In the outpatient cohorts, 1,542,565 commercial, 390,876 Medicare, and 94,878 Medicaid patients were selected, with 2.0%, 1.5%, and 6.4% new persistent opioid use, respectively. Across all 3 payers in both surgical settings, patients with new persistent opioid use had a higher comorbidity burden and more use of concomitant medications in the baseline period. In the 1-year period after index surgery, patients with new persistent opioid use had more inpatient admissions, emergency department visits, and ambulance/paramedic service use than patients without persistent use, regardless of payer and setting. Patients with new persistent opioid use had approximately 5 times more opioid prescriptions and also had more nonopioid pharmacy claims than those without persistent use across all cohorts. After covariate adjustment, predicted 1-year total health care costs were significantly higher for patients with new persistent opioid use compared with those without persistent use for all comparisons (commercial inpatient: $29,499 vs. $11,798; Medicare inpatient: $34,455 vs. $21,313; Medicaid inpatient: $14,622 vs. $6,678; commercial outpatient: $18,751 vs. $7,517; Medicare outpatient ($26,411 vs. $13,577; Medicaid outpatient: $12,381 vs. $6,784; all P < 0.001). CONCLUSIONS: New persistent opioid use after major surgery in opioid-naive patients is associated with increased health care utilization and costs in the year after surgery across all surgical settings and payers. DISCLOSURES: Funding for this study was provided by Heron Therapeutics, which participated in analysis and interpretation of data, drafting, reviewing, and approving the publication. All authors contributed to the analysis and interpretation of the data and development of the publication and maintained control over the final content. England and Evans-Shields are employees of Heron Therapeutics. Kong, Lew, Zimmerman, and Henriques are employees of IBM Watson Health, which was compensated by Heron Therapeutics for conducting this research. Brummett is a paid consultant for Heron Therapeutics, Vertex Pharmaceuticals, and Alosa Health and provides expert testimony. He further reports receipt of research funding from MDHHS (Sub K Michigan Open), NIDA (Centralized Pain Opioid Non-Responsiveness R01 DA038261-05), NIH0DHHS-US-16 PAF 07628 (R01 NR017096-05), NIH-DHHS (P50 AR070600-05 CORT), NIH-DHHS-US (K23 DA038718-04), NIH-DHHS-US-16-PAF06270 (R01 HD088712-05), NIH-DHHS-US-17-PAF02680 (R01 DA042859-05), and UM Michigan Genomics Initiative and holds a patent for peripheral perineural dexmedetomidine. Sun reports funding from the National Institute on Drug Abuse (K08DA042314) as well as consulting fees from the Mission Lisa Foundation that are unrelated to this work.

    View details for DOI 10.18553/jmcp.2021.20507

    View details for PubMedID 33624534

  • The link between health and economic preferences: Evidence from 22 OECD countries. Health economics Cen, X., Johnston, D. W., Kung, C. S., Shields, M. A., Sun, E. C. 2021


    We study the link between health status and economic preferences using survey data from 22 Organisation for Economic Co-operation and Development (OECD) countries. We hypothesize that there is a relationship between poor health and the preferences that people hold, and therefore their choices and decisions. We find that individuals with a limiting health condition are more risk averse and less patient, and that this is true for physical and mental health conditions. The magnitudes of the health gap are approximately 60% and 70% of the gender gap in risk and time preferences, respectively. Importantly, the health gaps are large for males, females, young, old, school dropouts, degree holders, employed, nonemployed, rich, and poor. They also hold for countries with different levels of gross domestic product (GDP), inequality, social expenditure, and disease burden.

    View details for DOI 10.1002/hec.4225

    View details for PubMedID 33502797

  • Making a business plan for starting a transitional pain service within the US healthcare system. Regional anesthesia and pain medicine Sun, E. C., Mariano, E. R., Narouze, S. n., Gabriel, R. A., Elsharkawy, H. n., Gulur, P. n., Merrick, S. K., Harrison, T. K., Clark, J. D. 2021


    Chronic pain imposes a tremendous economic burden of up to US$635 billion per year in terms of direct costs (such as the costs of treatment) and indirect costs (such as lost productivity and time away from work). In addition, the initiation of opioids for pain is associated with a more than doubling of pharmacy and all-cause medical costs. The high costs of chronic pain are particularly relevant for anesthesiologists because surgery represents an inciting event that can lead to chronic pain and long-term opioid use. While the presence of risk factors and an individual patient's postoperative pain trajectory may predict who is at high risk for chronic pain and opioid use after surgery, to date, there are few interventions proven to reduce these risks. One promising approach is the transitional pain service. Programs like this attempt to bridge the gap between acute and chronic pain management, provide continuity of care for complicated acute pain patients after discharge from the hospital, and offer interventions for patients who are on abnormal trajectories of pain resolution and/or opioid use. Despite awareness of chronic pain after surgery and the ongoing opioid epidemic, there are few examples of successful transitional pain service implementation in the USA. Key issues and concerns include financial incentives and the required investment from the hospital or healthcare system. We present an economic analysis and discussion of important considerations when developing a business plan for a transitional pain service.

    View details for DOI 10.1136/rapm-2021-102669

    View details for PubMedID 33879540

  • Association Between Preoperative Benzodiazepine Use and Postoperative Opioid Use and Health Care Costs. JAMA network open Rishel, C. A., Zhang, Y., Sun, E. C. 2020; 3 (10): e2018761


    Importance: The association between preoperative benzodiazepine use and long-term postoperative outcomes is not well understood.Objective: To characterize the association between preoperative benzodiazepine use and postoperative opioid use and health care costs.Design, Setting, and Participants: In this cohort study, retrospective analysis of private health insurance claims data on 946 561 opioid-naive patients (no opioid prescriptions filled in the year before surgery) throughout the US was conducted. Patients underwent 1 of 11 common surgical procedures between January 1, 2004, and December 31, 2016; data analysis was performed January 9, 2020.Exposures: Benzodiazepine use, defined as long term (≥10 prescriptions filled or ≥120 days supplied in the year before surgery) or intermittent (any use not meeting the criteria for long term).Main Outcomes and Measures: The primary outcome was opioid use 91 to 365 days after surgery. Secondary outcomes included opioid use 0 to 90 days after surgery and health care costs 0 to 30 days after surgery.Results: In this sample of 946 561 patients, the mean age was 59.8 years (range, 18-89 years); 615 065 were women (65.0%). Of these, 23 484 patients (2.5%) met the criteria for long-term preoperative benzodiazepine use and 47 669 patients (5.0%) met the criteria for intermittent use. After adjusting for confounders, long-term (odds ratio [OR], 1.59; 95% CI, 1.54-1.65; P<.001) and intermittent (OR, 1.47; 95% CI, 1.44-1.51; P<.001) benzodiazepine use were associated with an increased probability of any opioid use during postoperative days 91 to 365. For patients who used opioids in postoperative days 91 to 365, long-term benzodiazepine use was associated with a 44% increase in opioid dose (additional 0.6 mean daily morphine milligram equivalents [MMEs]; 95% CI, 0.3-0.8 MMEs; P<.001), although intermittent benzodiazepine use was not significantly different (0.0 average daily MMEs; 95% CI, -0.2 to 0.2 MMEs; P=.65). Preoperative benzodiazepine use was also associated with increased opioid use in postoperative days 0 to 90 for both long-term (32% increase, additional 1.9 average daily MMEs; 95% CI, 1.6-2.1 MMEs; P<.001) and intermittent (9% increase, additional 0.5 average daily MMEs; 95% CI, 0.4-0.6 MMEs; P<.001) users. Intermittent benzodiazepine use was associated with an increase in 30-day health care costs ($1155; 95% CI, $938-$1372; P<.001), while no significant difference was observed for long-term benzodiazepine use.Conclusions and Relevance: The findings of this study suggest that, among opioid-naive patients, preoperative benzodiazepine use may be associated with an increased risk of developing long-term opioid use and increased opioid dosages postoperatively, and also may be associated with increased health care costs.

