Differences in Regional Anesthesia Utilization by Hospital Region in the United States

doi:10.21203/rs.3.rs-1980696/v1

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Differences in Regional Anesthesia Utilization by Hospital Region in the United States

https://doi.org/10.21203/rs.3.rs-1980696/v1

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Background

Regional anesthesia (RA) has demonstrated distinct advantages over general anesthesia, including decreased infection risk, lower rates of complications, and improved patient satisfaction. As such, the rate of RA utilization has been increasing, particularly among outpatient orthopedic surgeries like total hip arthroplasty and total knee arthroplasty. However, no studies have examined utilization rates as a function of hospital region.

Methods

A national hospital database (Hospital Corporation of American, HCA) was queried for patients 18 years or older that received selected surgical procedure codes between January 2016 and June 2021. The included CPT codes were for total knee arthroplasty (TKA), total shoulder arthroplasty (TSA), anterior cruciate ligament reconstruction (ACLR), carpal tunnel release, total abdominal hysterectomy (TAH), open reduction and internal fixation (ORIF) of the ankle, and arteriovenous (AV) fistula creation. Regional anesthesia was defined as any form of neuraxial and/or peripheral nerve blocks. Basic summary statistics were utilized to calculate the rates of RA, and chi-squared analysis were calculated to determine significant differences in the rate of RA utilization.

Results

A total of 52068 patients were included, of which 2114 (4.06%) received RA. With respect to RA utilization by procedure, the greatest RA rates were for TSA (5.8%), TKA (4.5), and ACLR (3.6%), whereas the lowest RA rate was for TAH (1.1%). For the TKA cohort, the Midwest has a significantly greater utilization rate than the South or West (10.9% vs. 4.8% or 3.1%, p < 0.001). The Midwest also have the highest utilization rate in the ACLR cohort (8.1%, p < 0.001), TAH cohort (16.7%, p < 0.001) and AV fistula cohort (6.4%, p < 0.001). For the carpal tunnel cohort, the West had the highest utilization rate (11.8% vs. 8.1%, 1.1%, 0%, p < 0.001). The West region also had the highest utilization rate for the ankle ORIF cohort (7.8%, p < 0.001). No significant differences were found by region for TSA (p = 0.312).

Conclusion

Significant variations in RA utilization rates were found by region, with the West having the highest utilization for ankle ORIF and carpal tunnel, and the Midwest having the highest rate for TKA, ACLR, TAH, and AV fistula.

- summarise the state of scientific knowledge on this subject before you did your study and why this study needed to be done?

- Big data in the realm of regional anesthesia (RA) is on the rise as more and more studies have examined outcomes after RA in different patient populations (Beletsky et al. 2020, Hutton 2018, Surdhar 2022, etc). However, no study has sought to define regional anesthesia trends on a per hospital region database. Therefore, the current study employs a geography-based statistical methodology in which Medicare-based hospital regions (i.e. West, Northeast, South, Midwest) are used

- What this study adds – summarise what we now know as a result of this study that we did not know before?

- This study queries a large database across one of the largest hospital networks in the United States, reporting that different hospital regions have statistically different rates of RA utilization, on a per procedure basis but also by region overall. This study sets the foundation for further work examining regional differences RA delivery across various databases, as well as further work examining factors predictive of differential RA utilization rates (e.g. training hospital status, regional fellowship trained staff, etc).

- How this study might affect research, practice or policy – summarise the implications of this study?

- A study of this kind has the potential to implement research, practice, and policy. From a research perspective, further studies will have the opportunity to further define RA utilization rates across different databases and different hospital systems. From a practice perspective, hospital areas with relatively lower RA utilization rates have implement practice guidelines to help promote RA utilization, and track utilization rates over time. With respect to policies, studies of this kind have the potentially to be utilized internally from organizational perspective to motivate change and implement quality improvement measures.

Note: this manuscript was approved by the Riverside Community Hospital IRB, and deemed to be IRB exempt

Note: Institutional privileged were granted to utilize the nationwide HCA database for the purpose of database review

In the era of improved methods of data collection allowing for the construction of highly powered cohorts, the analysis of postoperative outcomes with the use of regional anesthesia (RA) as the primary anesthetic has emerged as a topic of increasing interest¹. Studies examining the use of RA with respect to various outcome measures have demonstrated convincing data supporting the benefit of RA. With respect to pain, RA demonstrates benefits in both the acute pain^2–4 and chronic pain setting post-operatively in the case of persistent postoperative pain after thoracotomy or breast surgery⁵. Other defined benefits of RA include decreased intraoperative⁶ and post-operative opioid requirements⁷ after various surgeries⁸, shorter mean times to discharge⁹ and improved same day discharge rates after clavicular surgery¹⁰, and generally improved patient satisfaction rates, particularly in upper extremity surgery¹¹.

