Bio


After completing both a Patient Safety Fellowship and a Masters in Health Services Research at Stanford, Dr. Mudumbai joined the faculty as an Assistant Professor in the Department of Anesthesiology, Perioperative, and Pain Medicine in 2014. Dr. Mudumbai is an outcomes and health services researcher who works to integrate his clinical, administrative, and research roles. Dr. Mudumbai's main research interests are in translational research: 1) optimizing therapeutic strategies and reducing adverse outcomes related to medication management, particularly opioids; and 2) measuring and improving the quality of perioperative and pain management.

Academic Appointments


Administrative Appointments


  • Director for Clinical Informatics Systems and Perioperative Analytics, VA Palo Alto HCS (2021 - Present)
  • Transfusion Committee, VA Palo Alto HCS (2015 - Present)
  • Medical Director for VISN 21 Clinical Informatics Systems and Perioperative Analytics, VISN 21, Veterans Health Administration; https://www.visn21.va.gov/ (2014 - 2021)

Honors & Awards


  • Junior Faculty Award, Association of University Anesthesiologists (2019)
  • Kosaka Finalist, Clinical Research, International Anesthesia Research Society (2019)
  • Best in Category, International Anesthesia Research Society (2012)

Boards, Advisory Committees, Professional Organizations


  • Member, American Society Of Anesthesiologists (2006 - Present)
  • Member, The American Society of Anesthesiology Committee on Electronic Media & Information Technology (2015 - Present)
  • Member, American Society of Regional Anesthesia & Pain Medicine (2016 - Present)
  • Member, Association of University Anesthesiologists (2018 - Present)

Professional Education


  • Patient Safety Fellowship, Stanford University, Patient Safety and Medical Simulation
  • MS, Stanford University, Health Services Research
  • Residency, Department of Anesthesiology, State University of New York -Health Science Center at Brooklyn (SUNY-HSCAB) and Mount Sinai Medical Center, Anesthesiology
  • MD, State University of New York -Health Science Center at Brooklyn (SUNY-HSCAB), Medical Education

Current Research and Scholarly Interests


Our research team focuses on

1)improving the ability of patients and clinicians to act on data through the evaluation of medication management and informatics tools in small groups and populations. We study the psychological, social, biologic, and system-level factors affecting medication use in order to advance the effectiveness at which clinicians work, and to inform public policy. We are currently involved in a multi-health care system study for the Food & Drug Administratio examinning the outcomes of opioids.

2) measuring and improving the quality of perioperative and pain management. We are actively working on a VA Health Services Research & Development (HSRD) Study on low value preoperative testing.

2023-24 Courses


All Publications


  • Collateral Damage as Crises Collide: Perioperative Opioids in the COVID-19 Era. Pain medicine (Malden, Mass.) Mudumbai, S. C., Mariano, E. R., Clark, J. D., Stafford, R. S. 2020

    View details for DOI 10.1093/pm/pnaa308

    View details for PubMedID 33150439

  • Perioperative Opioid Prescribing Patterns and Readmissions After Total Knee Arthroplasty in a National Cohort of Veterans Health Administration Patients. Pain medicine (Malden, Mass.) Mudumbai, S. C., Chung, P. n., Nguyen, N. n., Harris, B. n., Clark, J. D., Wagner, T. H., Giori, N. J., Stafford, R. S., Mariano, E. R. 2019

    Abstract

    Among Veterans Health Administration (VHA) patients who undergo total knee arthroplasty (TKA) nationally, what are the underlying readmission rates and associations with perioperative opioid use, and are there associations with other factors such as preoperative health care utilization?We retrospectively examined the records of 5,514 TKA patients (primary N = 4,955, 89.9%; revision N = 559, 10.1%) over one fiscal year (October 1, 2010-September 30, 2011) across VHA hospitals nationwide. Opioid use was classified into no opioids, tramadol only, short-acting only, or any long-acting. We measured readmission within 30 days and the number of days to readmission within 30 days. Extended Cox regression models were developed.The overall 30-day hospital readmission rate was 9.6% (N = 531; primary 9.5%, revision 11.1%). Both readmitted patients and the overall sample were similar on types of preoperative opioid use. Relative to patients without opioids, patients in the short-acting opioids only tier had the highest risk for 30-day hospital readmission (hazard ratio = 1.38, 95% confidence interval = 1.14-1.67). Preoperative opioid status was not associated with 30-day readmission. Other risk factors for 30-day readmission included older age (≥66 years), higher comorbidity and diagnosis-related group weights, greater preoperative health care utilization, an urban location, and use of preoperative anticonvulsants.Given the current opioid epidemic, the routine prescribing of short-acting opioids after surgery should be carefully considered to avoid increasing risks of 30-day hospital readmissions and other negative outcomes, particularly in the context of other predisposing factors.

    View details for DOI 10.1093/pm/pnz154

    View details for PubMedID 31309970

  • Development and validation of a predictive model for American Society of Anesthesiologists Physical Status. BMC health services research Mudumbai, S. C., Pershing, S. n., Bowe, T. n., Kamal, R. N., Sears, E. D., Finlay, A. K., Eisenberg, D. n., Hawn, M. T., Weng, Y. n., Trickey, A. W., Mariano, E. R., Harris, A. H. 2019; 19 (1): 859

    Abstract

    The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes.Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator.Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/- 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at https://s-spire-clintools.shinyapps.io/ASA_PS_Estimator/ CONCLUSIONS: Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.

    View details for DOI 10.1186/s12913-019-4640-x

    View details for PubMedID 31752856

  • Overdose Risk Associated with Opioid Use upon Hospital Discharge in Veterans Health Administration Surgical Patients. Pain medicine (Malden, Mass.) Mudumbai, S. C., Lewis, E. T., Oliva, E. M., Chung, P. D., Harris, B. n., Trafton, J. n., Mariano, E. R., Wagner, T. n., Clark, J. D., Stafford, R. S. 2018

    Abstract

    To determine an association between opioid use upon hospital discharge (ongoing and newly started) in surgical patients and risks of opioid overdose and delirium for the first year.Retrospective, cohort study.Population-level study of Veterans Health Administration patients.All Veterans Health Administration patients (N = 64,391) who underwent surgery in 2011, discharged after one or more days, and without a diagnosis of opioid overdose or delirium from 90 days before admission through 30 days postdischarge (to account for additional opioid dosing in the context of chronic use).Patients' opioid use was categorized as 1) no opioids, 2) tramadol only, 3) short-acting only, 4) long-acting only, 5) short- and long-acting. We calculated unadjusted incidence rates and the incidence rate ratio (IRR) for opioid overdose and drug delirium for two time intervals: postdischarge days 0-30 and days 31-365. We then modeled outcomes of opioid overdose and delirium for postdischarge days 31-365 using a multivariable extended Cox regression model. Sensitivity analysis examined risk factors for overdose for postdischarge days 0-30.Incidence of overdose was 11-fold greater from postdischarge days 0-30 than days 31-365: 26.3 events/person-year (N = 68) vs 2.4 events/person-year (N = 476; IRR = 10.80, 95% confidence interval [CI] = 8.37-13.92). Higher-intensity opioid use was associated with increasing risk of overdose for the year after surgery, with the highest risk for the short- and long-acting group (hazard ratio = 4.84, 95% CI = 3.28-7.14). Delirium (IRR = 10.66, 95% CI = 7.96-14.29) was also associated with higher opioid intensity.Surgical patients should be treated with the lowest effective intensity of opioids and be monitored to prevent opioid-related adverse events.

    View details for PubMedID 30137452

  • A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine. Pain management Mudumbai, S. C., Auyong, D. B., Memtsoudis, S. G., Mariano, E. R. 2018

    Abstract

    Anesthesiologists set up regional anesthesia and acute pain medicine programs in order to improve the patient outcomes and experience. Given the increasing frequency and volume of newly described techniques, applying a pragmatic framework can guide clinicians on how to critically review and consider implementing the new techniques into clinical practice. A proposed framework should consider how a technique: increases access; enhances efficiency; decreases disparities and improves outcomes. Quantifying the relative contribution of these four factors using a point system, which will be specific to each practice, can generate an overall scorecard to help clinicians make decisions on whether or not to incorporate a new technique into clinical practice or replace an incumbent technique within a clinical pathway.

    View details for PubMedID 30394193

  • Perioperative and ICU Healthcare Analytics within a Veterans Integrated System Network: a Qualitative Gap Analysis. Journal of medical systems Mudumbai, S. n., Ayer, F. n., Stefanko, J. n. 2017; 41 (8): 118

    Abstract

    Health care facilities are implementing analytics platforms as a way to document quality of care. However, few gap analyses exist on platforms specifically designed for patients treated in the Operating Room, Post-Anesthesia Care Unit, and Intensive Care Unit (ICU). As part of a quality improvement effort, we undertook a gap analysis of an existing analytics platform within the Veterans Healthcare Administration. The objectives were to identify themes associated with 1) current clinical use cases and stakeholder needs; 2) information flow and pain points; and 3) recommendations for future analytics development. Methods consisted of semi-structured interviews in 2 phases with a diverse set (n = 9) of support personnel and end users from five facilities across a Veterans Integrated Service Network. Phase 1 identified underlying needs and previous experiences with the analytics platform across various roles and operational responsibilities. Phase 2 validated preliminary feedback, lessons learned, and recommendations for improvement. Emerging themes suggested that the existing system met a small pool of national reporting requirements. However, pain points were identified with accessing data in several information system silos and performing multiple manual validation steps of data content. Notable recommendations included enhancing systems integration to create "one-stop shopping" for data, and developing a capability to perform trends analysis. Our gap analysis suggests that analytics platforms designed for surgical and ICU patients should employ approaches similar to those being used for primary care patients.

    View details for DOI 10.1007/s10916-017-0762-z

    View details for PubMedID 28685304

  • Time-to-Cessation of Postoperative Opioids: A Population-Level Analysis of the Veterans Affairs Health Care System. Pain medicine Mudumbai, S. C., Oliva, E. M., Lewis, E. T., Trafton, J., Posner, D., Mariano, E. R., Stafford, R. S., Wagner, T., Clark, J. D. 2016; 17 (9): 1732-1743

    Abstract

    This study aims to determine 1) the epidemiology of perioperative opioid use; and 2) the association between patterns of preoperative opioid use and time-to-cessation of postoperative opioids.Retrospective, cohort study.National, population-level study of Veterans Healthcare Administration (VHA) electronic clinical data.All VHA patients (n = 64,391) who underwent surgery in 2011, discharged after stays of ≥1 day, and receiving ≥1 opioid prescription within 90 days of discharge.Patients' preoperative opioid use were categorized as 1) no opioids, 2) tramadol only, 3) short-acting (SA) acute/intermittent (≤ 90 days fill), 4) SA chronic (> 90 days fill), or 5) any long-acting (LA). After defining cessation as 90 consecutive, opioid-free days, the authors calculated time-to-opioid-cessation (in days), from day 1 to day 365, after hospital discharge. The authors developed extended Cox regression models witha prioriidentified predictors. Sensitivity analyses used alternative cessation definitions (30 or 180 consecutive days).Almost 60% of the patients received preoperative opioids: tramadol (7.5%), SA acute/intermittent (24.1%), SA chronic (17.5%), and LA (5.2%). For patients opioid-free preoperatively, median time-to-cessation of opioids postoperatively was 15 days. The SA acute/intermittent cohort (HR =1.96; 95% CI =1.92-2.00) had greater risk for prolonged time-to-cessation than those opioid-free (reference), but lower risk than those taking tramadol only, SA chronic (HR = 9.09; 95% CI = 8.33-9.09), or LA opioids (HR = 9.09; 95% CI = 8.33-10.00). Diagnoses of chronic pain, substance-use, or affective disorders were weaker positive predictors. Sensitivity analyses maintained findings.Greater preoperative levels of opioid use were associated with progressively longer time-to-cessation postoperatively.