    View details for DOI 10.1001/jamanetworkopen.2020.18761

    View details for PubMedID 33107919

  • Incidence of and Factors Associated With Prolonged and Persistent Postoperative Opioid Use in Children 0-18 Years of Age. Anesthesia and analgesia Ward, A., De Souza, E., Miller, D., Wang, E., Sun, E. C., Bambos, N., Anderson, T. A. 2020; 131 (4): 1237-1248


    Long-term opioid use has negative health care consequences. Opioid-naïve adults are at risk for prolonged and persistent opioid use after surgery. While these outcomes have been examined in some adolescent and teenage populations, little is known about the risk of prolonged and persistent postoperative opioid use after common surgeries compared to children who do not undergo surgery and factors associated with these issues among pediatric surgical patients of all ages.Using a national administrative claims database, we identified 175,878 surgical visits by opioid-naïve children aged ≤18 years who underwent ≥1 of the 20 most common surgeries from each of 4 age groups between December 31, 2002, and December 30, 2017, and who filled a perioperative opioid prescription 30 days before to 14 days after surgery. Prolonged opioid use after surgery (filling ≥1 opioid prescription 90-180 days after surgery) was compared to a reference sample of 1,354,909 nonsurgical patients randomly assigned a false "surgery" date. Multivariable logistic regression models were used to estimate the association of surgical procedures and 22 other variables of interest with prolonged opioid use and persistent postoperative opioid use (filling ≥60 days' supply of opioids 90-365 days after surgery) for each age group.Prolonged opioid use after surgery occurred in 0.77%, 0.76%, 1.00%, and 3.80% of surgical patients ages 0-<2, 2-<6, 6-<12, and 12-18, respectively. It was significantly more common in surgical patients than in nonsurgical patients (ages 0-<2: odds ratio [OR] = 4.6 [95% confidence interval (CI), 3.7-5.6]; ages 2-<6: OR = 2.5 [95% CI, 2.1-2.8]; ages 6-<12: OR = 2.1 [95% CI, 1.9-2.4]; and ages 12-18: OR = 1.8 [95% CI, 1.7-1.9]). In the multivariable models for ages 0-<12 years, few surgical procedures and none of the other variables of interest were associated with prolonged opioid use. In the models for ages 12-18 years, 10 surgical procedures and 5 other variables of interest were associated with prolonged opioid use. Persistent postoperative opioid use occurred in <0.1% of patients in all age groups.Some patient characteristics and surgeries are positively and negatively associated with prolonged opioid use in opioid-naïve children of all ages, but persistent opioid use is rare. Specific pediatric subpopulations (eg, older patients with a history of mood/personality disorder or chronic pain) may be at markedly higher risk.

    View details for DOI 10.1213/ANE.0000000000004823

    View details for PubMedID 32925345

  • Mind Over Matter: Reducing Perioperative Opioid Use Through Patient Education. Anesthesia and analgesia Dunn, L. K., Sun, E. C. 2020; 130 (3): 556–58

    View details for DOI 10.1213/ANE.0000000000004569

    View details for PubMedID 32068584

  • The Safety and Efficacy of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for Laryngologic Surgery. The Laryngoscope Nekhendzy, V. n., Saxena, A. n., Mittal, B. n., Sun, E. n., Sung, K. n., Dewan, K. n., Damrose, E. J. 2020


    Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is an intraoperative ventilatory technique that allows avoidance of tracheal intubation (TI) or jet ventilation (JV) in selected laryngologic surgical cases. Unimpeded access to all parts of the glottis may improve surgical precision, decrease operative time, and potentially improve patient outcomes. The objective of this prospective, randomized, patient-blinded, 2-arm parallel pilot trial was to investigate the safety and efficacy of THRIVE use for adult patients undergoing nonlaser laryngologic surgery of short-to-intermediate duration.Twenty adult, American society of anesthesiology class 1-3 patients with body mass index (BMI) < 35 kg/m2 were randomly assigned to either an experimental THRIVE group or active comparator conventional ventilation group (TI or supraglottic high-frequency JV [SHFJV]). Primary outcomes included intraoperative oxygenation, anesthesia awakening/extubation time, time to laryngoscopic suspension, number of intraoperative suspension adjustments, and operative time. Secondary patient outcomes including postanesthesia and functional patient recovery were investigated.Compared to TI/SHFJV, THRIVE use was associated with significantly lower intraoperative oxygenation (SpO2 93.0 ± 5.6% vs. 98.7 ± 1.6%), shorter time to suspension (1.8 ± 1.1 minutes vs. 4.3 ± 2.1 minutes), fewer suspension adjustments (0.4 ± 0.5 vs. 1.7 ± 0.9), and lower postoperative pain scores on recovery room admission (1.3 ± 1.9 vs. 3.7 ± 2.9) and discharge (0.9 ± 1.3 vs. 2.7 ± 1.8). The study was underpowered to detect other possible outcome differences.We confirm the safe intraoperative oxygenation profile of THRIVE for selected patients undergoing nonlaser laryngologic surgery of short-to-intermediate duration. THRIVE facilitated surgical exposure and improved early patient recovery, suggesting a potential economic benefit for outpatient laryngologic procedures. The results of this exploratory study provide a framework for designing future adequately powered THRIVE (NCT03091179).II Laryngoscope, 2020.

    View details for DOI 10.1002/lary.28562

    View details for PubMedID 32078170

  • The Surgeon's Role in the Opioid Crisis: A Narrative Review and Call to Action. Frontiers in surgery Shadbolt, C., Abbott, J. H., Camacho, X., Clarke, P., Lohmander, L. S., Spelman, T., Sun, E. C., Thorlund, J. B., Zhang, Y., Dowsey, M. M., Choong, P. F. 2020; 7: 4


    Over the past two decades, there has been a sharp rise in the use of prescription opioids. In several countries, most notably the United States, opioid-related harm has been deemed a public health crisis. As surgeons are among the most prolific prescribers of opioids, growing attention is now being paid to the role that opioids play in surgical care. While opioids may sometimes be necessary to provide patients with adequate relief from acute pain after major surgery, the impact of opioids on the quality and safety of surgical care calls for greater scrutiny. This narrative review summarizes the available evidence on rates of persistent postsurgical opioid use and highlights the need to target known risk factors for persistent postoperative use before patients present for surgery. We draw attention to the mounting evidence that preoperative opioid exposure places patients at risk of persistent postoperative use, while also contributing to an increased risk of several other adverse clinical outcomes. By discussing the prevalence of excess opioid prescribing following surgery and highlighting significant variations in prescribing practices between countries, we note that there is a pressing need to optimize postoperative prescribing practices. Guided by the available evidence, we call for specific actions to be taken to address important research gaps and alleviate the harms associated with opioid use among surgical patients.

    View details for DOI 10.3389/fsurg.2020.00004

    View details for PubMedID 32133370

  • Predictors of post-anaesthesiology residency research productivity: preliminary report. British journal of anaesthesia Haight, E. S., Chen, F., Tanaka, P., Brock-Utne, J. G., Macario, A., Sun, E. C., Tawfik, V. L. 2019

    View details for DOI 10.1016/j.bja.2019.07.018

    View details for PubMedID 31474349

  • American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use: Definition, Incidence, Risk Factors, and Health Care System Initiatives ANESTHESIA AND ANALGESIA Kent, M. L., Hurley, R. W., Oderda, G. M., Gordon, D. B., Sun, E., Mythen, M., Miller, T. E., Shaw, A. D., Gan, T. J., Thacker, J. M., McEvoy, M. D., POQI-4 Working Grp 2019; 129 (2): 543–52
  • Outcomes Associated With Overlapping Surgery-Reply. JAMA Sun, E., Kheterpal, S., Jena, A. B. 2019; 322 (3): 275–76

    View details for DOI 10.1001/jama.2019.6475

    View details for PubMedID 31310295

  • Trends in Direct Hospital Payments to Anesthesia Groups: A Retrospective Cohort Study of Nonacademic Hospitals in California. Anesthesiology O'Connell, C., Dexter, F., Mauler, D. J., Sun, E. C. 2019


    WHAT WE ALREADY KNOW ABOUT THIS TOPIC: In the United States, anesthesia groups derive revenue from insurers and "direct payments" or "institutional support" from hospitalsDirect payments can represent a significant portion of group revenue and may enable the provision of services to patients covered by public insurers, which disproportionately represent low-resource and underserved populationsThe magnitude or characteristics of direct hospital payments to nonacademic private practice anesthesia groups is not well understood WHAT THIS ARTICLE TELLS US THAT IS NEW: Among 240 nonacademic California hospitals analyzed between 2002 and 2014, more hospitals made direct payments to an anesthesia group in 2014 than in 2002 and the median payment increasedHospitals where public insurers accounted for a larger fraction of anesthesia revenues were increasingly more likely to make direct payments to private anesthesia groupsDirect payments to private anesthesia groups are becoming increasingly important, particularly for hospitals providing care to underserved populations BACKGROUND:: In addition to payments for services, anesthesia groups in the United States often receive revenue from direct hospital payments. Understanding the magnitude of these payments and their association with the hospitals' payer mixes has important policy implications.METHODS: Using a dataset of financial reports from 240 nonacademic California hospitals between 2002 and 2014, the authors characterized the prevalence and magnitude of direct hospital payments to anesthesia groups, and analyzed the association between these payments and the fraction of anesthesia revenue derived from public payers (e.g., Medicaid).RESULTS: Of hospitals analyzed, 69% (124 of 180) made direct payments to an anesthesia group in 2014, compared to 52% (76 of 147) in 2002; the median payment increased from $242,351 (mean, $578,322; interquartile range, $72,753 to $523,861; all dollar values in 2018 U.S. dollars) to $765,128 (mean, $1,295,369; interquartile range, $267,006 to $1,503,163) during this time period. After adjusting for relevant covariates, hospitals where public insurers accounted for a larger fraction of anesthesia revenues were more likely to make direct payments to anesthesia groups (beta = 0.45; 95% CI, 0.10 to 0.81; P = 0.013), so that a 10-percentage point increase in the fraction of anesthesia revenue derived from public payers would be associated with a 4.5-percentage point increase in the probability of receiving any payment. Among hospitals making payments, our results (beta = 2.10; 95% CI, 0.74 to 3.45; P = 0.003) suggest that a 1-percentage point increase in the fraction of anesthesia revenue derived from public payers would be associated with a 2% relative increase in the amount paid.CONCLUSIONS: Direct payments from hospitals are becoming a larger financial consideration for anesthesia groups in California serving nonacademic hospitals, and are larger for groups working at hospitals serving publicly insured patients.