However, as retrospective database and prospective cohort studies continued to seek to define areas of distinct benefit for RA, there is a paucity of literature examining the evolution of the regional anesthesia practice over time. Without question, evolutions in both provider¹² and patient¹³ comfort with RA, as well as the evolution scope of the regional practice over the past 40 years¹⁴, have set the stage for a progressive landscape with demonstrable variability dependent on various factors (i.e. hospital resources, provider training, patient comfort, surgeon support, setting-specific variation¹⁵). While a few studies have examined utilization rates of RA over time^{16; 17}, no study has sought to comprehensively define regional anesthesia trends across numerous surgical procedures, or sought to examine RA utilization rates as a function of hospital regions (i.e. West, South, Northeast, Midwest).

Accordingly, the purpose of the current study is to utilize a highly powered national database (Healthcare Corporation of America, HCA) to examine RA utilization rates in a procedure specific manner. We have three specific hypothesis: a) significant variation will exist across surgical procedures, such that for some procedures (i.e. total shoulder arthroplasty, total knee arthroplasty) the RA utilization be 2–3 times the rate of other procedures (i.e. total abdominal hysterectomy, arteriovenous (AV) fistula), b) statistically significant variability in RA utilization by hospital region will exist for each procedure in question, and c) given that majority of HCA hospitals are located in the South, we expect the majority of RA anesthetics to be delivered in this hospital region, although its per case utilization rate may not necessarily be the highest.

Data Registry

Institutional permission was granted to utilize a national database collecting anesthetic case data across all Hospital Corporation of America (HCA) hospitals. This is a multi-centered clinical repository collecting de-identified data inclusive of demographic, preoperative, perioperative, and postoperative variables. All data utilized in this study was de-identified prior to analysis. Variables of interest included all demographic variables, hospital zip code (i.e. hospital region), perioperative and postoperative variables.

Study Population and Covariates

The study population of interest was adult individuals, age 18 years of age or older without an upper age limit. Other inclusion criteria included receipt of a surgical procedure of interest (See Table 1) between January 2016 and June 2021, and receipt of some form of anesthesia (i.e. general, regional, monitored anesthesia care (MAC), etc). There were no specific exclusion criteria for this study (Table 1).

Table 1

Surgical Procedures and Procedures of Interest
Common Procedural Terminology	Procedure of Interest
23472	Total Shoulder Arthroplasty
27447	Total Knee Arthroplasty
64721	Carpal Tunnel Surgery
29888	Anterior Cruciate Ligament Reconstruction
27766, 27792, 27814, 27823	Ankle Open Reduction & Internal Fixation
58150	Total Abdominal Hysterectomy
36830	Arteriovenous Fistula Creation

The primary outcome of interest in this study was the rate of regional anesthesia receipt, coded as a binary variable. The definition of RA in this study was neuraxial anesthesia (NA) (i.e. spinal, epidural) and/or some from of peripheral nerve block (PNBs), inclusive of upper extremity blocks (i.e. axillary, interscalene, supraclavicular, infraclavicular) and lower extremity blocks (i.e. IPACK, adductor canal, genicular, saphenous, popliteal). Preoperative variables included in this study included demographic factors (i.e. age, sex, race, body mass index, insurance status). Hospital region had 4 distinct regions – West, Northeast, South, Midwest – defined on a per state basis mirroring definition provided by hospital regions¹⁸.

Statistical Analysis

A power analysis was performed modeling chi-squared analysis, assuming a “worst-case” scenario with an effect size of 0.1, α equal to 0.05, power of 0.95, and 3 degrees of freedom, suggesting a minimal sample size of n = 1717. Analysis for this project involved primarily basic summary statistics of the rate of RA utilization, defined as total cases utilizing RA divided by total cases for a given CPT. On subgroup analysis, when we split cases up by region, univariate statistics involving Chi-squared analyses were performed to determine if statistically significant differences existed by region for a given CPT code. Additionally, specific data definitions used in this study include “% within RA”, corresponding to relative percentage in a given region of the total RA delivered for a given CPT, and “% within region” defined as the RA utilization rate within a given region. “% of total RA delivered” will also correspond to what share of the total RA count was delivered by a given region.