    View details for DOI 10.1093/pm/pnw015

    View details for PubMedID 27084410

  • Barriers to Implementation of Telehealth Pre-anesthesia Evaluation Visits in the Department of Veterans Affairs. Federal practitioner : for the health care professionals of the VA, DoD, and PHS Barbeito, A., Raghunathan, K., Connolly, S., Mariano, E. R., Blitz, J., Stafford, R. S., Mudumbai, S. 2023; 40 (7): 210-217a

    Abstract

    Evaluations are conducted days or weeks before a scheduled surgical or invasive procedure involving anesthesia to assess patients' preprocedure condition and risk, optimize status, and prepare them for their procedure. The traditional pre-anesthesia evaluation is conducted in person, although telehealth modalities have been used for several years and have accelerated since the advent of the COVID-19 pandemic.We surveyed 109 anesthesiology services to understand the barriers and facilitators to the adoption of telephone- and video-based pre-anesthesia evaluation visits within the US Department of Veterans Affairs (VA).The analysis included 55 responses from 50 facilities. Twenty-two facilities reported using both telephone and video, 11 telephone only, 5 video only, and 12 none of these modalities. For telehealth users, the ability to obtain a history of present illness, the ability to assess for comorbidities, and assess for health habits were rated highest while assessing nutritional status was lowest. Among nonusers of telehealth modalities, barriers to adoption included the inability to perform a physical examination and the inability to obtain vital signs. Respondents not using telephone cited concerns about safety, while respondents not using video also cited lack of information technology and staff support and patient-level barriers.We found no significant perceived advantages of video over telephone in the ability to conduct routine pre-anesthesia evaluations except for the perceived ability to assess nutritional status. Clinicians with no telehealth experience cited the inability to perform a physical examination and obtain vital signs as the most significant barriers to implementation. Future work should focus on delineating the most appropriate and valuable uses of telehealth for pre-anesthesia evaluation and/or optimization.

    View details for DOI 10.12788/fp.0387

    View details for PubMedID 37868714

    View details for PubMedCentralID PMC10588996

  • The Association between Alcohol Use Disorder and 1-year Mortality after Total Knee Arthroplasty in the United States Veterans Health Administration- A Retrospective Cohort Study Costin, B., Raghunathan, K., Ohnuma, T., Krishnamoorthy, V., Barbeito, A., Rolfzen, M., Bryan, W., Pepin, M., Mudumbai, S., Blitz, J., Pietrobon, R., Bartels, K. LIPPINCOTT WILLIAMS & WILKINS. 2023: 538
  • Frequency and costs of low-value preoperative tests for patients undergoing low-risk procedures in the veterans health administration. Perioperative medicine (London, England) Harris, A. H., Bowe, T., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Finlay, A. K., Hagedorn, H. J., Mudumbai, S. 2022; 11 (1): 33

    Abstract

    BACKGROUND: Clinical practice guidelines discourage routine preoperative screening tests for patients undergoing low-risk procedures. This study sought to determine the frequency and costs of potentially low-value preoperative screening tests in Veterans Health Administration (VA) patients undergoing low-risk procedures.METHODS: Using the VA Corporate Data Warehouse, we identified Operative Stress Score class 1 procedures ("very minor") performed without general anesthesia in VA during fiscal year 2019 and calculated the overall national and facility-level rates and costs of nine common tests received in the 30 preoperative days. Patient factors associated with receiving at least one screening test, and the number of tests received, were examined.RESULTS: Eighty-six thousand three hundred twenty-seven of 178,775 low-risk procedures (49.3%) were preceded by 321,917 potentially low-value screening tests representing $11,505,170 using Medicare average costs. Complete blood count was the most common (33.2% of procedures), followed by basic metabolic profile (32.0%), urinalysis (26.3%), electrocardiography (18.9%), and pulmonary function test (12.4%). Older age, female sex, Black race, and having more comorbidities were associated with higher odds of low-value testing. Transthoracic echocardiogram occurred prior to only 4.5% of the procedures but accounted for 47.8% of the total costs ($5,499,860). In 129 VA facilities, the facility-level proportion of procedures preceded by at least one test ranged from 0 to 81.2% and facility-level costs ranged from $0 to $388,476.CONCLUSIONS: Routine preoperative screening tests for very low-risk procedures are common and costly in some VA facilities. These results highlight a potential target to improve quality and value by reducing unnecessary care. Measures of low-value perioperative care could be integrated into VA's extensive quality monitoring and improvement infrastructure.

    View details for DOI 10.1186/s13741-022-00265-0

    View details for PubMedID 36096937

  • Single-center cross-sectional study of high opioid prescribing among U.S. veterans with peripheral arterial disease. Regional anesthesia and pain medicine Stern, J. R., Kou, A., Kapoor, A., Regala, S., He, H., Stafford, R. S., Mariano, E. R., Mudumbai, S. C. 2022

    View details for DOI 10.1136/rapm-2022-103574

    View details for PubMedID 35688513

  • A Comparative Utility Score for Digital Health Tools. Journal of medical systems Burton, J. C., Regala, S., Williams, D., Desai, A., He, H., Aalami, O., Mariano, E. R., Stafford, R. S., Mudumbai, S. C. 2022; 46 (6): 34

    Abstract

    Digital health tools (DHT) are increasingly poised to change healthcare delivery given the Coronavirus Disease 2019 (COVID-19) pandemic and the drive to telehealth. Establishing the potential utility of a given DHT could aid in identifying how it could be best used and further opportunities for healthcare improvement. We propose a metric, a Utility Factor Score, which quantifies the benefits of a DHT by explicitly defining adherence and linking it directly to satisfaction and health goals met. To provide data for how the comparative utility score can or should work, we illustrate in detail the application of our metrics across four DHTs with two simulated users. The Utility Factor Score can potentially facilitate integration of DHTs into various healthcare settings and should be evaluated within a clinical study.

    View details for DOI 10.1007/s10916-022-01821-3

    View details for PubMedID 35511408

  • Machine Learning Can Identify Geographic Disparities in Opioid Overdose Before and After the COVID-19 Pandemic He, H., Kou, A., Kapoor, A., Regala, S., Raghunathan, K., Mariano, E. R., Stafford, R. S., Mudumbai, S. LIPPINCOTT WILLIAMS & WILKINS. 2022: 708-709
  • Buprenorphine Prescribing During the COVID-19 Pandemic: An Initial Disparities Analysis from the California Opioid Overdose Surveillance Dashboard He, H., Regala, S., Kapoor, A., Raghunathan, K., Mariano, E. R., Stafford, R. S., Mudumbai, S. LIPPINCOTT WILLIAMS & WILKINS. 2022: 437-438
  • Effects of Buprenorphine Dose and Therapeutic Engagement on Illicit Opiate Use in Opioid Use Disorder Treatment Trials. International journal of environmental research and public health Bergen, A. W., Baurley, J. W., Ervin, C. M., McMahan, C. S., Bible, J., Stafford, R. S., Mudumbai, S. C., Saxon, A. J. 2022; 19 (7)

    Abstract

    The impact of agonist dose and of physician, staff and patient engagement on treatment have not been evaluated together in an analysis of treatment for opioid use disorder. Our hypotheses were that greater agonist dose and therapeutic engagement would be associated with reduced illicit opiate use in a time-dependent manner. Publicly-available treatment data from six buprenorphine efficacy and safety trials from the Federally-supported Clinical Trials Network were used to derive treatment variables. Three novel predictors were constructed to capture the time weighted effects of buprenorphine dosage (mg buprenorphine per day), dosing protocol (whether physician could adjust dose), and clinic visits (whether patient attended clinic). We used time-in-trial as a predictor to account for the therapeutic benefits of treatment persistence. The outcome was illicit opiate use defined by self-report or urinalysis. Trial participants (N = 3022 patients with opioid dependence, mean age 36 years, 33% female, 14% Black, 16% Hispanic) were analyzed using a generalized linear mixed model. Treatment variables dose, Odds Ratio (OR) = 0.63 (95% Confidence Interval (95%CI) 0.59-0.67), dosing protocol, OR = 0.70 (95%CI 0.65-0.76), time-in-trial, OR = 0.75 (95%CI 0.71-0.80) and clinic visits, OR = 0.81 (95%CI 0.76-0.87) were significant (p-values < 0.001) protective factors. Treatment implications support higher doses of buprenorphine and greater engagement of patients with providers and clinic staff.

    View details for DOI 10.3390/ijerph19074106

    View details for PubMedID 35409790

  • Naloxone Dispensing in Patients at Risk for Opioid Overdose After Total Knee Arthroplasty Within the Veterans Health Administration. Federal practitioner : for the health care professionals of the VA, DoD, and PHS Lahidji, S., Oliva, E., Jarzebowski, M., Mudumbai, S. C., Lake, T., Krishnamoorthy, V., Raghunathan, K., Bryan, W. E. 2022; 39 (2): 64-69

    Abstract

    Naloxone prescribing among patients undergoing surgery is not well described. This cohort study was designed to examine patients' risk factors for opioid overdose and their association with naloxone prescribing among veterans undergoing total knee arthroplasty (TKA) after a systemwide Overdose Education and Naloxone Distribution (OEND) initiative.A retrospective analysis of Veterans Health Administration (VHA) records was performed and consisted of 38,011 veterans undergoing primary TKA from 2013 to 2016. Patient overdose risk was determined using a validated risk index for overdose or serious opioid-induced respiratory depression (RIOSORD) based on patient diagnoses, health care utilization, and prescription drug use. Naloxone dispensing was examined from the year before surgery until 7 days after discharge. These rates were examined the year prior to implementation of a national OEND initiative (2013), the year of implementation (2014), and 2 years following implementation (2015-2016).In 2013, 3.3% of patients presenting for TKA had moderate or high risk for overdose and none were prescribed naloxone. By 2016, after OEND implementation, 2.2% of patients presenting for TKA had moderate or high risk for overdose, but only 10.9% of the moderate-risk and 12.7% of the high-risk patients were prescribed naloxone.Patients presenting for TKA routinely have risk factors for opioid overdose and significant proportions are at moderate or high risk for overdose. Despite this, most patients at moderate and high risk do not receive perioperative naloxone. Risk mitigation strategies using validated tools such as RIOSORD may help identify surgical patients at greatest risk for opioid overdose who could benefit from OEND.