    View details for DOI 10.1097/ALN.0000000000002819

    View details for PubMedID 31283739

  • Regional Anesthesia and Readmission Rates After Total Knee Arthroplasty Chi, D., Mariano, E. R., Memtsoudis, S. G., Baker, L. C., Sun, E. C. LIPPINCOTT WILLIAMS & WILKINS. 2019: 1319–27
  • Risk and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients With Newly Diagnosed Musculoskeletal Pain in the Neck, Shoulder, Knee, or Low Back ANNALS OF INTERNAL MEDICINE Moshfegh, J., George, S. Z., Sun, E. 2019; 170 (7): 504-505

    View details for DOI 10.7326/M18-2261

    View details for Web of Science ID 000463070700011

  • Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis. British journal of anaesthesia Memtsoudis, S. G., Cozowicz, C. n., Bekeris, J. n., Bekere, D. n., Liu, J. n., Soffin, E. M., Mariano, E. R., Johnson, R. L., Hargett, M. J., Lee, B. H., Wendel, P. n., Brouillette, M. n., Go, G. n., Kim, S. J., Baaklini, L. n., Wetmore, D. n., Hong, G. n., Goto, R. n., Jivanelli, B. n., Argyra, E. n., Barrington, M. J., Borgeat, A. n., De Andres, J. n., Elkassabany, N. M., Gautier, P. E., Gerner, P. n., Gonzalez Della Valle, A. n., Goytizolo, E. n., Kessler, P. n., Kopp, S. L., Lavand'Homme, P. n., MacLean, C. H., Mantilla, C. B., MacIsaac, D. n., McLawhorn, A. n., Neal, J. M., Parks, M. n., Parvizi, J. n., Pichler, L. n., Poeran, J. n., Poultsides, L. A., Sites, B. D., Stundner, O. n., Sun, E. C., Viscusi, E. R., Votta-Velis, E. G., Wu, C. L., Ya Deau, J. T., Sharrock, N. E. 2019


    Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes.The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations.The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87.Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation.neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty.PROSPERO CRD42018099935.

    View details for DOI 10.1016/j.bja.2019.05.042

    View details for PubMedID 31351590

  • The Penn Classification Predicts Hospital Mortality in Acute Stanford Type A and Type B Aortic Dissections. Journal of cardiothoracic and vascular anesthesia Tien, M. n., Ku, A. n., Martinez-Acero, N. n., Zvara, J. n., Sun, E. C., Cheung, A. T. 2019


    Mortality in acute aortic dissection varies depending on anatomic location, extent, and associated complications. The Stanford classification guides surgical versus medical management. The Penn classification stratifies mortality risk in patients with Stanford type A aortic dissections undergoing surgery. The objective of the present study was to determine whether the Penn classification can predict hospital mortality in patients with acute Stanford type A and type B aortic dissections undergoing surgical or medical management.Retrospective, observational study.Tertiary care, university hospital.Patients with acute aortic dissection between January 2008 and December 2017.Examination of hospital mortality after surgical or medical management.Three hundred fifty-two patients had confirmed dissections (186 type A, 166 type B). The overall mortality was 18.8% for type A and 13.3% for type B. Penn class A patients with type A or type B dissections undergoing surgical repair had the lowest mortality (both 3.1%). Penn class B, C, or B+C patients with type A dissections and Penn class B+C patients with type B dissections undergoing medical management had the greatest incidence of mortality (50.0%-57.1%). All others had intermediate mortality (6.7%-39.3%). Logistic regression analysis demonstrated that Penn class B, C, and B+C patients had a greater odds of mortality and predicted mortality than did Penn class A patients.The Penn classification predicts hospital mortality in patients with acute Stanford type A or type B aortic dissections undergoing surgical or medical management. Early endovascular repair may confer lower risk of mortality in patients with type B dissections presenting without ischemia.

    View details for DOI 10.1053/j.jvca.2019.08.036

    View details for PubMedID 31558394

  • Regional Anesthesia: A Silver Bullet, Red Herring, or Neither? Anesthesiology Sun, E. C., Memtsoudis, S. G., Mariano, E. R. 2019; 131 (6): 1205–6

    View details for DOI 10.1097/ALN.0000000000002964

    View details for PubMedID 31730550

  • Association of Early Physical Therapy With Long-term Opioid Use Among Opioid-Naive Patients With Musculoskeletal Pain. JAMA network open Sun, E., Moshfegh, J., Rishel, C. A., Cook, C. E., Goode, A. P., George, S. Z. 2018; 1 (8): e185909


    Nonpharmacologic methods of reducing the risk of new chronic opioid use among patients with musculoskeletal pain are important given the burden of the opioid epidemic in the United States.To determine the association between early physical therapy and subsequent opioid use in patients with new musculoskeletal pain diagnosis.This cross-sectional analysis of health care insurance claims data between January 1, 2007, and December 31, 2015, included privately insured patients who presented with musculoskeletal pain to an outpatient physician office or an emergency department at various US facilities from January 1, 2008, to December 31, 2014. The sample comprised 88 985 opioid-naive patients aged 18 to 64 years with a new diagnosis of musculoskeletal shoulder, neck, knee, or low back pain. The data set (obtained from the IBM MarketScan Commercial database) included person-level International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis codes, Current Procedural Terminology codes, and date of service as well as pharmaceutical information (National Drug Code, generic name, dose, and number of days supplied). Early physical therapy was defined as at least 1 session received within 90 days of the index date, the earliest date a relevant diagnosis was provided. Data analysis was conducted from March 1, 2018, to May 18, 2018.Opioid use between 91 and 365 days after the index date.Of the 88 985 patients included, 51 351 (57.7%) were male and 37 634 (42.3%) were female with a mean (SD) age of 46 (11.0) years. Among these patients, 26 096 (29.3%) received early physical therapy. After adjusting for potential confounders, early physical therapy was associated with a statistically significant reduction in the incidence of any opioid use between 91 and 365 days after the index date for patients with shoulder pain (odds ratio [OR], 0.85; 95% CI, 0.77-0.95; P = .003), neck pain (OR, 0.92; 95% CI, 0.85-0.99; P = .03), knee pain (OR, 0.84; 95% CI, 0.77-0.91; P < .001), and low back pain (OR, 0.93; 95% CI, 0.88-0.98; P = .004). For patients who did use opioids, early physical therapy was associated with an approximately 10% statistically significant reduction in the amount of opioid use, measured in oral morphine milligram equivalents, for shoulder pain (-9.7%; 95% CI, -18.5% to -0.8%; P = .03), knee pain (-10.3%; 95% CI, -17.8% to -2.7%; P = .007), and low back pain (-5.1%; 95% CI, -10.2% to 0.0%; P = .046), but not for neck pain (-3.8%; 95% CI, -10.8% to 3.3%; P = .30).Early physical therapy appears to be associated with subsequent reductions in longer-term opioid use and lower-intensity opioid use for all of the musculoskeletal pain regions examined.

    View details for DOI 10.1001/jamanetworkopen.2018.5909

    View details for PubMedID 30646297

    View details for PubMedCentralID PMC6324326

  • United States State-Level Variation in the Use of Neuraxial Analgesia During Labor for Pregnant Women. JAMA network open Butwick, A. J., Bentley, J., Wong, C. A., Snowden, J. M., Sun, E., Guo, N. 2018; 1 (8): e186567


    Neuraxial labor analgesia is recognized as the most effective method of providing pain relief during labor. Little is known about variation in the rates of neuraxial analgesia across US states. Identifying the presence and extent of variation may provide insights into practice variation and may indicate where access to neuraxial analgesia is inadequate.To test the hypothesis that variation exists in neuraxial labor analgesia use among US states.Retrospective, population-based, cross-sectional analysis using US birth certificate data. Participants were 2 625 950 women who underwent labor in 2015.State-specific prevalence of neuraxial analgesia per 100 women who underwent labor and variability in neuraxial analgesia use among states, assessed using multilevel multivariable regression modeling with the median odds ratio and the intraclass correlation coefficient to evaluate variation by state.In the study population of 2 625 950 women, 0.1% (n = 2010) were younger than 15 years, 7.0% (n = 183 546) were between the ages of 15 and 19 years, 23.6% (n = 620 118) were between the ages of 20 and 24 years, 29.6% (n = 777 957) were between the ages of 25 and 29 years, 26.0% (n = 683 656) were between the ages of 30 and 34 years, 11.4% (n = 298 237) were between the ages of 35 and 39 years, 2.2% (n = 57 130) were between the ages of 40 and 44 years, and 0.1% (n = 3296) were between the ages of 45 and 54 years. More than 90% were privately insured or insured with Medicaid. Neuraxial analgesia was used by 73.1% (n = 1 920 368) of women. After adjustment for antepartum, obstetric, and intrapartum factors, Maine had the lowest neuraxial analgesia prevalence (36.6%; 95% CI, 33.2%-40.1%) and Nevada the highest (80.1%; 95% CI, 78.3%-81.7%). The adjusted median odds ratio was 1.5 (95% CI, 1.4-1.6), and the intraclass correlation coefficient was 5.4% (95% CI, 4.0%-7.9%).Results of this study suggest that a small portion of the overall variation in neuraxial analgesia use is explained by US states. Unmeasured patient-level and hospital-level factors likely account for a large portion of the variation between states. Efforts should be made to understand what the main reasons are for this variation and whether the variation influences maternal or perinatal outcomes.