A total of n = 52,068 surgical cases met inclusion criteria in the study, with n = 2,114 (4.23%) of those cases receiving RA. Among the surgical techniques, the large majority of surgical cases involves TKA (n = 29440), followed by carpal tunnel (n = 8045), ankle ORIF (n = 6319), and ACLR (n = 2729). Demographic characteristics of the study population are summarized by Table 2, demonstrating statistically significant differences across regional and non-regional populations for the distributions of sex (p = 0.02), race (p < < 0.001), hospital region (p < 0.001), Medicaid insurance (p < 0.001), CCI (p = 0.02) and ASA (p < 0.001). When examining total RA anesthetics delivered by hospital region, the South region (65.9% of total) represented a disproportionate amount of RA delivered compared to the West (25.8%) and Midwest (8.2%) (Χ² = 2454, p < 0.01). The Midwest region had the highest overall RA utilization rate (7.8%) when compared to the West (5.2%), South (3.6%) and Northeast (0.1%) regions (p < 0.01)(Table 3). When examining overall RA utilization rates by procedure, significant variations existed by procedure, such that the procedure with the highest rate of RA utilization was TSA (5.8%) followed by TKA (4.8%), and the procedure with the lowest rate of RA utilization was TAH (1.1%)(p < 0.01)(Table 3). When examining RA utilization rates based on hospital region, important trends emerge. First, the Midwest region has the highest relative rates of RA utilization for TSA (9.9%), TKA (10.9%), ACLR (8.1%) and AV fistula (each p < 0.01). Notably, there is a disproportionate rate of RA utilization in the Midwest region for TAH (16.7%), a higher utilization rate than the Northeast (0.4%), South (2.5%) and West (1.1%) combined (p < 0.01). The West region has the highest relative rates of RA utilization for carpal tunnel surgery (11.8%), and a particularly disproportionate rate of RA utilization for ankle ORIF (7.8) when compared to the Midwest (1.9%), Northeast (1.3%), and South (2.5%) regions (both p < 0.01)(Table 4).

Table 2

Demographics of the Study Population BMI: body mass index, CCI: Charleson Comorbidity Index; ACLR: anterior cruciate ligament reconstruction, ASA: American Society of Anesthesiology Physical Classification, STD: standard deviation
	Total N/Mean	RA = 0 (n = 49954)	RA = 1 (n = 2114)	P-value
Age (yrs, STD)	61.7 +/- 14.8	61.7 +/- 14.8	61.5 +/- 14.5	0.71
Female Sex (n, %)	30597 (58.76%)	29406 (58.87%)	1191 (56.34%)	0.02
Black Race (n, %)	5734 (11%)	5566 (11.14%)	168 (7.95%)	< 0.001
Obese BMI (n,%)	13938 (26.77%)	13359 (26.74%)	579 (27.39%)	0.85
Surgical Category - Carpal Tunnel - TKA - ACLR	8037 (15.44%) 29438 (56.54%) 2728 (5.24%)	7779 (15.57%) 28116 (56.28%) 2630 (5.26%)	258 (12.2%) 1322 (62.64%) 98 (4.64%)	< 0.001
Region - South - Midwest - West	38614 (74.16%) 2238 (4.30%) 10438 (20.1%)	37220 (74.51%) 2064 (4.13%) 9893 (19.8%)	1394 (65.94%) 174 (8.23%) 545 (5.78%)	< 0.001
Medicaid (n,%)	3268 (6.28%)	31.85 (6.38%)	83 (3.93%9	< 0.001
CCI	2.60	2.60	2.50	0.02
ASA	2.5 +/- 0.7	2.51 +/- 0.7	2.4 +/- 0.7	< 0.001

BMI: body mass index, CCI: Charleson Comorbidity Index; ACLR: anterior cruciate ligament reconstruction, ASA: American Society of Anesthesiology Physical Classification, STD: standard deviation

Table 3

RA Utilization Rates by Procedure
	Total N	RA Utilization %
TSA	132	6.2%
TKA	1272	4.5%
Carpal Tunnel	278	3.2%
ACLR	103	4.6%
Ankle ORIF	221	3.3%
TAH	31	0.6%
AV Fistula	97	4.3%
TSA: total shoulder arthroplasty; TKA: total knee arthroplasty; ACLR: anterior cruciate ligament reconstruction; ORIF: open reduction and internal fixation; TAH: total abdominal hysterectomy; AV: arteriovenous