    View details for DOI 10.12788/fp.0227

    View details for PubMedID 35444385

    View details for PubMedCentralID PMC9014941

  • Impact of the Veterans Affairs National Abdominal Aortic Screening Program Garcia-Toca, M., Hlatky, M. A., Dalman, R. L., Itoga, N., Kou, A., Mudumbai, S., Lee, J. T., Aalami, O. MOSBY-ELSEVIER. 2021: E48-E49
  • Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration. JAMA network open Mudumbai, S. C., Pershing, S., Bowe, T., Kamal, R. N., Sears, E. D., Hawn, M. T., Eisenberg, D., Finlay, A. K., Hagedorn, H., Harris, A. H. 2021; 4 (5): e217470

    Abstract

    Importance: The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system.Objective: To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA.Design, Setting, and Participants: This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included.Exposures: A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation.Main Outcomes and Measures: Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram).Results: A total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P<.001) at the facility level and 0.06 (P<.001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given.Conclusions and Relevance: Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.

    View details for DOI 10.1001/jamanetworkopen.2021.7470

    View details for PubMedID 33956131

  • Naloxone Dispensing in Patients at Risk for Opioid Overdose after Total Knee Arthroplasty within the Veterans Health Administration Jarzebowski, M., Lahidji, S., Oliva, E., Mudumbai, S., Lake, T., Krishnamoorthy, V., Raghunathan, K., Bryan, W. E. LIPPINCOTT WILLIAMS & WILKINS. 2021: 640-642
  • Linking Preoperative and Intraoperative Data for Risk Prediction More Answers or Just More Data? JAMA NETWORK OPEN Mudumbai, S. C., Rashidi, P. 2021; 4 (3): e212547
  • Overdose Risk and Naloxone Dispensing around Total Knee Arthroplasty: Trends in the VHA between 2010 and 2016 Lahidji, S., Oliva, E., Mudumbai, S., Bryan, W. E., Lake, T., Krishnamoorthy, V., Raghunathan, K. LIPPINCOTT WILLIAMS & WILKINS. 2020: 601-602
  • Implementation of a patient-specific tapering protocol at discharge decreases total opioid dose prescribed for 6 weeks after elective primary spine surgery. Regional anesthesia and pain medicine Joo, S. S., Hunter, O. O., Tamboli, M., Leng, J. C., Harrison, T. K., Kassab, K., Keeton, J. D., Skirboll, S., Tharin, S., Saleh, E., Mudumbai, S. C., Wang, R. R., Kou, A., Mariano, E. R. 2020

    Abstract

    BACKGROUND AND OBJECTIVES: At our institution, we developed an individualized discharge opioid prescribing and tapering protocol for joint replacement patients and implemented the same protocol for neurosurgical spine patients. We then tested the hypothesis that this protocol will decrease the oral morphine milligram equivalent (MME) dose of opioid prescribed postdischarge after elective primary spine surgery.METHODS: In this retrospective cohort study, we identified all consecutive elective primary spine surgery cases 1year before and after introduction of the protocol. This protocol used the patient's prior 24-hour inpatient opioid consumption to determine discharge opioid pill count and tapering schedule. The primary outcome was total opioid dose prescribed in oral MME from discharge through 6 weeks. Secondary outcomes included in-hospital opioid consumption in MME, hospital length of stay, MME prescribed at discharge, opioid refills, and rates of minor and major adverse events.RESULTS: Eighty-three cases comprised the final sample (45 preintervention and 38 postintervention). There were no differences in baseline characteristics. The total oral MME (median (IQR)) from discharge through 6 weeks postoperatively was 900 (420-1440) preintervention compared with 300 (112-806) postintervention (p<0.01, Mann-Whitney U test), and opioid refill rates were not different between groups. There were no differences in other outcomes.CONCLUSIONS: This patient-specific prescribing and tapering protocol effectively decreases the total opioid dose prescribed for 6 weeks postdischarge after elective primary spine surgery. Our experience also demonstrates the potential generalizability of this protocol, which was originally designed for joint replacement patients, to other surgical populations.

    View details for DOI 10.1136/rapm-2020-101324

    View details for PubMedID 32238478

  • Prevalence and Factors Associated With Low-Value Preoperative Testing for Patients Undergoing Carpal Tunnel Release at an Academic Medical Center. Hand (New York, N.Y.) Ding, Q., Trickey, A. W., Mudumbai, S., Kamal, R. N., Sears, E. D., Harris, A. H. 2020: 1558944720906498

    Abstract

    Background: Routine preoperative screening tests before low-risk surgery cannot be justified if the risks to patients are not outweighed by benefits. Several studies and professional guidelines suggest avoiding screening tests prior to minor operations. We aimed to assess the prevalence and patient characteristics associated with low-value preoperative tests (LVTs) prior to carpal tunnel release (CTR) at an academic medical center. Methods: From electronic medical records, we identified patients aged ≥18 who underwent CTR from 2015 to 2017. We determined the occurrence of 9 common LVTs, such as complete blood count (CBC), basic metabolic profile (BMP), and electrocardiogram (ECG), in the 30 days prior to CTR. Multivariable logistic and Poisson regression were used to identify factors associated with receiving any LVT and the number of LVTs, respectively. Results: Among 572 patients, 248 (43.4%) had at least 1 LVT. The most common tests were ECG (31.3% of CTRs), CBC (27.3% of CTRs), and BMP (23.6% of CTRs). Patient factors associated with higher odds of receiving LVT included older age, higher Elixhauser comorbidity score, and general or regional anesthesia (vs monitored anesthesia care). Conclusions: Low-value preoperative tests were frequently received by patients undergoing CTR and were associated with anesthesia type, age, and number of comorbidities. Although our study focused on CTR, these results likely have implications for other commonly performed low-risk procedures. These findings can help guide efforts to improve the quality and value of surgery for carpal tunnel syndrome and facilitate the development of strategies to reduce LVT, such as audit feedback and provider education.

    View details for DOI 10.1177/1558944720906498

    View details for PubMedID 32100568

  • An ultrasound-guided fascia iliaca catheter technique does not impair ambulatory ability within a clinical pathway for total hip arthroplasty. Korean journal of anesthesiology Mudumbai, S. C., Kim, T. E., Howard, S. K., Giori, N. J., Woolson, S. n., Ganaway, T. n., Kou, A. n., King, R. n., Mariano, E. R. 2020; 73 (3): 267

    View details for DOI 10.4097/kjae.2016.69.4.368.e1

    View details for PubMedID 32506897

  • Making the case for a procedure-specific definition of chronic postoperative opioid use. Regional anesthesia and pain medicine Tamboli, M. n., Mariano, E. R., El-Boghdadly, K. n., Elkassabany, N. M., Kou, A. n., Chung, P. n., Mudumbai, S. C. 2020

    View details for DOI 10.1136/rapm-2020-101327

    View details for PubMedID 32213559

  • An analysis of perioperative eye injury in a veterans affairs inpatient surgical population. Journal of clinical anesthesia Tamboli, M. n., Kou, A. n., Wang, R. R., Walters, T. L., Mudumbai, S. C., Mariano, E. R. 2020; 66: 109913

    View details for DOI 10.1016/j.jclinane.2020.109913

    View details for PubMedID 32480206

  • Outcomes of Ambulatory Upper Extremity Surgery Patients Discharged Home with Perineural Catheters from a Veterans Health Administration Medical Center PAIN MEDICINE King, R., Mariano, E. R., Yajnik, M., Kou, A., Kim, T., Hunter, O. O., Howard, S. K., Mudumbai, S. C. 2019; 20 (11): 2256–62

    View details for DOI 10.1093/pm/pnz023

    View details for Web of Science ID 000504316200019

  • Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery. Anesthesia and analgesia Harris, A. H., Meerwijk, E. L., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Finlay, A. K., Hagedorn, H., Mudumbai, S. 2019; 129 (3): 804-811

    Abstract

    The American Society of Anesthesiologists (ASA) Choosing Wisely Top-5 list of activities to avoid includes "Don't obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery - specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal." Accordingly, we define low-value preoperative tests (LVTs) as those performed before minor surgery in patients without significant systemic disease. The objective of the current study was to examine the extent, variability, drivers, and costs of LVTs before carpal tunnel release (CTR) surgeries in the US Veterans Health Administration (VHA).Using fiscal year (FY) 2015-2017 data derived from the VHA Corporate Data Warehouse (CDW), we determined the overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days before CTR in ASA physical status (PS) I-II patients. We also examined the patient, procedure, and facility factors associated with receiving ≥1 LVT with mixed-effects logistic regression and the number of tests received with mixed-effects negative binomial regression.From FY15-17, 10,000 ASA class I-II patients received a CTR by 699 surgeons in 125 VHA facilities. Overall, 47.0% of patients had a CTR that was preceded by ≥1 LVT, with substantial variability between facilities (range = 0%-100%; interquartile range = 36.3%), representing $339,717 in costs. Older age and female sex were associated with higher odds of receiving ≥1 LVT. Local versus other modes of anesthesia were associated with lower odds of receiving ≥1 LVT. Several facilities experienced large (>25%) increases or decreases from FY15 to FY17 in the proportion of patients receiving ≥1 LVT.Counter to guidance from the ASA, we found that almost half of CTRs performed on ASA class I-II VHA patients were preceded by ≥1 LVT. Although the total cost of these tests is relatively modest, CTR is just one of many low-risk procedures (eg, trigger finger release, cataract surgery) that may involve similar preoperative testing practices. These results will inform site selection for qualitative investigation of the drivers of low-value testing and the development of interventions to improve preoperative testing practice, especially in locations where rates of LVT are high.

    View details for DOI 10.1213/ANE.0000000000004291

    View details for PubMedID 31425223

  • Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery. Anesthesia and analgesia Harris, A. H., Meerwijk, E. L., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Finlay, A. K., Hagedorn, H., Mudumbai, S. 2019

    Abstract

    BACKGROUND: The American Society of Anesthesiologists (ASA) Choosing Wisely Top-5 list of activities to avoid includes "Don't obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery - specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal." Accordingly, we define low-value preoperative tests (LVTs) as those performed before minor surgery in patients without significant systemic disease. The objective of the current study was to examine the extent, variability, drivers, and costs of LVTs before carpal tunnel release (CTR) surgeries in the US Veterans Health Administration (VHA).METHODS: Using fiscal year (FY) 2015-2017 data derived from the VHA Corporate Data Warehouse (CDW), we determined the overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days before CTR in ASA physical status (PS) I-II patients. We also examined the patient, procedure, and facility factors associated with receiving ≥1 LVT with mixed-effects logistic regression and the number of tests received with mixed-effects negative binomial regression.RESULTS: From FY15-17, 10,000 ASA class I-II patients received a CTR by 699 surgeons in 125 VHA facilities. Overall, 47.0% of patients had a CTR that was preceded by ≥1 LVT, with substantial variability between facilities (range = 0%-100%; interquartile range = 36.3%), representing $339,717 in costs. Older age and female sex were associated with higher odds of receiving ≥1 LVT. Local versus other modes of anesthesia were associated with lower odds of receiving ≥1 LVT. Several facilities experienced large (>25%) increases or decreases from FY15 to FY17 in the proportion of patients receiving ≥1 LVT.CONCLUSIONS: Counter to guidance from the ASA, we found that almost half of CTRs performed on ASA class I-II VHA patients were preceded by ≥1 LVT. Although the total cost of these tests is relatively modest, CTR is just one of many low-risk procedures (eg, trigger finger release, cataract surgery) that may involve similar preoperative testing practices. These results will inform site selection for qualitative investigation of the drivers of low-value testing and the development of interventions to improve preoperative testing practice, especially in locations where rates of LVT are high.