    View details for DOI 10.1001/jamanetworkopen.2018.6567

    View details for PubMedID 30646335

    View details for PubMedCentralID PMC6324365

  • Comparison of Anesthesia Times and Billing Patterns by Anesthesia Practitioners. JAMA network open Sun, E. C., Dutton, R. P., Jena, A. B. 2018; 1 (7): e184288


    Most physicians must exercise discretion in choosing billing details that determine payment for their services. Understanding the degree to which physicians inappropriately use this discretion has important implications for payment policies. However, separating higher case complexity from inappropriate billing has made this a challenging issue to study. Anesthesia offers a useful test case because practitioners are partly compensated by self-reported length of time (anesthesia time) spent on a case.To characterize the incidence and consequences of inappropriate billing practices among anesthesia practitioners.In this cross-sectional study of data from a large anesthesia registry, 6 261 955 procedures performed by 4221 anesthesia practitioners (physician anesthesiologists, nurse anesthetists, and anesthesiologist assistants) between January 1, 2010, and March 31, 2015, were studied. A total of 3047 practitioners practiced primarily in community hospitals, whereas 453 practiced primarily in university hospitals and 721 practiced in other settings (eg, specialty hospital).Practitioners with anomalous patterns were identified as those reporting an unusually high number of anesthesia times ending in a multiple of 5 minutes (eg, 65 minutes).Incidence of anomalous patterns among anesthesia practitioners and the increase in anesthesia times associated with these patterns.This study included 4221 practitioners who each performed at least 300 anesthetic procedures. Practitioners in the top fifth percentile reported anesthesia times ending in a multiple of 5 minutes a mean (SD) of 53.7% (13.7%) of the time (range, 36.8%-96.1%), whereas practitioners in the 6th to 10th percentiles reported anesthesia times ending in a multiple of 5 minutes a mean (SD) of 31.8% (2.0%) of the time (range, 29.2%-36.7%). Practitioners in the top fifth percentile submitted billing for anesthesia times that exceeded the expected time by a mean of 21.5 minutes (95% CI, 15.8-27.1 minutes).In this study, findings suggest that anesthesia practitioners with the highest tendency to report anesthesia times ending in a multiple of 5 minutes did so with high frequency, which reflects anomalous billing. These practitioners also sought payment for longer-than-expected anesthesia times, which would correspond to higher payment for their services.

    View details for DOI 10.1001/jamanetworkopen.2018.4288

    View details for PubMedID 30646351

    View details for PubMedCentralID PMC6324364

  • Anesthesia Care Team Composition and Surgical Outcomes ANESTHESIOLOGY Sun, E. C., Miller, T. R., Moshfegh, J., Baker, L. C. 2018; 129 (4): 700–709
  • Liposomal Bupivacaine Does Not Reduce Inpatient Opioid Prescription or Related Complications after Knee Arthroplasty: A Database Analysis ANESTHESIOLOGY Pichler, L., Poeran, J., Zubizarreta, N., Cozowicz, C., Sun, E. C., Mazumdar, M., Memtsoudis, S. G. 2018; 129 (4): 689-699
  • Intraoperative analgesic regimens and surgical duration after spine surgery Response NEUROSURGICAL FOCUS O'Connell, C., Sun, E., Ratliff, J. K., Veeravagu, A. 2018; 45 (3)
  • Treating Chronic Pain: Is Buprenorphine the (or Even an) Answer? ANESTHESIA AND ANALGESIA Sun, E. C., Mao, J., Anderson, T. 2018; 127 (2): 336-337
  • Cost-benefit Analysis of Maintaining a Fully Stocked Malignant Hyperthermia Cart versus an Initial Dantrolene Treatment Dose for Maternity Units ANESTHESIOLOGY Ho, P. T., Carvalho, B., Sun, E. C., Macario, A., Riley, E. T. 2018; 129 (2): 249-259
  • Preoperative depression, lumbar fusion, and opioid use: an assessment of postoperative prescription, quality, and economic outcomes. Neurosurgical focus O'Connell, C. n., Azad, T. D., Mittal, V. n., Vail, D. n., Johnson, E. n., Desai, A. n., Sun, E. n., Ratliff, J. K., Veeravagu, A. n. 2018; 44 (1): E5


    OBJECTIVE Preoperative depression has been linked to a variety of adverse outcomes following lumbar fusion, including increased pain, disability, and 30-day readmission rates. The goal of the present study was to determine whether preoperative depression is associated with increased narcotic use following lumbar fusion. Moreover, the authors examined the association between preoperative depression and a variety of secondary quality indicator and economic outcomes, including complications, 30-day readmissions, revision surgeries, likelihood of discharge home, and 1- and 2-year costs. METHODS A retrospective analysis was conducted using a national longitudinal administrative database (MarketScan) containing diagnostic and reimbursement data on patients with a variety of private insurance providers and Medicare for the period from 2007 to 2014. Multivariable logistic and negative binomial regressions were performed to assess the relationship between preoperative depression and the primary postoperative opioid use outcomes while controlling for demographic, comorbidity, and preoperative prescription drug-use variables. Logistic and log-linear regressions were also used to evaluate the association between depression and the secondary outcomes of complications, 30-day readmissions, revisions, likelihood of discharge home, and 1- and 2-year costs. RESULTS The authors identified 60,597 patients who had undergone lumbar fusion and met the study inclusion criteria, 4985 of whom also had a preoperative diagnosis of depression and 21,905 of whom had a diagnosis of spondylolisthesis at the time of surgery. A preoperative depression diagnosis was associated with increased cumulative opioid use (β = 0.25, p < 0.001), an increased risk of chronic use (OR 1.28, 95% CI 1.17-1.40), and a decreased probability of opioid cessation (OR 0.96, 95% CI 0.95-0.98) following lumbar fusion. In terms of secondary outcomes, preoperative depression was also associated with a slightly increased risk of complications (OR 1.14, 95% CI 1.03-1.25), revision fusions (OR 1.15, 95% CI 1.05-1.26), and 30-day readmissions (OR 1.19, 95% CI 1.04-1.36), although it was not significantly associated with the probability of discharge to home (OR 0.92, 95% CI 0.84-1.01). Preoperative depression also resulted in increased costs at 1 (β = 0.06, p < 0.001) and 2 (β = 0.09, p < 0.001) years postoperatively. CONCLUSIONS Although these findings must be interpreted in the context of the limitations inherent to retrospective studies utilizing administrative data, they provide additional evidence for the link between a preoperative diagnosis of depression and adverse outcomes, particularly increased opioid use, following lumbar fusion.

    View details for DOI 10.3171/2017.10.FOCUS17563

    View details for PubMedID 29290135

  • A matched case-control comparison of hospital costs and outcomes for knee replacement patients admitted postoperatively to acute care versus rehabilitation. Journal of anesthesia Tse, B. K., Walters, T. L., Howard, S. K., Kim, T. E., Memtsoudis, S. G., Sun, E. C., Kou, A., Graham, L., King, R., Mariano, E. R. 2017


    For select total knee arthroplasty (TKA) patients, we have established an alternative pathway to bypass the acute care surgical ward and directly admit patients from the post-anesthesia care unit to on-campus rehabilitation. We retrospectively examined whether this 'fast track' pathway decreased costs and improved patient outcomes. After reviewing records of consecutive primary unilateral TKA patients over a 15-month period, each patient admitted to rehabilitation was matched with a control admitted to the acute care ward. The primary outcome was estimated total hospitalization cost (length of stay in days multiplied by the average cost per day). Secondary outcomes were length of stay, in-hospital pain scores, opioid use, maximum ambulatory distance and 30-day readmission, morbidity, and mortality. Of the 262 TKA patients during the study period, 14 were admitted to rehabilitation and were matched to 14 patients admitted to acute care. Estimated total hospitalization cost [median (10th-90th percentiles)] was US$30,755 (US$23,066-38,444) for ward patients compared to US$17,620 (US$13,215-33,918) for rehabilitation patients (P = 0.006). This difference [mean (95% CI)] was US$10,143 (US$2174-18,112). There were no other differences. For facilities similar to ours, direct postoperative admission of select TKA patients to subacute rehabilitation may be less costly than acute care and may not negatively affect outcomes.