Table 4

Percent RA Utilization by Hospital Region and Surgery
	Midwest	Northeast	South	West
TSA	9.9%	0.0%	5.5%	6.2%
TKA	10.9%	0.0%	4.8%	3.1%
Carpal Tunnel Release	8.1%	0.0%	1.1%	11.8%
ACLR	8.1%	0.0%	2.2%	7.6%
Ankle ORIF	1.9%	1.3%	2.5%	7.8%
TAH	16.7%	0.4%	2.5%	1.1%
AV Fistula	6.4%	0.0%	2.1%	6.1%
ACLR: anterior cruciate ligament reconstruction; AV: arteriovenous; ORIF: open reduction and internal fixation; RA: regional anesthesia; TAH: total abdominal hysterectomy; TSA: total shoulder arthroplasty; TKA: total knee arthroplasty

The main finding in this study is that different hospital regions (i.e. Midwest, Northeast, South, West) have statistically significant differences RA utilization rates, both when compared overall by region, as well as when examined by procedure. Additionally, significant differences in RA utilization rates exist between procedures, such that common orthopedic procedures (i.e. TSA, TKA, ACLR) had the highest rates of RA utilization while non-orthopedic procedures (i.e. TAH, AV fistula) had significantly lower rates of RA utilization. Lastly, our studies aligns with previous studies in demonstrating that general anesthesia (GA) techniques remain the primary anesthetic of choice for most common RA use cases¹⁶, despite increasing literature demonstrating benefits of RA^{19; 20}.

With respect to the role of hospital region without stratification by surgical procedure, important trends emerged. First, the South region delivered the overwhelming majority of RA overall, delivering 65.9% of all RA in the study. This is largely because the majority of HCA hospital area located within this state-based region, with the West region having the next most hospitals per region. This is in stark contrast to the Northeast region, a region in which HCA only has 1 hospital. When examining this data on a within-region basis, the Midwest has the greatest mean within region RA utilization rate, despite only equating to 0.3% of total anesthetics delivered. This contrasts with the South, which comprised 65.9% of delivered RA but on a within region basis, had a RA utilization rate of 3.6%. These important trends suggest two important take-aways: a) regions that have high total RA delivery rates may not necessarily have high RA utilization rates, b) total delivery rates by hospital region are influenced by the numbers of hospitals within a given region, as well as the volume of each contributing hospital, among other factors.

Our analysis of RA utilization rates by procedure overall revealed important trends to suggest differences in RA utilization based on procedural subtype. The top three procedures in terms of RA utilization rates were TSA, TKA and ACLR, each representing a common, high-volume orthopedic procedure with applicable upper extremity or lower extremity blocks, respectively. Regional techniques for TAH are evolving and represent a relatively new indication for the use of RA, with either quadratus lumborum block²¹, superior hypogastric block²², or transversus abdominis plane block²³. For this reason, it is not surprising for RA utilization rates to be lower for this relatively newer indication than for more established surgical indications such as TSA²⁴ and TKA^25–28. In addition, a study Cozowicz et al.¹⁶ in 2016 documented the use of neuraxial anesthesia for TKA between 2006 to 2013 as 24.7%-21.3%, and the use of peripheral nerve blocks for TKA during the same time period as increasing from 10.3–20.4%. Although our study data is not stratified on a yearly basis likely that of Cosowicz et al, our published data reflects a relatively lower rate of RA utilization for TKA (4.5%), which may be attributable to various factors including hospital urbanicity^{16; 29}, resource limitations¹², and physician training and comfort level³⁰.

When examining RA utilization by hospital region, important trends emerge on a per procedure basis between the Midwest, Northeast, South and West regions. For both TSA and TKA, the Midwest region, which is responsible for delivering the third most RA behind the South and West, had the highest utilization rate by a wide margin (mean differences 2.8% and 6.1%, respectively). The Midwest also had the highest RA utilization rate for ACLR, TAH and AV fistula, suggesting it has the highest overall mean RA utilization rate. We believe this represents an important trend in RA utilization that should be tested across various databases (i.e. NIS, private databases). A similar finding worth examining is the fact that the West has statistically significant increase (mean difference + 3.7%) in RA utilization rates during carpal tunnel (11.8%) compared to other regions. We felt that local infiltration might be confounder in this relationship, so we excluded it from the analysis, only isolating true block administration. Therefore, this data reflected that West region has disproportionate RA utilization rates for both carpal tunnel and ankle ORIF, underlining important practice trends that uniquely defined the West region.