    View details for DOI 10.1213/ANE.0000000000004291

    View details for PubMedID 31206428

  • IMPLEMENTATION OF A DISTRIBUTED RESEARCH NETWORK VIRTUAL DATA WAREHOUSE FOR A MULTI-CENTER OBSERVATIONAL STUDY Mudumbai, S., Wu, F., Chambers, J., Kapoor, A., Lee, J. S., Clark, D., Mariano, E. R., Stafford, R. S. LIPPINCOTT WILLIAMS & WILKINS. 2019: 925–26
  • Variation in Surgeons' Requests for General Anesthesia When Scheduling Carpal Tunnel Release. Hand (New York, N.Y.) Harris, A. H., Meerwijk, E. L., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Finlay, A. K., Hagedorn, H., Marshall, N., Mudumbai, S. C. 2019: 1558944719828006

    Abstract

    BACKGROUND: Carpal tunnel release (CTR) can be performed with a variety of anesthesia techniques. General anesthesia is associated with higher risk profile and increased resource utilization, suggesting it should not be routinely used for CTR. The purpose of this study was to examine the patient factors associated with surgeons' requests for general anesthesia for CTR and the frequency of routine use of general anesthesia by Veterans Health Administration (VHA) surgeons and facilities.METHODS: National VHA data for fiscal years 2015 and 2017 were used to identify patients receiving CTR. Mixed-effects logistic regression was used to evaluate patient, procedure, and surgeon factors associated with requests by the surgeon for general anesthesia versus other anesthesia techniques.RESULTS: In all, 18 145 patients underwent CTR performed by 780 surgeons in 113 VHA facilities. Overall, there were 2218 (12.2%) requests for general anesthesia. Although some patient (eg, older age, obesity), procedure (eg, open vs endoscopic), and surgeon (eg, higher volume) factors were associated with lower odds of requests for general anesthesia, there was substantial facility- and surgeon-level variability. The percentage of patients with general anesthesia requested ranged from 0% to 100% across surgeons. Three facilities and 28 surgeons who performed at least 5 CTRs requested general anesthesia for more than 75% of patients.CONCLUSIONS: Where CTR is performed and by whom appear to influence requests for general anesthesia more than patient factors in this study. Avoidance of routine use of general anesthesia for CTR should be considered in future clinical practice guidelines and quality measures.

    View details for PubMedID 30789047

  • Peripheral nerve blocks are not associated with increased risk of perioperative peripheral nerve injury in a Veterans Affairs inpatient surgical population REGIONAL ANESTHESIA AND PAIN MEDICINE Yajnik, M., Kou, A., Mudumbai, S. C., Walters, T. L., Howard, S. K., Kim, E., Mariano, E. R. 2019; 44 (1): 81–85
  • Impact of an Opioid Safety Initiative on Patients Undergoing Total Knee Arthroplasty: A Time Series Analysis. Anesthesiology Chen, Q. n., Hsia, H. L., Overman, R. n., Bryan, W. n., Pepin, M. n., Mariano, E. R., Mudumbai, S. C., Buchheit, T. n., Krishnamoorthy, V. n., Good, C. B., Brookhart, M. A., Raghunathan, K. n. 2019; 131 (2): 369–80

    Abstract

    Opioid overuse remains rampant even in hospitals, but whether administrative opioid safety initiatives reduce use remains unclear WHAT THIS ARTICLE TELLS US THAT IS NEW: The authors evaluated the effects of a Veterans Administration national Opioid Safety Initiative using interrupted time series analysis to compare trends before and after starting the initiativeThere was a trivial increase in pain scores, and a substantial reduction in patients with chronic preoperative and postoperative opioid prescriptions BACKGROUND:: The Opioid Safety Initiative decreased high-dose prescriptions across the Veterans Health Administration. This study sought to examine the impact of this intervention (i.e., the Opioid Safety Initiative) on pain scores and opioid prescriptions in patients undergoing total knee arthroplasty.This was an ecological study of group-level data among 700 to 850 patients per month over 72 consecutive months (January 2010 to December 2015). The authors examined characteristics of cohorts treated before versus after rollout of the Opioid Safety Initiative (October 2013). Each month, the authors aggregated at the group-level the differences between mean postoperative and preoperative pain scores for each patient (averaged over 6-month periods), and measured proportions of patients (per 1,000) with opioid (and nonopioid) prescriptions for more than 3 months in 6-month periods, preoperatively and postoperatively. The authors compared postintervention trends versus trends forecasted based on preintervention measures.After the Opioid Safety Initiative, patients were slightly older and sicker, but had lower mortality rates (postintervention n = 28,509 vs. preintervention n = 31,547). Postoperative pain scores were slightly higher and the decrease in opioid use was statistically significant, i.e., 871 (95% CI, 474 to 1,268) fewer patients with chronic postoperative prescriptions. In time series analyses, mean postoperative minus preoperative pain scores had increased from 0.65 to 0.81, by 0.16 points (95% CI, 0.05 to 0.27). Proportions of patients with chronic postoperative and chronic preoperative opioid prescriptions had declined by 20% (n = 3,355 vs. expected n = 4,226) and by 13% (n = 5,861 vs. expected n = 6,724), respectively. Nonopioid analgesia had increased. Sensitivity analyses confirmed all findings.A system-wide initiative combining guideline dissemination with audit and feedback was effective in significantly decreasing opioid prescriptions in populations undergoing total knee arthroplasty, while minimally impacting pain scores.

    View details for DOI 10.1097/ALN.0000000000002771

    View details for PubMedID 31314748

  • Five-year follow-up to assess long-term sustainability of changing clinical practice regarding anesthesia and regional analgesia for lower extremity arthroplasty. Korean journal of anesthesiology Tamboli, M. n., Leng, J. C., Hunter, O. O., Kou, A. n., Mudumbai, S. C., Memtsoudis, S. G., Walters, T. L., Lochbaum, G. M., Mariano, E. R. 2019

    Abstract

    Long-term sustainability of clinical practice changes in anesthesia has not been previously reported. Therefore, we performed a 5-year audit following implementation of a clinical pathway change to favor spinal anesthesia for total knee arthroplasty (TKA). We similarly evaluated a parallel cohort of patients undergoing total hip arthroplasty (THA) which did not undergo clinical pathway change as well as the utilization of regional analgesia.We identified all primary unilateral TKA and THA cases performed from January 2013 through December 2018 to include data from one-year pre-implementation and 5-years post-implementation of the clinical pathway change. Our primary outcome was the overall rate of spinal anesthesia usage. Secondary outcomes included rate of nerve block utilization, 30-day postoperative complications, and resource utilization variables such as hospital readmission, emergency department visits, and blood transfusions.The sample consisted of 1859 cases (1250 TKAs, 609 THAs). In the first year post-implementation, 174/221 (78.7%) TKAs received spinal anesthesia compared to 23/186 (12.4%) in the year before implementation (p<0.001). In the subsequent 4-year period, 647/843 (77.2%) TKAs received spinal anesthesia (p=0.532 vs. year 1). For THA, 78/124 (62.9%) received spinal anesthesia in the year after implementation compared to 48/116 (41.4%) pre-implementation (p=0.001), but this rate decreased in the subsequent 4-year period to 193/369 (52.3%) (p=0.040 vs. year 1). Utilization of regional analgesia was high in both groups, and there were no differences in other outcomes.A clinical pathway change promoting spinal anesthesia for TKA can be effectively implemented and sustained over a 5-year period.

    View details for DOI 10.4097/kja.19400

    View details for PubMedID 31865661

  • Spinal anesthesia increases the rate of opioid-free recovery after transurethral urologic surgery. Journal of clinical anesthesia Tien, M. n., Kou, A. n., Leppert, J. T., Mariano, E. R., Mudumbai, S. C. 2019; 60: 109–10

    View details for DOI 10.1016/j.jclinane.2019.09.013

    View details for PubMedID 31614296

  • Outcomes of Ambulatory Upper Extremity Surgery Patients Discharged Home with Perineural Catheters from a Veterans Health Administration Medical Center. Pain medicine (Malden, Mass.) King, R. n., Mariano, E. R., Yajnik, M. n., Kou, A. n., Kim, T. E., Hunter, O. O., Howard, S. K., Mudumbai, S. C. 2019

    Abstract

    The feasibility and safety of managing ambulatory continuous peripheral nerve blocks (CPNB) in Veterans Health Administration (VHA) patients are currently unknown. We aimed to characterize the outcomes of a large VHA cohort of ambulatory upper extremity surgery patients discharged with CPNB and identify differences, if any, between catheter types.With institutional review board approval, we reviewed data for consecutive patients from a single VHA hospital who had received ambulatory CPNB for upper extremity surgery from March 2011 to May 2017. The composite primary outcome was the occurrence of any catheter-related issue or additional all-cause health care intervention after discharge. Our secondary outcome was the ability to achieve regular daily telephone contact.Five hundred one patients formed the final sample. The incidence of any issue or health care intervention was 104/274 (38%) for infraclavicular, 58/185 (31%) for interscalene, and 14/42 (33%) for supraclavicular; these rates did not differ between groups. Higher ASA status was associated with greater odds of having any issue, whereas increasing age was slightly protective. Distance was associated with an increase in catheter-related issues (P < 0.01) but not additional health care interventions (P = 0.51). Only interscalene catheter patients (3%) reported breathing difficulty. Infraclavicular catheter patients had the most emergency room visits but rarely for CPNB issues. Consistent daily telephone contact was not achieved.For VHA ambulatory CPNB patients, the combined incidence of a catheter-related issue or additional health care intervention was approximately one in three patients and did not differ by brachial plexus catheter type. Serious adverse events were generally uncommon.

    View details for PubMedID 30856269

  • Peripheral nerve blocks are not associated with increased risk of perioperative peripheral nerve injury in a Veterans Affairs inpatient surgical population. Regional anesthesia and pain medicine Yajnik, M. n., Kou, A. n., Mudumbai, S. C., Walters, T. L., Howard, S. K., Edward Kim, T. n., Mariano, E. R. 2019; 44 (1): 81–85

    Abstract

    Perioperative peripheral nerve injury (PNI) is a known complication in patients undergoing surgery with or without regional anesthesia. The incidence of new PNI in a Veterans Affairs (VA) inpatient surgical population has not been previously described; therefore, the incidence, risk factors, and clinical course of new PNI in this cohort are unknown. We hypothesized that peripheral nerve blocks do not increase PNI incidence.We conducted a 5-year review of a Perioperative Surgical Home database including all consecutive surgical inpatients. The primary outcome was new PNI between groups that did or did not have peripheral nerve blockade. Potential confounders were first examined individually using logistic regression, and then included simultaneously together within a mixed-effects logistic regression model. Electronic records of patients with new PNI were reviewed for up to a year postoperatively.The incidence of new PNI was 1.2% (114/9558 cases); 30 of 3380 patients with nerve block experienced new PNI (0.9%) compared with 84 of 6178 non-block patients (1.4%; p=0.053). General anesthesia alone, younger age, and American Society of Anesthesiologists physical status <3 were associated with higher incidence of new PNI. Patients who received transversus abdominis plane blocks had increased odds for PNI (OR, 3.20, 95% CI 1.34 to 7.63), but these cases correlated with minimally invasive general and urologic surgery. One hundred PNI cases had 1-year follow-up: 82% resolved by 3 months and only one patient did not recover in a year.The incidence of new perioperative PNI for VA surgical inpatients is 1.2% and the use of peripheral nerve blocks is not an independent risk factor.