    View details for DOI 10.1007/s00540-017-2372-9

    View details for PubMedID 28477230

  • Lack of Association Between the Use of Nerve Blockade and the Risk of Postoperative Chronic Opioid Use Among Patients Undergoing Total Knee Arthroplasty: Evidence from the Marketscan Database. Anesthesia and analgesia Sun, E. C., Bateman, B. T., Memtsoudis, S. G., Neuman, M. D., Mariano, E. R., Baker, L. C. 2017


    Total knee arthroplasty (TKA) is associated with high rates of prolonged opioid use after surgery (10%-34%). By decreasing opioid use in the immediate postoperative period, perioperative nerve blockade has been hypothesized to decrease the risk of persistent opioid use.Using health care utilization data, we constructed a sample of 120,080 patients undergoing TKA between 2002 and 2012 and used billing data to identify the utilization of peripheral or neuraxial blockade. We then used a multivariable logistic regression to estimate the association between nerve blockade and the risk of chronic opioid use, defined as having filled ≥10 prescriptions or ≥120 days' supply for an opioid in the first postsurgical year. Our analyses were adjusted for an extensive set of potential confounding variables, including -medical comorbidities, previous opioid use, and previous use of other medications.We did not find an association between nerve blockade and the risk of postsurgical chronic opioid use across any of these 3 groups: adjusted relative risk (ARR) 0.984 for patients opioid-naïve in the year before surgery (98.3% confidence interval [CI], 0.870-1.12, P = .794), ARR 1.02 for intermittent opioid users (98.3% CI, 0.948-1.09, P = .617), and ARR 0.986 (98.3% CI, 0.963-1.01, P = .257) for chronic opioid users. Similar results held for alternative measures of postsurgical opioid use.Although the use of perioperative nerve blockade for TKA may improve short-term outcomes, the analyzed types of blocks do not appear to decrease the risk of persistent opioid use in the longer term.

    View details for DOI 10.1213/ANE.0000000000001943

    View details for PubMedID 28430692

  • Hospitals with briefer than average lengths of stays for common surgical procedures do not have greater odds of either re-admission or use of short-term care facilities. Anaesthesia and intensive care Dexter, F., Epstein, R. H., Dexter, E. U., Lubarsky, D. A., Sun, E. C. 2017; 45 (2): 210-219


    We considered whether senior hospital managers and department chairs need to be concerned that small reductions in average hospital length of stay (LOS) may be associated with greater rates of re-admission, use of home health care, and/or transfers to short-term care facilities. The 2013 United States Nationwide Readmissions Database was used to study surgical Diagnosis Related Groups (DRG) with 1) national median LOS ≥3 days and 2) ≥10 hospitals in the database that each had ≥100 discharges for the DRG. Dependent variables were considered individually: 1) re-admission within 30 days of discharge, 2) discharge disposition to home health care, and/or 3) discharge disposition of transfer to short-term care facility (i.e., inpatient rehabilitation hospital or skilled nursing facility). While controlling for DRG, each one-day decrease in hospital median LOS was associated with an odds of re-admission nationwide of 0.95 (95% confidence interval [CI] 0.92-0.99; P=0.012), odds of disposition upon discharge being home care of 0.95 (95% CI 0.83-1.10; P=0.64), and odds of transfer to short-term care facility of 0.68 (95% CI 0.54-0.85; P=0.0008). Results were insensitive to the addition of patient-specific data. In the USA, patients at hospitals with briefer median LOS across multiple common surgical procedures did not have a greater risk for either hospital re-admission within 30 days of discharge or transfer to an inpatient rehabilitation hospital or a skilled nursing facility. The generalisable implication is that, across many surgical procedures, DRG-based financial incentives to shorten hospital stays seem not to influence post-acute care decisions.

    View details for PubMedID 28267943

  • "Opt Out" and Access to Anesthesia Care for Elective and Urgent Surgeries among U.S. Medicare Beneficiaries. Anesthesiology Sun, E. C., Dexter, F., Miller, T. R., Baker, L. C. 2017; 126 (3): 461-471


    In 2001, the Centers for Medicare and Medicaid Services issued a rule allowing U.S. states to "opt out" of the regulations requiring physician supervision of nurse anesthetists in an effort to increase access to anesthesia care. Whether "opt out" has successfully achieved this goal remains unknown.Using Medicare administrative claims data, we examined whether "opt out" reduced the distance traveled by patients, a common measure of access, for patients undergoing total knee arthroplasty, total hip arthroplasty, cataract surgery, colonoscopy/sigmoidoscopy, esophagogastroduodenoscopy, appendectomy, or hip fracture repair. In addition, we examined whether "opt out" was associated with an increase in the use of anesthesia care for cataract surgery, colonoscopy/sigmoidoscopy, or esophagogastroduodenoscopy. Our analysis used a difference-in-differences approach with a robust set of controls to minimize confounding."Opt out" did not reduce the percentage of patients who traveled outside of their home zip code except in the case of total hip arthroplasty (2.2% point reduction; P = 0.007). For patients travelling outside of their zip code, "opt out" had no significant effect on the distance traveled among any of the procedures we examined, with point estimates ranging from a 7.9-km decrease for appendectomy (95% CI, -19 to 3.4; P = 0.173) to a 1.6-km increase (95% CI, -5.1 to 8.2; P = 0.641) for total hip arthroplasty. There was also no significant effect on the use of anesthesia for esophagogastroduodenoscopy, appendectomy, or cataract surgery."Opt out" was associated with little or no increased access to anesthesia care for several common procedures.

    View details for DOI 10.1097/ALN.0000000000001504

    View details for PubMedID 28106610

  • Into the Wilderness?: The Growing Importance of Nonoperating Room Anesthesia Care in the United States. Anesthesia and analgesia Lu, A. C., Wald, S. H., Sun, E. C. 2017; 124 (4): 1044–46

    View details for PubMedID 28319544

  • In Response. Anesthesia and analgesia Sun, E. C., Bateman, B. T., Memtsoudis, S. G., Neuman, M. D., Mariano, E. R., Baker, L. C. 2017

    View details for PubMedID 29239946

  • Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesthesia and analgesia Hah, J. M., Bateman, B. T., Ratliff, J. n., Curtin, C. n., Sun, E. n. 2017; 125 (5): 1733–40


    Physicians, policymakers, and researchers are increasingly focused on finding ways to decrease opioid use and overdose in the United States both of which have sharply increased over the past decade. While many efforts are focused on the management of chronic pain, the use of opioids in surgical patients presents a particularly challenging problem requiring clinicians to balance 2 competing interests: managing acute pain in the immediate postoperative period and minimizing the risks of persistent opioid use after the surgery. Finding ways to minimize this risk is particularly salient in light of a growing literature suggesting that postsurgical patients are at increased risk for chronic opioid use. The perioperative care team, including surgeons and anesthesiologists, is poised to develop clinical- and systems-based interventions aimed at providing pain relief in the immediate postoperative period while also reducing the risks of opioid use longer term. In this paper, we discuss the consequences of chronic opioid use after surgery and present an analysis of the extent to which surgery has been associated with chronic opioid use. We follow with a discussion of the risk factors that are associated with chronic opioid use after surgery and proceed with an analysis of the extent to which opioid-sparing perioperative interventions (eg, nerve blockade) have been shown to reduce the risk of chronic opioid use after surgery. We then conclude with a discussion of future research directions.

    View details for PubMedID 29049117

  • Distribution of Prescription Opioid Use Among Privately Insured Adults Without Cancer: United States, 2001-2013. Annals of internal medicine Sun, E. C., Jena, A. B. 2017

    View details for PubMedID 28892817

  • Lack of Association Between the Use of Nerve Blockade and the Risk of Persistent Opioid Use Among Patients Undergoing Shoulder Arthroplasty: Evidence From the Marketscan Database. Anesthesia and analgesia Mueller, K. G., Memtsoudis, S. G., Mariano, E. R., Baker, L. C., Mackey, S. n., Sun, E. C. 2017


    Persistent opioid use following surgery has received increasing attention from policymakers, researchers, and clinicians. Perioperative nerve blockade has been hypothesized to decrease the risk of persistent opioid use. We examined whether nerve blockade was associated with a decreased risk of persistent opioid use among patients undergoing shoulder arthroplasty, a procedure with high rates of persistent postoperative pain.Using health care claims data, we constructed a sample of 6695 patients undergoing shoulder arthroplasty between 2002 and 2012 and used billing data to identify the utilization of nerve blockade. We then used a multivariable logistic regression to estimate the association between nerve blockade and 2 measures of opioid use: having filled at least 1 prescription for an opioid between postoperative days (PODs) 0 and 90, and between POD 91 and 365. This regression adjusted for a variety of potential confounders, such as preoperative opioid use and medical history.There was no association between nerve blockade and our 2 measures of persistent opioid use: adjusted odds ratio, 1.12 (97.5% confidence interval, 0.939-1.34; P = .15) for opioid use between POD 0 and 90, and adjusted odds ratio, 0.997 (97.5% confidence interval, 0.875-1.14; P = .95) for opioid use between POD 91 and 365.Although the use of perioperative nerve blockade may offer short-term benefits, in this study, it was not associated with a reduction in the risk of persistent opioid use for patients undergoing shoulder arthroplasty.

