Gaidici, Tony

Objective Designation of a Medical Power of Attorney (MPOA) is a key component of advance care planning (ACP) that ensures patient preferences are honored when decision-making capacity is not present. This study aimed to quantify MPOA documentation rates and identify demographic and clinical factors associated with documentation presence. Methods We conducted a retrospective observational study using electronic health record data from 979 610 adult hospitalization encounters representing 459 365 unique patients within a large U.S. healthcare system from January 1, 2020, through December 31, 2021. All hospitalized patients aged ≥18 years were included. The primary outcome was MPOA documentation. Demographic and clinical variables were analyzed using multivariable logistic regression. Statistical significance was defined as P < .05. Results Among 979 610 encounters, 260 752 encounters (26.6%) had documented MPOA. Male sex, White race, older age (67.0 vs 54.3 years), and unmarried status were associated with a higher MPOA documentation rate (all, P < .001). In multivariable analyses, male sex (adjusted odds ratio [AOR], 1.07; 95% CI, 1.06-1.08) and unmarried status (AOR range, 1.41-1.75) were associated with higher odds of MPOA documentation. Dementia (AOR, 1.90; 95% CI, 1.86-1.93) and malignancy (AOR, 2.22; 95% CI, 2.19-2.25) were associated with higher odds, while discharge against medical advice was associated with lower odds (AOR, 0.91; 95% CI, 0.88-0.94) of MPOA documentation. Conclusions MPOA documentation rates were low, highlighting missed opportunities to identify alternate decision makers when a patient lacks capacity. Targeted interventions to promote surrogate decision-maker designation and documentation are needed, especially in inpatient care settings.

Background: Supracondylar humerus fractures (SCH) are the most common type of elbow fracture in children, with many cases requiring surgery. Treatment of postoperative pain for SCH has high variability, but can often be treated effectively with minimal or no opioids. Furthermore, there is significant morbidity related to pediatric opioid consumption. The goal of this study was to characterize prescription patterns in the United States following closed reduction and percutaneous pinning (CRPP) of SCH. Methods: All patients aged 10 or younger years who underwent CRPP of SCH from January 2010 to December 2021 were identified in the PearlDiver Mariner Claims Database. The primary outcome was postoperative pain medication prescriptions in the 30 days following SCH CRPP. Patient demographics, prescription duration, and morphine milligram equivalents (MME) were analyzed. Multivariable-log-binomial mixed regression models were constructed to assess factors associated with increased opioid prescription. Results: In total, 43,611 SCH CRPP cases in patients aged 10 or younger were identified from 2010 to 2021. Throughout the study period, 48.6% of patients (21,191/43,611) received and filled a narcotic pain prescription. The percentage of patients receiving opioid medication decreased from 54.7% in 2010 to 27.4% in 2021. Opioid prescriptions totaled a mean of 6.1±2.1 days of narcotics with a mean of 79.2 MME prescribed per patient. Increased patient age, increased Elixhauser comorbidity index, and Medicaid insurance were all associated with increased opioid prescription (P<0.001). Living in the Northeast, increased family income, and commercial insurance were associated with decreased opioid prescriptions (P<0.001). Conclusions: Nearly half of the patients over the past decade treated with CRPP for SCH received a narcotic prescription. However, there has been a steady decline in the proportion of patients being prescribed opioids, with only 27.4% receiving opioids in 2021. Further, patients with increased comorbidities or those insured by Medicaid with lower mean family income may be at risk for increased opioid prescription. While efforts have been made to reduce opioid overprescribing, there continues to be room for further reduction in opioid utilization after CRPP for SCH moving forward.