    View details for PubMedID 30640657

  • Practice Patterns in Perioperative Nonopioid Analgesic Administration by Anesthesiologists in a Veterans Affairs Hospital. Pain medicine (Malden, Mass.) Kwong, J. Z., Mudumbai, S. C., Hernandez-Boussard, T. n., Popat, R. A., Mariano, E. R. 2019

    Abstract

    Although multimodal analgesia (MMA) is recommended for perioperative pain management, previous studies have found substantial variability in its utilization. To better understand the factors that influence anesthesiologists' choices, we assessed the associations between patient or surgical characteristics and number of nonopioid analgesic modes received intraoperatively across a variety of surgeries in a university-affiliated Veteran Affairs hospital.We included elective inpatient surgeries (orthopedic, thoracic, spine, abdominal, and pelvic procedures) that used at least one nonopioid analgesic within a one-year period. Multivariable multinomial logistic regression models were used to estimate adjusted odds ratios and 95% confidence intervals (CIs). We also described the combinations of analgesia used in each surgical subtype and conducted exploratory analyses to test the associations between the number of modes used and postoperative outcomes.Of the 1,087 procedures identified, 33%, 53%, and 14% were managed with one, two, and three or more modes, respectively. Older patients had lower odds of receiving three or more modes (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI] = 0.15-0.52), as were patients with more comorbidities (two modes: aOR = 0.87, 95% CI = 0.79-0.96; three or more modes: aOR = 0.81, 95% CI = 0.71-0.94). Utilization varied across surgical subtypes P < 0.0001). Increasing the number of modes, particularly use of regional anesthesia, was associated with shorter length of stay.Our study suggests that age, comorbidities, and surgical type contribute to variability in MMA utilization. Risks and benefits of multiple modes should be carefully considered for older and sicker patients. Future directions include developing patient- and procedure-specific perioperative MMA recommendations.

    View details for DOI 10.1093/pm/pnz226

    View details for PubMedID 31559430

  • A Multidisciplinary Patient-Specific Opioid Prescribing and Tapering Protocol Is Associated with a Decrease in Total Opioid Dose Prescribed for Six Weeks After Total Hip Arthroplasty. Pain medicine (Malden, Mass.) Tamboli, M. n., Mariano, E. R., Gustafson, K. E., Briones, B. L., Hunter, O. O., Wang, R. R., Harrison, T. K., Kou, A. n., Mudumbai, S. C., Kim, T. E., Indelli, P. F., Giori, N. J. 2019

    Abstract

    This retrospective cohort study tested the hypothesis that implementing a multidisciplinary patient-specific discharge protocol for prescribing and tapering opioids after total hip arthroplasty (THA) will decrease the morphine milligram equivalent (MME) dose of opioids prescribed.With institutional review board approval, we analyzed a Perioperative Surgical Home database and prescription data for all primary THA patients three months before (PRE) and three months after (POST) implementation of this new discharge opioid protocol based on patients' prior 24-hour inpatient opioid consumption. The primary outcome was total opioid dosage in MME prescribed and opioid refills for six weeks after surgery. Secondary outcomes included the number of tablets and MME prescribed at discharge, in-hospital opioid consumption, length of stay, and postoperative complications.Forty-nine cases (25 PRE and 24 POST) were included. Total median (10th-90th percentiles) MME for six weeks postoperatively was 900 (57-2082) MME PRE vs 295 (69-741) MME POST (mean difference = 721, 95% confidence interval [CI] = 127-1316, P = 0.007, Mann-Whitney U test). Refill rates did not differ. The median (10th-90th percentiles) initial discharge prescription in MME was 675 (57-1035) PRE vs 180 (18-534) POST (mean difference = 387, 95% CI = 156-618, P = 0.003, Mann-Whitney U test) MME. There were no differences in other outcomes.Implementation of a patient-specific prescribing and tapering protocol decreases the mean six-week dosage of opioid prescribed by 63% after THA without increasing the refill rate.

    View details for DOI 10.1093/pm/pnz260

    View details for PubMedID 31710680

  • Are Case Volume and Facility Complexity Level Associated With Postoperative Complications After Hip Fracture Surgery in the Veterans Affairs Healthcare System? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Wong, J. K., Kim, T., Mudumbai, S. C., Memtsoudis, S. G., Giori, N. J., Howard, S. K., Oka, R. K., King, R., Mariano, E. R. 2019; 477 (1): 177–90
  • A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine PAIN MANAGEMENT Mudumbai, S. C., Auyong, D. B., Memtsoudis, S. G., Mariano, E. R. 2018; 8 (6): 475–85
  • Low Value Preoperative Testing for Carpal Tunnel Release in the Veterans Health Administration Sox-Harris, A., Meerwijk, E. L., Kamal, R. N., Sears, E., Finlay, A. K., Hawn, M. T., Eisenberg, D., Mudumbai, S. ELSEVIER SCIENCE INC. 2018: E32
  • Are Case Volume and Facility Complexity Level Associated With Postoperative Complications After Hip Fracture Surgery in the Veterans Affairs Healthcare System? Clinical orthopaedics and related research Wong, J. K., Kim, T. E., Mudumbai, S. C., Memtsoudis, S. G., Giori, N. J., Howard, S. K., Oka, R. K., King, R., Mariano, E. R. 2018

    Abstract

    BACKGROUND: Hospital-related factors associated with mortality and morbidity after hip fracture surgery are not completely understood. The Veterans Health Administration (VHA) is the largest single-payer, networked healthcare system in the country serving a relatively homogenous patient population with facilities that vary in size and resource availability. These characteristics provide some degree of financial and patient-level controls to explore the association, if any, between surgical volume and facility resource availability and hospital performance regarding postoperative complications after hip fracture surgery.QUESTIONS/PURPOSES: (1) Do VHA facilities with the highest complexity level designation (Level 1a) have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-complexity level facilities? (2) Do VHA facilities with higher hip fracture surgical volume have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-volume facilities?METHODS: We explored the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database from October 2001 to September 2012 for records of hip fracture surgery performed. Data reliability of the VASQIP database has been previously validated. We excluded nine of the 98 VHA facilities for contributing fewer than 30 records. The remaining 89 VHA facilities provided 23,029 records. The VHA designates a complexity level to each facility based on multiple criteria. We labeled facilities with a complexity Level 1a (38 facilities)-the highest achievable VHA designated complexity level-as high complexity; we labeled all other complexity level designations as low complexity (51 facilities). Facility volume was divided into tertiles: high (> 277 hip fracture procedures during the sampling frame), medium (204 to 277 procedures), and low (< 204 procedures). The patient population treated by low-complexity facilities was older, had a higher prevalence of severe chronic obstructive pulmonary disease (26% versus 22%, p < 0.001), and had a higher percentage of patients having surgery within 2 days of hospital admission (83% versus 76%, p < 0.001). High-complexity facilities treated more patients with recent congestive heart failure exacerbation (4% versus 3%, p < 0.001). We defined major postoperative complications as having at least one of the following: death within 30 days of surgery, cardiac arrest requiring cardiopulmonary resuscitation, new q-wave myocardial infarction, deep vein thrombosis and/or pulmonary embolism, ventilator dependence for at least 48 hours after surgery, reintubation for respiratory or cardiac failure, acute renal failure requiring renal replacement therapy, progressive renal insufficiency with a rise in serum creatinine of at least 2 mg/dL from preoperative value, pneumonia, or surgical site infection. We used the observed-to-expected ratio (O/E ratio)-a risk-adjusted metric to classify facility performance-for major postoperative complications to assess the performance of VHA facilities. Outlier facilities with 95% confidence intervals (95% CI) for O/E ratio completely less than 1.0 were labeled "exceed expectation;" those that were completely greater than 1.0 were labeled "below expectation." We compared differences in the distribution of outlier facilities between high and low-complexity facilities, and between high-, medium-, and low-volume facilities using Fisher's exact test.RESULTS: We observed no association between facility complexity level and the distribution of outlier facilities (high-complexity: 5% exceeded expectation, 5% below expectation; low-complexity: 8% exceeded expectation, 2% below expectation; p = 0.742). Compared with high-complexity facilities, the adjusted odds ratio for major postoperative complications for low-complexity facilities was 0.85 (95% CI, 0.67-1.09; p = 0.108).We observed no association between facility volume and the distribution of outlier facilities: 3% exceeded expectation and 3% below expectation for high-volume; 10% exceeded expectation and 3% below expectation for medium-volume; and 7% exceeded expectation and 3% below expectation for low-volume; p = 0.890). The adjusted odds ratios for major postoperative complications were 0.87 (95% CI, 0.73-1.05) for low- versus high-volume facilities and 0.89 (95% CI, 0.79-1.02] for medium- versus high-volume facilities (p = 0.155).CONCLUSIONS: These results do not support restricting facilities from treating hip fracture patients based on historical surgical volume or facility resource availability. Identification of consistent performance outliers may help health care organizations with multiple facilities determine allocation of services and identify characteristics and processes that determine outlier status in the interest of continued quality improvement.LEVEL OF EVIDENCE: Level III, therapeutic study.

    View details for PubMedID 30179946

  • Persistent Postoperative Opioid Use in Older Head and Neck Cancer Patients. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Saraswathula, A. n., Chen, M. M., Mudumbai, S. C., Whittemore, A. S., Divi, V. n. 2018: 194599818778276

    Abstract

    Objectives Despite the epidemic of opioid overuse among American patients, there are limited data regarding the prevalence of such use among patients with head and neck cancer (HNC). Here, we report on the prevalence of persistent postoperative opioid (PPO) use and its risk factors among older patients with HNC undergoing surgery. Study Design Retrospective cohort study. Setting Surveillance, Epidemiology, and End Results (SEER)-Medicare linked cancer registry-claims database. Subjects and Methods We identified patients aged 66 years or older who were diagnosed with HNC from 2008 to 2013, underwent primary surgical resection for their cancers, and met certain insurance and discharge criteria. The primary outcome was PPO use, defined as new opioid prescriptions 90 to 180 days postoperatively. We used multivariable logistic regression to evaluate associations between PPO use and factors such as demographics and postoperative treatment. Results Of the 1190 eligible patients with HNC, 866 (72.8%) received opioid prescriptions attributable to their surgery. Among these 866 patients, the prevalence of PPO use was 33.3% overall; it was 48.3% among the 428 patients with preoperative opioid use compared to 18.5% among the 438 opioid-naive patients (adjusted odds ratio [OR], 3.96; 95% confidence interval [CI], 2.80-5.59). Other factors associated with PPO use include postoperative radiotherapy (OR, 1.99; 95%, CI 1.33-2.98) and Charlson comorbidity index (OR, 1.20; 95% CI, 1.03-1.41). Postoperative chemotherapy (OR, 1.19; 95% CI, 0.73-1.95) was not significantly associated with PPO use. Conclusions PPO use is a substantial problem in older surgical patients with HNC, one that warrants consideration of alternative treatment strategies and continued examination of prescription guidelines for patients with HNC.