    View details for PubMedID 28742777

  • Readmissions to Different Hospitals After Common Surgical Procedures and Consequences for Implementation of Perioperative Surgical Home Programs. Anesthesia and analgesia Dexter, F. n., Epstein, R. H., Sun, E. C., Lubarsky, D. A., Dexter, E. U. 2017


    We consider whether there should be greater priority of information sharing about postacute surgical resources used: (1) at skilled nursing facilities or inpatient rehabilitation hospitals to which patients are transferred upon discharge (when applicable) versus (2) at different hospitals where readmissions occur. Obtaining and storing data electronically from these 2 sources for Perioperative Surgical Home initiatives are dissimilar; both can be challenging depending on the country and health system.Using the 2013 US Nationwide Readmissions Database, we studied discharges of surgical diagnosis-related group (DRG) with US national median length of stay (LOS) ≥ 3 days and ≥ 10 hospitals each with ≥ 100 discharges for the Medicare Severity DRG.Nationwide, 16.15% (95% confidence interval [CI], 15.14%-17.22%) of discharges were with a disposition of "not to home" (ie, transfer to a skilled nursing facility or an inpatient rehabilitation hospital). Within 30 days, 0.88% of discharges (0.82%-0.95%) were followed by readmission and to a different hospital than the original hospital where the surgery was performed. Among all discharges, disposition "not to home" versus "to home" was associated with greater odds that the patient would have readmission within 30 days and to a different hospital than where the surgery was performed (2.11, 95% CI, 1.96-2.27; P < .0001). In part, this was because disposition "not to home" was associated with greater odds of readmission to any hospital (1.90, 95% CI, 1.82-1.98; P < .0001). In addition, among the subset of discharges with readmission within 30 days, disposition "not to home" versus "to home" was associated with greater odds that the readmission was to a different hospital than where the surgery was performed (1.20, 95% CI, 1.11-1.31; P < .0001). There was no association between the hospitals' median LOS for the DRG and the odds that readmission was to a different hospital (P = .82). The odds ratio per each 1 day decrease in the hospital median LOS was 1.01 (95% CI, 0.91-1.12).Departments and hospitals wishing to demonstrate the value of their Perioperative Surgical Home initiatives, or to calculate risk assumption contracts, should ensure that their informatics priorities include obtaining accurate data on resource use at postacute care facilities such as skilled nursing facilities. Although approximately a quarter of readmissions are to different hospitals than where surgery was performed, provided that is recognized, obtaining those missing data is of less importance.

    View details for DOI 10.1213/ANE.0000000000002017

    View details for PubMedID 28598923

  • The Effect of "Opt-Out" Regulation on Access to Surgical Care for Urgent Cases in the United States: Evidence from the National Inpatient Sample ANESTHESIA AND ANALGESIA Sun, E., Dexter, F., Miller, T. R. 2016; 122 (6): 1983-1991


    In 2001, the Center for Medicare and Medicaid Services issued a rule permitting states to "opt-out" of federal regulations requiring physician supervision of nurse anesthetists. We examined the extent to which this rule increased access to anesthesia care for urgent cases.Using data from a national sample of inpatient discharges, we examined whether opt-out was associated with an increase in the percentage of patients receiving a therapeutic procedure among patients admitted for appendicitis, bowel obstruction, choledocholithiasis, or hip fracture. We chose these 4 diagnoses because they represent instances where urgent access to a procedure requiring anesthesia is often indicated. In addition, we examined whether opt-out was associated with a reduction in the number of appendicitis patients who presented with a ruptured appendix. In addition to controlling for patient morbidities and demographics, our analysis incorporated a difference-in-differences approach, with additional controls for state-year trends, to reduce confounding.Across all 4 diagnoses, opt-out was not associated with a statistically significant change in the percentage of patients who received a procedure (0.0315 percentage point increase, 95% confidence interval [CI] -0.843 to 0.906 percentage point increase). When broken down by diagnosis, opt-out was also not associated with statistically significant changes in the percentage of patients who received a procedure for bowel obstruction (0.511 percentage point decrease, 95% CI -2.28 to 1.26), choledocholithiasis (2.78 percentage point decrease, 95% CI -6.12 to 0.565), and hip fracture (0.291 percentage point increase, 95% CI -1.76 to 2.94). Opt-out was associated with a small but statistically significant increase in the percentage of appendicitis patients receiving an appendectomy (0.876 percentage point increase, 95% CI 0.194 to 1.56); however, there was no significant change in the percentage of patients presenting with a ruptured appendix (-0.914 percentage point decrease, 95% CI -2.41 to 0.582). Subanalyses showed that the effects of opt-out did not differ in rural versus urban areas.Based on 2 measures of access, opt-out does not appear to have significantly increased access to anesthesia for urgent inpatient conditions.

    View details for DOI 10.1213/ANE.0000000000001154

    View details for Web of Science ID 000376463000038

    View details for PubMedID 27195640

  • In the United States, "Opt-Out" States Show No Increase in Access to Anesthesia Services for Medicare Beneficiaries Compared with Non-"Opt-Out" States. A & A case reports Sun, E. C., Miller, T. R., Halzack, N. M. 2016; 6 (9): 283-285


    In the United States, anesthesia care can be provided by anesthesiologists or nurse anesthetists. Since 2001, 17 states have exercised their right to "opt-out" of the federal requirement that a physician supervise the administration of anesthesia by a nurse anesthetist, with the majority citing increased access to anesthesia care as the rationale for their decision. By using Medicare data, we found that most (4 of 5) cohorts of "opt-out" states likely experienced smaller growth in anesthesia utilization rates compared with non-"opt-out" states, suggesting that opt-out was not associated with an increase in access to anesthesia care.

    View details for DOI 10.1213/XAA.0000000000000293

    View details for PubMedID 26895523

  • Does the Modifier "QZ" Accurately Reflect Independent Nurse Anesthetist Practice: And Why Does It Matter? A & A case reports Sun, E. 2016; 6 (7): 220-221

    View details for DOI 10.1213/XAA.0000000000000254

    View details for PubMedID 27032042

  • No Significant Association between Anesthesia Group Concentration and Private Insurer Payments in the United States ANESTHESIOLOGY Sun, E. C., Dexter, F., Macario, A., Miller, T. R., Baker, L. C. 2015; 123 (3): 507-514


    Markets for physician services are becoming increasingly concentrated, with many areas being dominated by a few groups. Antitrust authorities are concerned that increasing concentration will lead to inappropriately high payments for physician services from private insurers. The authors examined the association between market concentration and private insurer payments for anesthesia services.The authors obtained data on average payments from private insurers for five commonly used anesthesia Current Procedure Terminology codes for physicians located in 229 counties in the United States between 2002 and 2010. The authors calculated a measure of market concentration (the Herfindahl-Hirschman Index [HHI]) for anesthesiologists in each county using Medicare claims data. The authors then estimated the association between market concentration and private insurer payments using a difference-in-differences approach to minimize confounding.Private insurer payments to anesthesiologists in more concentrated markets were not significantly different from payments in less concentrated markets. Compared with the 25% of counties with the least concentration (counties with an HHI in the 0th to 25th percentile), payments in counties in the 25th to 50th percentile of HHI were approximately 0.51% less (95% CI, -2.3 to 1.3%, P = 0.95), whereas payments in counties in the 50th to 75th percentile of HHI were approximately 2.8% less (95% CI, -6.7 to 1.4%, P = 0.41) and payments in counties in the 75th to 100th percentile were approximately 3.1% less (95% CI, -8.1 to 1.2%, P = 0.32).Increasing market concentration of anesthesia groups is not associated with significantly greater payments from private insurers.

    View details for DOI 10.1097/ALN.0000000000000779

    View details for Web of Science ID 000363536900005

    View details for PubMedID 26192028

  • Concentration In Orthopedic Markets Was Associated With A 7 Percent Increase In Physician Fees For Total Knee Replacements. Health affairs (Project Hope) Sun, E., Baker, L. C. 2015; 34 (6): 916-21


    Physician groups are growing larger in size and fewer in number. Although this consolidation could result in improved patient care, the resulting increase in market concentration also could allow larger groups to negotiate higher physician fees from private insurers. We examined the association between market concentration and physician fees in the case of total knee arthroplasty by calculating market concentration for orthopedic groups practicing in a given market and by analyzing administrative claims data from Marketscan. In the period 2001-10 the average professional fee for total knee arthroplasty was $2,537. During this time, in markets that moved from the bottom quartile of concentration to the top quartile, physician fees paid by private payers increased by $168 per procedure. The increase nearly offset the $261 decline in fees that we observed, absent changes in market concentration. These findings suggest that caution should be used in implementing policies designed to encourage further group concentration, which could produce similar effects.

    View details for DOI 10.1377/hlthaff.2014.1325

    View details for PubMedID 26056195

  • Does the Declining Lethality of Gunshot Injuries Mask a Rising Epidemic of Gun Violence in the United States? JOURNAL OF GENERAL INTERNAL MEDICINE Jena, A. B., Sun, E. C., Prasad, V. 2014; 29 (7): 1065-1069


    Recent mass shootings in the U.S. have reignited the important public health debate concerning measures to decrease the epidemic of gun violence. Editorialists and gun lobbyists have criticized the recent focus on gun violence, arguing that gun-related homicide rates have been stable in the last decade. While true, data from the U.S. Centers for Disease Control and Prevention also demonstrate that although gun-related homicide rates were stable between 2002 and 2011, rates of violent gunshot injuries increased. These seemingly paradoxical trends may reflect the declining lethality of gunshot injuries brought about by surgical advances in the care of the patient with penetrating trauma. Focusing on gun-related homicide rates as a summary statistic of gun violence, rather than total violent gunshot injuries, can therefore misrepresent the rising epidemic of gun violence in the U.S.