Our study is not without important limitations each reader must consider. First of all, this study is a retrospective data study compiling data to establish trends. The findings in the studies are limited to associations, and do not necessarily imply any causal associations given limitations in study design. Secondly, the mean RA utilization rates in our study are just that – means. They are means across the timeline included in the study. However, based on previous studies, we know that RA utilizations rates may significantly change, and that is, improve over time. Therefore, in future studies from our group, it will be necessary to complicate these trends by analyzing RA utilization rates on a per year basis. Third, although univariate statistics allowed us to identify important trends in data, we were unable to perform further analyses like those in Cozowicz et al.¹⁶ and stratify our data by hospital urbanicity and other possible factors. Lastly, this data is comprised of HCA-hospital data across the nation. It is data from 1 hospital system; therefore, it does not represent a particularly heterogenous group of hospitals (i.e. academic, private, safety net, etc) and instead represents the HCA private hospital network. We therefore do not know the exact type size or number of hospitals included in the sample. In addition, we do not know the severity of clinical lesions for the surgeries involved, despite higher ASA classifications being linked to decreases of regional anesthesia receipt in previous studies.

Significant variations in RA utilization rates were found by region within the United States, with the West having the highest utilization for ankle ORIF and carpal tunnel, and the Midwest having the highest rate for TKA, ACLR, TAH, and AV fistula. Future studies should consider using a similar statistical approach in national databases (i.e. NSQIP, NIS) to see what different in RA utilization rates exist.

Ethnics Approval/Consent for Participation: This study was deemed to be IRB exempt (i.e. waived) by the institutional review board (IRB) at Riverside Community Hospital (4445 Magnolia Avenue, Riverside, CA 92501, United States). The need for informed consent was waived by the ethics committee/Institutional Review Board of Riverside Community Hospital (RCH), because of the retrospective nature of the study." Given the use of de-identified data. IRB exempt status (i.e. waived) was granted based on the use of de-identified patient data devoid of any information linking the data points to patient data. Database of study in this study was the Hospital Corporation of America (HCA) database. Research involving human participants, human material, or human data, has been performed in accordance with the Declaration of Helsinki.

Consent for Publication: not applicable

Availability of Data and Materials: data analyzed for the current study are available in the Hospital Corporation of America (HCA) database and belongs to a private hospital corporation. Due to individual privacy, we cannot freely share data that could compromise patient health protection laws. However, the data will be held on a protected computer after the study and can be re-queried on request from the corresponding author should further questions arise.

Funding: none

Conflict of Interest: Alexander Beletsky, Morgan Currie, Jonathan Shen, Hunter Brooks, Mahesh Desilva, Nutan Winston do not have any competing interests to report. Dr. Rodney A. Gabriel reports funding for research from Heron Therapeutics, SPR Therapeutics, Infutronics, Ferrosan Medical, and Myoscience.

Author Contributions:

Alexander Beletsky: This author helped interpret the data, draft the initial manuscript, and critically revise the manuscript.

Morgan Currie: This author helped with study design and assisted in initial drafting of the manuscript.

Muhammad Helwany: This author helped with interpretation of the data, and critically revised the manuscript.

Jonathan Shen: This author helped with interpretation of the data, and critically revised the manuscript.

Hunter Brooks: This author helped draft and critically revised the manuscript.

Mahesh Desilva: This author helped interpret the data, draft the initial manuscript, and critically revise the manuscript.

Nutan Winston: This author helped design the study, acquire, analyze, and interpret the data, draft the initial manuscript, and critically revise the manuscript.

Rodney A. Gabriel: This author helped design the study, acquire, analyze, and interpret the data, draft the initial manuscript, and critically revise the manuscript.

Funding: none

Acknowledgements: none

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Competing interest reported. Alexander Beletsky, Morgan Currie, Jonathan Shen, Hunter Brooks, Mahesh Desilva, Nutan Winston do not have any competing interests to report. Dr. Rodney A. Gabriel reports funding for research from Heron Therapeutics, SPR Therapeutics, Infutronics, Ferrosan Medical, and Myoscience.

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Differences in Regional Anesthesia Utilization by Hospital Region in the United States

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Abstract

Background

Methods

Results

Conclusion

What Is Already Known On This Topic

Background

Methods

Data Registry

Study Population and Covariates

Statistical Analysis

Results

Discussion

Limitations

Conclusion

Declarations

References

Additional Declarations

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