    View details for PubMedID 29807503

  • The Perioperative Surgical Home model facilitates change implementation in anesthetic technique within a clinical pathway for total knee arthroplasty. Healthcare (Amsterdam, Netherlands) Mudumbai, S. C., Walters, T. L., Howard, S. K., Kim, T. E., Lochbaum, G. M., Memtsoudis, S. G., Kain, Z. N., Kou, A., King, R., Mariano, E. R. 2016; 4 (4): 334-339

    Abstract

    The challenge of knowledge translation in medical settings is well known, and implementing change in clinical practice can take years. For the increasing number total knee arthroplasty (TKA) patients annually, there is ample evidence to endorse neuraxial anesthesia over general anesthesia. The rate of adoption of this practice, however, is slow at the current time. We hypothesized that a Perioperative Surgical Home (PSH) model facilitates rapid change implementation in anesthesia.The PSH clinical pathways workgroup at a tertiary care Veterans Affairs hospital embarked on a 5-month process of changing the preferred anesthetic technique for patients undergoing TKA. This process involved multiple sequential steps: literature review; development of a work document; training of staff; and prospective collection of data. To assess the impact of this change, we examined data 6 months before (PRE, n=90) and after (POST) change implementation (n=128), and our primary outcome was the overall proportion of spinal anesthesia usage for each 6 month period. Secondary outcomes included minor and major complications associated with anesthetic technique.Over a period of one year, there was an increase in the proportion of patients who received spinal anesthesia (13% vs. 63%, p<0.001). For the following year, 53-92% of TKA patients per month received spinal anesthesia. There were no differences in major complications.Rapid and sustained change implementation in clinical anesthesia practice based on emerging evidence is feasible.Perioperative Surgical Home model may facilitate rapid change implementation in surgical care.Cohort study, Level 2.

    View details for DOI 10.1016/j.hjdsi.2016.03.002

    View details for PubMedID 28007227

  • An ultrasound-guided fascia iliaca catheter technique does not impair ambulatory ability within a clinical pathway for total hip arthroplasty. Korean journal of anesthesiology Mudumbai, S. C., Kim, T. E., Howard, S. K., Giori, N. J., Woolson, S., Ganaway, T., Kou, A., King, R., Mariano, E. R. 2016; 69 (4): 368-375

    Abstract

    Both neuraxial and peripheral regional analgesic techniques offer postoperative analgesia for total hip arthroplasty (THA) patients. While no single technique is preferred, quadriceps muscle weakness from peripheral nerve blocks may impede rehabilitation. We designed this study to compare postoperative ambulation outcome in THA patients who were treated with a new ultrasound-guided fascia iliaca catheter (FIC) technique or intrathecal morphine (ITM).We reviewed the electronic health records of a sequential series of primary unilateral THA patients who were part of a standardized clinical pathway; apart from differences in regional analgesic technique, all other aspects of the pathway were the same. Our primary outcome was total ambulation distance (meters) combined for postoperative days 1 and 2. Secondary outcomes included daily opioid consumption (morphine milligram equivalents) and analgesic-related side effects. We examined the association between the primary outcome and analgesic technique by performing crude and adjusted ordinary least-squares linear regression. A P value < 0.05 was considered statistically-significant.The study analyzed the records of 179 patients (fascia iliaca, n = 106; intrathecal, n = 73). The primary outcome (total ambulation distance) did not differ between the groups (P = 0.08). Body mass index (BMI) was the only factor (β = -1.7 [95% CI -0.5 to -2.9], P < 0.01) associated with ambulation distance. Opioid consumption did not differ, while increased pruritus was seen in the intrathecal group (P < 0.01).BMI affects postoperative ambulation outcome after hip arthroplasty, whereas the type of regional analgesic technique used does not. An ultrasound-guided FIC technique offers similar analgesia with fewer side effects when compared with ITM.

    View details for DOI 10.4097/kjae.2016.69.4.368

    View details for PubMedID 27482314

  • Can bedside patient-reported numbness predict postoperative ambulation ability for total knee arthroplasty patients with nerve block catheters? Korean journal of anesthesiology Mudumbai, S. C., Ganaway, T., Kim, T. E., Howard, S. K., Giori, N. J., Shum, C., Mariano, E. R. 2016; 69 (1): 32-36

    Abstract

    Adductor canal catheters offer advantages over femoral nerve catheters for knee replacement patients because they produce less quadriceps muscle weakness; however, applying adductor canal catheters in bedside clinical practice remains challenging. There is currently no patient-reported outcome that accurately predicts patients' physical function after knee replacement. The present study evaluates the validity of a relatively new patient-reported outcome, i.e., a numbness score obtained using a numeric rating scale, and assesses its predictive value on postoperative ambulation.We conducted a retrospective cohort study pooling data from two previously-published clinical trials using identical research methodologies. Both studies recruited patients undergoing knee replacement; one studied adductor canal catheters while the other studied femoral nerve catheters. Our primary outcome was patient-reported numbness scores on postoperative day 1. We also examined postoperative day 1 ambulation distance and its association with postoperative numbness using linear regression, adjusting for age, body mass index, and physical status.Data from 94 subjects were included (femoral subjects, n = 46; adductor canal subjects, n = 48). Adductor canal patients reported decreased numbness (median [10(th)-90(th) percentiles]) compared to femoral patients (0 [0-5] vs. 4 [0-10], P = 0.001). Adductor canal patients also ambulated seven times further on postoperative day 1 relative to femoral patients. There was a significant association between postoperative day 1 total ambulation distance and numbness (Beta = -2.6; 95% CI: -4.5, -0.8, P = 0.01) with R(2) = 0.1.Adductor canal catheters facilitate improved early ambulation and produce less patient-reported numbness after knee replacement, but the correlation between these two variables is weak.

    View details for DOI 10.4097/kjae.2016.69.1.32

    View details for PubMedID 26885299

  • Implementation of an Anesthesia Information Management System in an Ambulatory Surgery Center JOURNAL OF MEDICAL SYSTEMS Mudumbai, S. C. 2016; 40 (1)

    Abstract

    Anesthesia information management systems (AIMS) are increasingly being implemented throughout the United States. However, little information exists on the implementation process for AIMS within ambulatory surgery centers (ASC). The objectives of this descriptive study are to document: 1) the phases of implementation of an AIMS at an ASC; and 2) lessons learnt from a socio-technical perspective. The ASC, within the Veterans Health Administration (VHA), has hosted an AIMS since 2008. As a quality improvement effort, we implemented a new version of the AIMS. This new version involved fundamental software changes to enhance clinical care such as real-time importing of laboratory data and total hardware exchange. The pre-implementation phase involved coordinated preparation over six months between multiple informatics teams along with local leadership. During this time, we conducted component, integration, and validation testing to ensure correct data flow from medical devices to AIMS and centralized databases. The implementation phase occurred in September 2014 over three days and was successful. Over the next several months, during post-implementation phase, we addressed residual items like latency of the application. Important lessons learnt from the implementation included the utility of partnering early with executive leadership; ensuring end user acceptance of new clinical workflow; continuous testing of data flow; use of a staged rollout; and providing additional personnel throughout implementation. Implementation of an AIMS at an ASC can utilize methods developed for large hospitals. However, issues unique to an ASC such as limited number of support personnel and distinctive workflows must be considered.

    View details for DOI 10.1007/s10916-015-0390-4

    View details for Web of Science ID 000365418600026

    View details for PubMedID 26537130

  • Invasive Mechanical Ventilation in California Over 2000-2009: Implications for Emergency Medicine. The western journal of emergency medicine Mudumbai, S. C., Barr, J., Scott, J., Mariano, E. R., Bertaccini, E., Nguyen, H., Memtsoudis, S. G., Cason, B., Phibbs, C. S., Wagner, T. 2015; 16 (5): 696-706

    Abstract

    Patients who require invasive mechanical ventilation (IMV) often represent a sequence of care between the emergency department (ED) and intensive care unit (ICU). Despite being the most populous state, little information exists to define patterns of IMV use within the state of California.We examined data from the masked Patient Discharge Database of California's Office of Statewide Health Planning and Development from 2000-2009. Adult patients who received IMV during their stay were identified using the International Classification of Diseases 9th Revision and Clinical Modification procedure codes (96.70, 96.71, 96.72). Patients were divided into age strata (18-34yr, 35-64yr, and >65yr). Using descriptive statistics and regression analyses, for IMV discharges during the study period, we quantified the number of ED vs. non-ED based admissions; changes in patient characteristics and clinical outcome; evaluated the marginal costs for IMV; determined predictors for prolonged acute mechanical ventilation (PAMV, i.e. IMV>96hr); and projected the number of IMV discharges and ED-based admissions by year 2020.There were 696,634 IMV discharges available for analysis. From 2000-2009, IMV discharges increased by 2.8%/year: n=60,933 (293/100,000 persons) in 2000 to n=79,868 (328/100,000 persons) in 2009. While ED-based admissions grew by 3.8%/year, non-ED-based admissions remained stable (0%). During 2000-2009, fastest growth was noted for 1) the 35-64 year age strata; 2) Hispanics; 3) patients with non-Medicare public insurance; and 4) patients requiring PAMV. Average total patient cost-adjusted charges per hospital discharge increased by 29% from 2000 (from $42,528 to $60,215 in 2014 dollars) along with increases in the number of patients discharged to home and skilled nursing facilities. Higher marginal costs were noted for younger patients (ages 18-34yr), non-whites, and publicly insured patients. Some of the strongest predictors for PAMV were age 35-64 years (OR=1.12; 95% CI [1.09-1.14], p<0.05); non-Whites; and non-Medicare public insurance. Our models suggest that by 2020, IMV discharges will grow to n=153,153 (377 IMV discharges/100,000 persons) with 99,095 admitted through the ED.Based on sustained growth over the past decade, by the year 2020, we project a further increase to 153,153 IMV discharges with 99,095 admitted through the ED. Given limited ICU bed capacities, ongoing increases in the number and type of IMV patients have the potential to adversely affect California EDs that often admit patients to ICUs.