    View details for DOI 10.1007/s11606-014-2779-z

    View details for Web of Science ID 000338207100023

    View details for PubMedID 24452421

    View details for PubMedCentralID PMC4061370

  • Mortality Among High-Risk Patients With Acute Myocardial Infarction Admitted to US Teaching-Intensive Hospitals in July A Retrospective Observational Study CIRCULATION Jena, A. B., Sun, E. C., Romley, J. A. 2013; 128 (25): 2754-?


    Studies of whether inpatient mortality in US teaching hospitals rises in July as a result of organizational disruption and relative inexperience of new physicians (July effect) find small and mixed results, perhaps because study populations primarily include low-risk inpatients whose mortality outcomes are unlikely to exhibit a July effect.Using the US Nationwide Inpatient sample, we estimated difference-in-difference models of mortality, percutaneous coronary intervention rates, and bleeding complication rates, for high- and low-risk patients with acute myocardial infarction admitted to 98 teaching-intensive and 1353 non-teaching-intensive hospitals during May and July 2002 to 2008. Among patients in the top quartile of predicted acute myocardial infarction mortality (high risk), adjusted mortality was lower in May than July in teaching-intensive hospitals (18.8% in May, 22.7% in July, P<0.01), but similar in non-teaching-intensive hospitals (22.5% in May, 22.8% in July, P=0.70). Among patients in the lowest three quartiles of predicted acute myocardial infarction mortality (low risk), adjusted mortality was similar in May and July in both teaching-intensive hospitals (2.1% in May, 1.9% in July, P=0.45) and non-teaching-intensive hospitals (2.7% in May, 2.8% in July, P=0.21). Differences in percutaneous coronary intervention and bleeding complication rates could not explain the observed July mortality effect among high risk patients.High-risk acute myocardial infarction patients experience similar mortality in teaching- and non-teaching-intensive hospitals in July, but lower mortality in teaching-intensive hospitals in May. Low-risk patients experience no such July effect in teaching-intensive hospitals.

    View details for DOI 10.1161/CIRCULATIONAHA.113.004074

    View details for Web of Science ID 000330348100013

    View details for PubMedID 24152859

    View details for PubMedCentralID PMC4125575

  • Firearm Legislation and Gun-Related Fatalities JAMA INTERNAL MEDICINE Jena, A. B., Sun, E. C., Prasad, V. 2013; 173 (21): 2011
  • Community-Acquired Pneumonia and Proton Pump Inhibitors JOURNAL OF GENERAL INTERNAL MEDICINE Jena, A. B., Sun, E., Goldman, D. 2013; 28 (7): 874-875

    View details for DOI 10.1007/s11606-013-2430-4

    View details for Web of Science ID 000320508100010

    View details for PubMedID 23549958

    View details for PubMedCentralID PMC3682033

  • Confounding in the Association of Proton Pump Inhibitor Use With Risk of Community-Acquired Pneumonia JOURNAL OF GENERAL INTERNAL MEDICINE Jena, A. B., Sun, E., Goldman, D. P. 2013; 28 (2): 223-230


    Use of proton pump inhibitors (PPIs) is associated with community-acquired pneumonia (CAP), an association which may be confounded by unobserved patient and prescriber characteristics.We assessed for confounding in the association between PPI use and CAP by using a 'falsification approach,' which estimated whether PPI use is also implausibly associated with other common medical conditions for which no known pathophysiologic link exists.Retrospective claims-based cohort study.Six private U.S. health plans.Individuals who filled at least one prescription for a PPI (N = 26,436) and those who never did (N = 28,054) over 11 years.Multivariate linear regression of the association between a filled prescription for a PPI and a diagnosis of CAP in each 3-month quarter. In falsification analyses, we tested for implausible associations between PPI use in each quarter and rates of osteoarthritis, chest pain, urinary tract infection (UTI), deep venous thrombosis (DVT), skin infection, and rheumatoid arthritis. Independent variables included an indicator for whether a prescription for a PPI was filled in a given quarter, and quarterly indicators for various co-morbidities, age, income, geographic location, and marital status.Compared to nonusers, those ever using a PPI had higher adjusted rates of CAP in quarters in which no prescription was filled (68 vs. 61 cases per 10,000 persons, p < 0.001). Similar associations were noted for all conditions (e.g. chest pain, 336 vs. 282 cases, p < 0.001; UTI, 151 vs. 139 cases, p < 0.001). Among those ever using a PPI, quarters in which a prescription was filled were associated with higher adjusted rates of CAP (111 vs. 68 cases per 10,000, p < 0.001) and all other conditions (e.g. chest pain, 597 vs. 336 cases, p < 0.001; UTI, 186 vs. 151 cases, p < 0.001), compared to quarters in which no prescription was filled.PPI use is associated with CAP, but also implausibly associated with common medical conditions. Observed associations between PPI use and CAP may be confounded.

    View details for DOI 10.1007/s11606-012-2211-5

    View details for Web of Science ID 000314067900013

    View details for PubMedID 22956446

    View details for PubMedCentralID PMC3614140

  • Behind-the-Counter Statins: A Silver Bullet for Reducing Costs and Increasing Access? HEALTH SERVICES RESEARCH Sood, N., Sun, E., Zhuo, X. 2012; 47 (1): 174-187


    To examine how the 2004 introduction of behind-the-counter (BTC) simvastatin in the United Kingdom affected utilization, prices, and expenditures.Secondary data on simvastatin utilization, prices, and expenditures between 1997 and 2007 in the United Kingdom and four other countries.We used a difference-in-differences approach to estimate how the introduction of BTC simvastatin affected utilization, prices, and expenditures. This approach compares outcomes in the United Kingdom before and after the introduction of BTC simvastatin, using outcomes in countries where the drug remained prescription only to control for possible confounders.Data on simvastain utilization, prices, and expenditures between 1997 and 2007 in the United Kingdom and four other countries were obtained from an outside vendor.The introduction of BTC simvastatin in the United Kingdom led to a significant increase in utilization of simvastatin and a significant decline in expenditures for simvastatin purchases. Our results are robust to alternate model specifications.Behind-the-counter statins have the potential to simultaneously increase use of statins and lower expenditures.

    View details for DOI 10.1111/j.1475-6773.2011.01315.x

    View details for Web of Science ID 000299040600011

    View details for PubMedID 22091792

    View details for PubMedCentralID PMC3447239

  • A Reexamination of the Costs of Medical R&D Regulation. Forum for health economics & policy Philipson, T. J., Sun, E. n., Goldman, D. n., Jena, A. B. 2012; 15 (2): 1–28


    Recent evidence suggests that the economic value of increased health has been enormous, with most of these gains being driven by medical R&D. The R&D process for pharmaceuticals is particularly expensive and time consuming, with well-known studies from the Tufts Center for the Study of Drug Development suggesting that developing a single successful drug costs around $1 billion and takes roughly 12 years. We argue that these estimates are incomplete because they do not incorporate the social costs imposed by the regulatory process, namely the costs to producers in terms of forgone profits and the costs to consumers in terms of delayed access to drugs. In this article, we develop a framework to estimate the social costs imposed by the regulatory process. Under this framework, delays in drug development are socially costly because of reduced consumer surplus (due to delayed access to beneficial therapies), reduced producer variable profits, and increased R&D expenditures. We apply this framework to the case of therapies aimed at treating AIDS, non-Hodgkin's lymphoma, and breast cancer. In each case, we find that the effects of drug delays on consumer surplus and variable producer profits are far larger than the effects on R&D costs. These findings suggest that patients, not firms, would be the primary beneficiaries from any improvements in streamlining the drug development process.

    View details for DOI 10.1515/fhep-2012-0020

    View details for PubMedID 31419852

  • Do We Need the FDA? Improving the Regulation of Pharmaceutical Products Regulation vs Litigation:Persepectives from Economics and Law Philipson, T. J., Sun, E. C., Goldman, D. P. edited by Kessler, D., Shleifer, A. University of Chicago Press. 2011
  • Can an Acute Pain Service Be Cost-Effective? ANESTHESIA AND ANALGESIA Sun, E., Dexter, F., Macario, A. 2010; 111 (4): 841-844

    View details for DOI 10.1213/ANE.0b013e3181f33533

    View details for Web of Science ID 000282310200005

    View details for PubMedID 20870982

  • An economic evaluation of the war on cancer JOURNAL OF HEALTH ECONOMICS Lakdawalla, D. N., Sun, E. C., Jena, A. B., Reyes, C. M., Goldman, D. P., Philipson, T. J. 2010; 29 (3): 333-346


    For decades, the US public and private sectors have committed substantial resources towards cancer research, but the societal payoff has not been well-understood. We quantify the value of recent gains in cancer survival, and analyze the distribution of value among various stakeholders. Between 1988 and 2000, life expectancy for cancer patients increased by roughly four years, and the average willingness-to-pay for these survival gains was roughly $322,000. Improvements in cancer survival during this period created 23 million additional life-years and roughly $1.9 trillion of additional social value, implying that the average life-year was worth approximately $82,000 to its recipient. Health care providers and pharmaceutical companies appropriated 5-19% of this total, with the rest accruing to patients. The share of value flowing to patients has been rising over time. In terms of economic rates of return, R&D investments against cancer have been a success, particularly from the patient's point of view.