    View details for DOI 10.5811/westjem.2015.6.25736

    View details for PubMedID 26587094

  • A retrospective comparative provider workload analysis for femoral nerve and adductor canal catheters following knee arthroplasty JOURNAL OF ANESTHESIA Rasmussen, M., Kim, E., Kim, T. E., Howard, S. K., Mudumbai, S., Giori, N. J., Woolson, S., Ganaway, T., Mariano, E. R. 2015; 29 (2): 303-307

    Abstract

    Adductor canal catheters preserve quadriceps strength better than femoral nerve catheters and may facilitate postoperative ambulation following total knee arthroplasty. However, the effect of this newer technique on provider workload, if any, is unknown. We conducted a retrospective provider workload analysis comparing these two catheter techniques; all other aspects of the clinical pathway remained the same. The primary outcome was number of interventions recorded per patient postoperatively. Secondary outcomes included infusion duration, ambulation distance, opioid consumption, and hospital length of stay. Adductor canal patients required a median (10-90th percentiles) of 0.0 (0.0-2.6) interventions compared to 1.0 (0.3-3.0) interventions for femoral patients (p < 0.001); 18/23 adductor canal patients (78 %) compared to 2/22 femoral patients (9 %) required no interventions (p < 0.001). Adductor canal catheter infusions lasted 2.0 (1.4-2.0) days compared to 1.5 (1.0-2.7) days in the femoral group (p = 0.016). Adductor canal patients ambulated further [mean (SD)] than femoral patients on postoperative day 1 [24.5 (21.7) vs. 11.9 (14.6) meters, respectively; p = 0.030] and day 2 [44.9 (26.3) vs. 22.0 (22.2) meters, respectively; p = 0.003]. Postoperative opioid consumption and length of stay were similar between groups. We conclude that adductor canal catheters offer both patient and provider benefits when compared to femoral nerve catheters.

    View details for DOI 10.1007/s00540-014-1910-y

    View details for Web of Science ID 000352859100025

    View details for PubMedID 25217117

  • Variations in inpatient pediatric anesthesia in California from 2000 to 2009: a caseload and geographic analysis PEDIATRIC ANESTHESIA Mudumbai, S. C., Honkanen, A., Chan, J., Schmitt, S., Saynina, O., Hackel, A., Gregory, G., Phibbs, C. S., Wise, P. H. 2014; 24 (12): 1295-1301

    Abstract

    Regional referral systems are considered important for children hospitalized for surgery, but there is little information on existing systems.To examine geographic variations in anesthetic caseloads in California for surgical inpatients ≤6 years and to evaluate the feasibility of regionalizing anesthetic care.We reviewed California's unmasked patient discharge database between 2000 and 2009 to determine surgical procedures, dates, and inpatient anesthetic caseloads. Hospitals were classified as urban or rural and were further stratified as low, intermediate, high, and very high volume.We reviewed 257,541 anesthetic cases from 402 hospitals. Seventeen California Children's Services (CCS) hospitals conducted about two-thirds of all inpatient anesthetics; 385 non-CCS hospitals accounted for the rest. Urban hospitals comprised 82% of low- and intermediate-volume centers (n = 297) and 100% of the high- and very high-volume centers (n = 41). Ninety percent (n = 361) of hospitals performed <100 cases annually. Although potentially lower risk procedures such as appendectomies were the most frequent in urban low- and intermediate-volume hospitals, fairly complex neurosurgical and general surgeries were also performed. The median distance from urban lower-volume hospitals to the nearest high- or very high-volume center was 12 miles. Up to 98% (n = 40,316) of inpatient anesthetics at low- or intermediate-volume centers could have been transferred to higher-volume centers within 25 miles of smaller centers.Many urban California hospitals maintained low annual inpatient anesthetic caseloads for children ≤6 years while conducting potentially more complex procedures. Further efforts are necessary to define the scope of pediatric anesthetic care at urban low- and intermediate-volume hospitals in California.

    View details for DOI 10.1111/pan.12500

    View details for Web of Science ID 000345151700015

  • Continuous Adductor Canal Blocks Are Superior to Continuous Femoral Nerve Blocks in Promoting Early Ambulation After TKA. Clinical orthopaedics and related research Mudumbai, S. C., Kim, T. E., Howard, S. K., Workman, J. J., Giori, N., Woolson, S., Ganaway, T., King, R., Mariano, E. R. 2014; 472 (5): 1377-1383

    Abstract

    Femoral continuous peripheral nerve blocks (CPNBs) provide effective analgesia after TKA but have been associated with quadriceps weakness and delayed ambulation. A promising alternative is adductor canal CPNB that delivers a primarily sensory blockade; however, the differential effects of these two techniques on functional outcomes after TKA are not well established.We determined whether, after TKA, patients with adductor canal CPNB versus patients with femoral CPNB demonstrated (1) greater total ambulation distance on Postoperative Day (POD) 1 and 2 and (2) decreased daily opioid consumption, pain scores, and hospital length of stay.Between October 2011 and October 2012, 180 patients underwent primary TKA at our practice site, of whom 93% (n = 168) had CPNBs. In this sequential series, the first 102 patients had femoral CPNBs, and the next 66 had adductor canal CPNBs. The change resulted from a modification to our clinical pathway, which involved only a change to the block. An evaluator not involved in the patients' care reviewed their medical records to record the parameters noted above.Ambulation distances were higher in the adductor canal group than in the femoral group on POD 1 (median [10(th)-90(th) percentiles]: 37 m [0-90 m] versus 6 m [0-51 m]; p < 0.001) and POD 2 (60 m [0-120 m] versus 21 m [0-78 m]; p = 0.003). Adjusted linear regression confirmed the association between adductor canal catheter use and ambulation distance on POD 1 (B = 23; 95% CI = 14-33; p < 0.001) and POD 2 (B = 19; 95% CI = 5-33; p = 0.008). Pain scores, daily opioid consumption, and hospital length of stay were similar between groups.Adductor canal CPNB may promote greater early postoperative ambulation compared to femoral CPNB after TKA without a reduction in analgesia. Future randomized studies are needed to validate our major findings.Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.1007/s11999-013-3197-y

    View details for PubMedID 23897505

  • Thirty-day mortality risk associated with the postoperative nonresumption of angiotensin-converting enzyme inhibitors: A retrospective study of the veterans affairs healthcare system. Journal of hospital medicine Mudumbai, S. C., Takemoto, S., Cason, B. A., Au, S., Upadhyay, A., Wallace, A. W. 2014; 9 (5): 289-296

    Abstract

    Angiotensin-converting enzyme inhibitors (ACE-Is) are a widely used class of cardiovascular medication. However, limited data exist on the risks of postoperative nonresumption of an ACE-I.To evaluate the factors and 30-day mortality risks associated with the postoperative nonresumption of an ACE-I.A retrospective cohort study.Veterans Affairs (VA) Healthcare System.A total of 294,505 admissions in 240,978 patients with multiple preoperative prescription refills (>3) for an ACE-I who underwent inpatient surgery from calendar years 1999 to 2012.None.We classified surgical admissions based upon the timing of postoperative resumption of an ACE-I prescription from the day of surgery through postoperative days 0 to 14 and 15 to 30, and collected 30-day mortality data. We evaluated the relationship between 30-day mortality and the nonresumption of an ACE-I from postoperative day 0 to 14 using proportional hazard regression models, adjusting for patient- and hospital-level risk factors. Sensitivity analyses were conducted using more homogeneous subpopulations and propensity score models.Twenty-five percent of our cohort did not resume an ACE-I during the 14 days following surgery. Nonresumption of an ACE-I within postoperative day 0 to 14 was independently associated with increased 30-day mortality (hazard ratio: 3.44; 95% confidence interval: 3.30-3.60; P < 0.001) compared to the restart group. Sensitivity analyses maintained this relationship.Nonresumption of an ACE-I is common after major inpatient surgery in the large VA Health Care System. Restarting of an ACE-I within postoperative day 0 to 14 is, however, associated with decreased 30-day mortality. Careful attention to the issue of timely reinstitution of chronic medications such as an ACE-I is indicated.

    View details for DOI 10.1002/jhm.2182

    View details for PubMedID 24799360

  • Effectiveness of preoperative beta-blockade on intra-operative heart rate in vascular surgery cases conducted under regional or local anesthesia. SpringerPlus Mudumbai, S. C., Wagner, T., Mahajan, S., King, R., Heidenreich, P. A., Hlatky, M., Wallace, A. W., Mariano, E. R. 2014; 3: 227-?

    Abstract

    Preoperative β-blockade has been posited to result in better outcomes for vascular surgery patients by attenuating acute hemodynamic changes associated with stress. However, the incremental effectiveness, if any, of β-blocker usage in blunting heart rate responsiveness for vascular surgery patients who avoid general anesthesia remains unknown.We reviewed an existing database and identified 213 consecutive vascular surgery cases from 2005-2011 conducted without general anesthesia (i.e., under monitored anesthesia care or regional anesthesia) at a tertiary care Veterans Administration medical center and categorized patients based on presence or absence of preoperative β-blocker prescription. For this series of patients, with the primary outcome of maximum heart rate during the interval between operating room entry to surgical incision, we examined the association of maximal heart rate and preoperative β-blocker usage by performing crude and multivariate linear regression, adjusting for relevant patient factors.Of 213 eligible cases, 137 were prescribed preoperative β-blockers, and 76 were not. The two groups were comparable across baseline patient factors and intraoperative medication doses. The β-blocker group experienced lower maximal heart rates during the period of evaluation compared to the non-β-blocker group (85 ± 22 bpm vs. 98 ± 36 bpm, respectively; p = 0.002). Adjusted linear regression confirmed a statistically-significant association between lower maximal heart rate and the use of β-blockers (Beta = -11.5; 95% CI [-3.7, -19.3] p = 0.004).The addition of preoperative β-blockers, even when general anesthesia is avoided, may be beneficial in further attenuating stress-induced hemodynamic changes for vascular surgery patients.

    View details for DOI 10.1186/2193-1801-3-227

    View details for PubMedID 24855591

    View details for PubMedCentralID PMC4024108

  • Effectiveness of preoperative beta-blockade on intra-operative heart rate in vascular surgery cases conducted under regional or local anesthesia. SpringerPlus Mudumbai, S. C., Wagner, T., Mahajan, S., King, R., Heidenreich, P. A., Hlatky, M., Wallace, A. W., Mariano, E. R. 2014; 3: 227-?

    View details for DOI 10.1186/2193-1801-3-227

    View details for PubMedID 24855591

  • Association of age and packed red blood cell transfusion to 1-year survival - an observational study of ICU patients TRANSFUSION MEDICINE Mudumbai, S. C., Cronkite, R., Hu, K. U., Heidenreich, P. A., Gonzalez, C., Bertaccini, E., Stafford, R. S., Cason, B. A., Mariano, E. R., Wagner, T. 2013; 23 (4): 231-237

    Abstract

    OBJECTIVES: To compare the 1-year survival for different age strata of intensive care unit (ICU) patients after receipt of packed red blood cell (PRBC) transfusions. BACKGROUND: Despite guidelines documenting risks of PRBC transfusion and data showing that increasing age is associated with ICU mortality, little data exist on whether age alters the transfusion-related risk of decreased survival. METHODS: We retrospectively examined data on 2393 consecutive male ICU patients admitted to a tertiary-care hospital from 2003 to 2009 in age strata: 21-50, 51-60, 61-70, 71-80 and >80 years. We calculated Cox regression models to determine the modifying effect of age on the impact of PRBC transfusion on 1-year survival by using interaction terms between receipt of transfusion and age strata, controlling for type of admission and Charlson co-morbidity indices. We also examined the distribution of admission haematocrit and whether transfusion rates differed by age strata. RESULTS: All age strata experienced statistically similar risks of decreased 1-year survival after receipt of PRBC transfusions. However, patients age >80 were more likely than younger cohorts to have haematocrits of 25-30% at admission and were transfused at approximately twice the rate of each of the younger age strata. DISCUSSION: We found no significant interaction between receipt of red cell transfusion and age, as variables, and survival at 1 year as an outcome.