    View details for DOI 10.1016/j.jhealeco.2010.02.006

    View details for Web of Science ID 000278297200001

    View details for PubMedID 20363520

  • The Value of Specialty Oncology Drugs HEALTH SERVICES RESEARCH Goldman, D. P., Jena, A. B., Lakdawalla, D. N., Malin, J. L., Malkin, J. D., Sun, E. 2010; 45 (1): 115-132


    To estimate patients' elasticity of demand, willingness to pay, and consumer surplus for five high-cost specialty medications treating metastatic disease or hematologic malignancies.Claims data from 71 private health plans from 1997 to 2005.This is a revealed preference analysis of the demand for specialty drugs among cancer patients. We exploit differences in plan generosity to examine how utilization of specialty oncology drugs varies with patient out-of-pocket costs.We extracted key variables from administrative health insurance claims records.A 25 percent reduction in out-of-pocket costs leads to a 5 percent increase in the probability that a patient initiates specialty cancer drug therapy. Among patients who initiate, a 25 percent reduction in out-of-pocket costs reduces the number of treatments (claims) by 1-3 percent, depending on the drug. On average, the value of these drugs to patients who use them is about four times the total cost paid by the patient and his or her insurer, although this ratio may be lower for oral specialty therapies.The decision to initiate therapy with specialty oncology drugs is responsive to price, but not highly so. Among patients who initiate therapy, the amount of treatment is equally responsive. The drugs we examine are highly valued by patients in excess of their total costs, although oral agents warrant further scrutiny as copayments increase.

    View details for DOI 10.1111/j.1475-6773.2009.01059.x

    View details for Web of Science ID 000273456400008

    View details for PubMedID 19878344

  • The Contributions of Improved Therapy and Earlier Detection to Cancer Survival Gains, 1988-2000 Forum for Health Economics & Policy Sun, E. C., Jena, A. B., Lakdawalla, D. N., Goldman, D. P. 2010; 13 (2)
  • Health and Wealth Disparities in the United States Philipson, T. J., Jena, A. B., Sun, E. C. American Enterprise Institute Press. 2010
  • Medicare Part D After 2 Years AMERICAN JOURNAL OF MANAGED CARE Joyce, G. F., Goldman, D. P., Vogt, W. B., Sun, E., Jena, A. B. 2009; 15 (8): 536-544


    To assess the broad impacts of Medicare Part D and the extent to which prior concerns have been realized.We used administrative data to summarize beneficiary enrollment and plan participation in Part D, and compared pharmaceutical use and out-of-pocket spending before and after the introduction of Part D. We characterized the benefit designs of the 10 largest Part D plans in 2006 and compared them with the benefit designs of 7 non-Part D plans often cited as examples of low-cost or comprehensive drug benefits.By 2008, nearly 90% of seniors had drug coverage at least as generous as the standard Part D benefit. Excluding premiums, annual out-of-pocket spending in the 10 largest Part D plans was comparable to that of other private and public drug benefits, with the most prominent differences attributable to out-of-pocket spending on drugs not covered in the plan. Poorer beneficiaries have gained the most from Part D in terms of increased access to medications and reduced out-of-pocket spending.Coverage under Part D is comparable to that under non-Part D plans with respect to key features that are likely to be important to Medicare beneficiaries--access to medications and out-of-pocket costs. Nonetheless, concerns remain over drug pricing and gaps in coverage. The government should continue to monitor the competitiveness of the Part D market to ensure it meets the diverse needs of Medicare beneficiaries.

    View details for Web of Science ID 000269316600007

    View details for PubMedID 19670957

  • Is the food and drug administration safe and effective? JOURNAL OF ECONOMIC PERSPECTIVES Philipson, T. J., Sun, E. 2008; 22 (1): 85–102

    View details for DOI 10.1257/jep.22.1.85

    View details for Web of Science ID 000253915900005

    View details for PubMedID 19728421

  • Cost-benefit analysis of the FDA: The case of the prescription drug user fee acts JOURNAL OF PUBLIC ECONOMICS Philipson, T., Berndt, E. R., Gottschalk, A. H., Sun, E. 2008; 92 (5-6): 1306-1325
  • Drug licenses: A new model for pharmaceutical pricing HEALTH AFFAIRS Goldman, D. P., Jena, A. B., Phillipson, T., Sun, E. 2008; 27 (1): 122-129


    High drug prices are a major barrier to patients' access to drugs and compliance with treatment. Yet low drug prices are often argued to provide inadequate incentives for innovation. We propose a drug-licensing model for health care, which has the promise of increasing drug use without altering patients' out-of-pocket spending, health plans' costs, or drug companies' profits. In such a model, people would purchase annual drug licenses that would guarantee unfettered access to a clinically optimal number of prescriptions over the course of a year. Using the example of statins, we illustrate how such a model could be implemented.

    View details for Web of Science ID 000257188400014

    View details for PubMedID 18180487

  • Salivary gland cancer in the United States CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION Sun, E. C., Curtis, R., Melbye, M., Goedert, J. J. 1999; 8 (12): 1095-1100


    The risk of salivary gland cancer (SGC) is increased in atomic bomb survivors and after radiotherapy, but other risk factors are not well established. Some studies have suggested an association of SGC with breast cancer and with exposure to various viruses or UVB radiation. Corroborating evidence of these associations was sought by using population-based registries to examine the demographic distribution of SGC, patterns of secondary primary cancers after SGC, and risk of SGC with AIDS. SGC incidence per 100,000 persons did not change between 1973 and 1992, averaging 1.2 in males and 0.8 in females, with a steep age gradient. To examine the relationship between UVB exposure and SGC, population-based, age-adjusted incidence rates of SGC were plotted against the UVB insolation of each registry site. Regression analysis suggested no correlation between SGC incidence and increasing UVB insolation (beta = 0.10, R2 = 0.08). SGC also did not appear to be associated with second cancers that have been linked to herpes or papilloma viruses or with AIDS [observed/expected (O/E) ratio, <2.8], but all of these conditions are so uncommon that only very large relative risks would have been statistically significant. Women with SGC before age 35 had a statistically nonsignificant elevation in breast cancer risk [O/E, 3.30; 95% confidence interval (CI), 0.66-9.65], and older women had no increased risk of breast cancer. SGC patients were at increased risk for nonsalivary, second-primary oropharyngeal cancers (O/E, 3.27; 95% CI, 2.00-5.05), thyroid cancer (O/E, 3.31; 95% CI, 1.07-7.73), and lung cancer (O/E, 1.86; 95% CI, 1.45-2.35), particularly in patients whose SGC was treated with radiotherapy (O/E, 2.83; 95% CI, 2.06-3.80). In summary, SGC remains rare and does not appear to be associated with AIDS, virally related malignancies, or UVB. Patients who have had SGC, however, should be monitored for subsequent oropharyngeal, thyroid, and lung cancers.

    View details for Web of Science ID 000084320100008

    View details for PubMedID 10613342

  • Epidemiology of squamous cell conjunctival cancer CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION Sun, E. C., Fears, T. R., Goedert, J. J. 1997; 6 (2): 73-77


    The etiology of squamous cell carcinoma of the conjunctiva (SCCC) is not well known. A possible role of UVB radiation is suggested by an excess of SCCC in tropical countries and by the association between squamous cell skin cancer and exposure to UVB. Human papillomavirus type 16 also may be involved, given that it has been detected in benign and malignant conjunctival lesions and is the primary etiological agent involved in carcinoma of the anogenital tract. To examine the relationship between UVB exposure and SCCC, population-based age-adjusted incidence rates of SCCC and of conjunctival melanoma and squamous cell cancer of the eyelid were plotted against the UVB insolation of each registry site. Incidence data were examined further for patterns of second primary cancers among people with SCCC. SCCC was rare in the United States, with an incidence rate of 0.03 per 100,000 persons, although the rate was approximately 5-fold higher among males and whites. Regression analysis suggested a link between UVB exposure and SCCC rates (beta = 2.25; r = 0.58) that was as strong as that for squamous cell carcinoma of the eyelid (beta = 2.73; r = 0.62) and much stronger than for conjunctival melanoma (beta = 0.28; r = 0.02). Risk of a second malignancy after SCCC was not increased overall (20 observed and 14.1 expected), although a significant excess of salivary gland cancer (4 observed and 0.03 expected) and a borderline excess of lung cancer (6 observed and 2.4 expected) were noted. These observations suggest that UV radiation likely contributes to SCCC development. Additional research is needed to define the other exposures and host susceptibility that likely interact with UV-related genetic damage in the multifactorial development of this rare neoplasm.

    View details for Web of Science ID A1997WG44500001

    View details for PubMedID 9037556