    View details for DOI 10.1111/tme.12010

    View details for Web of Science ID 000321975300005

    View details for PubMedID 23480030

  • Vascular Surgery Patients Prescribed Preoperative beta-Blockers Experienced a Decrease in the Maximal Heart Rate Observed During Induction of General Anesthesia JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA Mudumbai, S. C., Wagner, T., Mahajan, S., King, R., Heidenreich, P. A., Hlatky, M., Wallace, A., Mariano, E. R. 2012; 26 (3): 414-419

    Abstract

    To investigate the association of preoperative β-blocker usage and maximal heart rates observed during the induction of general anesthesia.Retrospective descriptive, univariate, and multivariate analyses of electronic hospital and anesthesia medical records.A tertiary-care medical center within the Veterans Health Administration.Consecutive adult elective and emergent patients presenting for vascular surgery during calendar years 2005 to 2011.None.Of the 430 eligible cases, 218 were prescribed β-blockers, and 212 were not taking β-blockers. The two groups were comparable across baseline patient factors (ie, demographic, morphometric, surgical duration, and surgical procedures) and induction medication doses. The β-blocker group experienced a lower maximal heart rate during the induction of general anesthesia compared with the non-β-blocker group (105 ± 41 beats/min v 115 ± 45 beats/min, respectively; p < 0.01). Adjusted linear regression found a statistically significant association between lower maximal heart rate and the use of β-blockers (β = -11.1 beats/min, p < 0.01). There was no difference between groups in total intraoperative β-blocker administration.Preoperative β-blockade of vascular surgery patients undergoing general anesthesia is associated with a lower maximal heart rate during anesthetic induction. There may be potential benefits in administering β-blockers to reduce physiologic stress in this surgical population at risk for perioperative cardiac morbidity. Future research should further explore intraoperative hemodynamic effects in light of existing practice guidelines for optimal medication selection, dosage, and heart rate control.

    View details for DOI 10.1053/j.jvca.2011.09.027

    View details for Web of Science ID 000304215800011

    View details for PubMedID 22138312

  • External Validation of Simulation-Based Assessments With Other Performance Measures of Third-Year Anesthesiology Residents SIMULATION IN HEALTHCARE Mudumbai, S. C., Gaba, D. M., Boulet, J. R., Howard, S. K., Davies, M. F. 2012; 7 (2): 73-80

    Abstract

    There has been interest in the use of high-fidelity medical simulation to evaluate performance. We hypothesized that technical and nontechnical performance in the simulated environment is related to other various criterion measures, providing evidence to support the validity of the scores from the performance-based assessment.Twelve third-year anesthesia residents participated in a series of 6 short 5-minute scenarios and 1 longer 30-minute scenario. The short scenarios measured technical skills, whereas the longer one focused on nontechnical skills. Two independent raters scored subjects using analytic and holistic ratings. Short scenarios involved acute hemorrhage, blocked endotracheal tube, bronchospasm, hyperkalemia, tension pneumothorax, and unstable ventricular tachycardia. The long scenario concerned management of myocardial ischemia/infarction leading to cardiac arrest. Scores from the simulations were correlated with (a) rankings generated from an Internet-based global ranking instrument that categorized residents based on overall clinical ability and (b) residency board scores.There were moderate correlations between various participant scores from the simulation-based assessment and aggregate rankings based on the global ranking instrument and residency examination scores.The associations between simulator performance, both for technical and nontechnical skills, and other markers of ability provide some evidence to support the validity of simulation-based assessment scores. Replication studies with larger numbers of residents are warranted.

    View details for DOI 10.1097/SIH.0b013e31823d018a

    View details for Web of Science ID 000302776800001

    View details for PubMedID 22374230

  • Association of admission hematocrit with 6-month and 1-year mortality in intensive care unit patients TRANSFUSION Mudumbai, S. C., Cronkite, R., Hu, K. U., Wagner, T., Hayashi, K., Ozanne, G. M., Davies, M. F., Heidenreich, P., Bertaccini, E. 2011; 51 (10): 2148-2159

    Abstract

    This study examined the association of hematocrit (Hct) levels measured upon intensive care unit (ICU) admission and red blood cell transfusions to long-term (1-year or 180-day) mortality for both surgical and medical patients.Administrative and laboratory data were collected retrospectively on 2393 consecutive medical and surgical male patients admitted to the ICU between 2003 and 2009. We stratified patients based on their median Hct level during the first 24 hours of their ICU stay (Hct < 25.0%, 25% ≤ Hct < 30%, 30% ≤ Hct < 39%, and 39.0% and higher). An extended Cox regression analysis was conducted to identify the time period after ICU admission (0 to <180, 180 to 365 days) when low Hct (<25.0) was most strongly associated with mortality. The unadjusted and adjusted relationship between admission Hct level, receipt of a transfusion, and 180-day mortality was assessed using Cox proportional hazards regression modeling.Patients with an Hct level of less than 25% who were not transfused had the worst mortality risk overall (hazard ratio [HR], 6.26; 95% confidence interval [CI], 3.05-12.85; p < 0.001) during the 6 months after ICU admission than patients with a Hct level of 39.0% or more who were not transfused. Within the subgroup of patients with a Hct level of less than 25% only, receipt of a transfusion was associated with a significant reduction in the risk of mortality (HR, 0.40; 95% CI, 0.19-0.85; p = 0.017).Anemia of a Hct level of less than 25% upon admission to the ICU, in the absence of a transfusion, is associated with long-term mortality. Our study suggests that there may be Hct levels below which the transfusion risk-to-benefit imbalance reverses.

    View details for DOI 10.1111/j.1537-2995.2011.03134.x

    View details for Web of Science ID 000295917700014

    View details for PubMedID 21985048

  • Feasibility of an internet-based global ranking instrument. Journal of graduate medical education Mudumbai, S. C., Gaba, D. M., Boulet, J., Howard, S. K., Davies, M. F. 2011; 3 (1): 67-74

    Abstract

    Single-item global ratings are commonly used at the end of undergraduate clerkships and residency rotations to measure specific competencies and/or to compare the performances of individuals against their peers. We hypothesized that an Internet-based instrument would be feasible to adequately distinguish high- and low-ability residents.After receiving Institutional Review Board approval, we developed an Internet-based global ranking instrument to rank 42 third-year residents (21 in 2008 and 21 in 2009) in a major university teaching hospital's department of anesthesiology. Evaluators were anesthesia attendings and nonphysicians in 3 tertiary-referral hospitals. Evaluators were asked this ranking question: "When it comes to overall clinical ability, how does this individual compare to all their peers?"For 2008, 111 evaluators completed the ranking exercise; for 2009, 79 completed it. Residents were rank-ordered using the median of evaluator categorizations and the frequency of ratings per assigned relative performance quintile. Across evaluator groups and study years, the summary evaluation data consistently distinguished the top and bottom resident cohorts.An Internet-based instrument, using a single-item global ranking, demonstrated feasibility and can be used to differentiate top- and bottom-performing cohorts. Although ranking individuals yields norm-referenced measures of ability, successfully identifying poorly performing residents using online technologies is efficient and will be useful in developing and administering targeted evaluation and remediation programs.

    View details for DOI 10.4300/JGME-D-10-00162.1

    View details for PubMedID 22379525

  • Use of Medical Simulation to Explore Equipment Failures and Human-Machine Interactions in Anesthesia Machine Pipeline Supply Crossover ANESTHESIA AND ANALGESIA Mudumbai, S. C., Fanning, R., Howard, S. K., Davies, M. F., Gaba, D. M. 2010; 110 (5): 1292-1296

    Abstract

    High-fidelity medical simulation can be used to explore failure modes of technology and equipment and human-machine interactions. We present the use of an equipment malfunction simulation scenario, oxygen (O(2))/nitrous oxide (N(2)O) pipeline crossover, to probe residents' knowledge and their use of anesthetic equipment in a rapidly escalating crisis.In this descriptive study, 20 third-year anesthesia residents were paired into 10 two-member teams. The scenario involved an Ohmeda Modulus SE 7500 anesthetic machine with a Datex AS/3 monitor that provided vital signs and gas monitoring. Before the scenario started, we switched pipeline connections so that N(2)O entered through the O(2) pipeline and vice versa. Because of the switched pipeline, the auxiliary O(2) flowmeter delivered N(2)O instead of O(2). Two expert, independent raters reviewed videotaped scenarios and recorded the alarms explicitly noted by participants and methods of ventilation.Nine pairs became aware of the low fraction of inspired O(2) (Fio(2)) alarm. Only 3 pairs recognized the high fraction of inspired N(2)O (Fin(2)o) alarm. One group failed to recognize both the low Fio(2) and the high Fin(2)o alarms. Nine groups took 3 or more steps before instigating a definitive route of oxygenation. Seven groups used the auxiliary O(2) flowmeter at some point during the management steps.The fact that so many participants used the auxiliary O(2) flowmeter may expose machine factors and related human-machine interactions during an equipment crisis. Use of the auxiliary O(2) flowmeter as a presumed external source of O(2) contributed to delays in definitive treatment. Many participants also failed to notice the presence of high N(2)O. This may have been, in part, attributable to 2 facts that we uncovered during our video review: (a) the transitory nature of the "high N(2)O" alert, and (b) the dominance of the low Fio(2) alarm, which many chose to mute. We suggest that the use of high-fidelity simulations may be a promising avenue to further examine hypotheses related to failure modes of equipment and possible management response strategies of clinicians.

    View details for DOI 10.1213/ANE.0b013e3181d7e097

    View details for Web of Science ID 000277130700010

    View details for PubMedID 20418294

  • Trigger Video of Simulated Intraoperative Cardiac Arrest Goldhaber-Fiebert , S., Harrison, K., Mudumbai, S. C., Howard, S., McCowan, K., Gaba, D. MedEd Portal, The Journal of Teaching and Learning Resources. Washington DC. 2010 (6): 0.15766/mep_2374-8265.7826

    Abstract

    ntroduction: At Stanford University School of Medicine and the Veterans Affairs Palo Alto Healthcare System, anesthesia residents felt they were missing an understanding of, and the ability to practice, the principles of crisis resource management (CRM) during an intraoperative crisis. Given residents extensive training using a high-fidelity patient simulator, and appreciation for the ability to both make mistakes without hurting patients, we created this intraoperative cardiac arrest simulation. This resource is a first step in bridging the gap between the theoretical and active application of team management principles by trainees. Methods: The session for both resident and instructor training begins with a trigger video for interactive discussion. The video is not presented as a perfect model, but rather as a practical example of how principles of CRM may be applied in situ. Participants are encouraged to discuss how specific principles were applied effectively or not and how this affects patient care. Participates then proceed to several simulated scenarios during which they can practice, reflect on, and discuss how they themselves apply the principles of CRM. Results: The use of this trigger video in our CRM simulation course, has been positively received by all participants. One trainee stated: "It was extremely helpful to see a model of how to actually put into action the principles of CRM. In watching and discussing the video, I became better equipped to implement the principles myself in subsequent simulations and in actual patient care." Discussion: It is important to give medical trainees a controlled environment in which to practice CRM and reflect on their medical/teamwork management of the scenario. This trigger video and simulation are a favorable tool for creating a controlled environment.