Healthcare disparities in quality represent one of the greatest challenges in achieving uniformly high-quality care (1). Research reporting disparities in surgical outcomes are abundant (2-6). The cornerstone of delivering high quality healthcare is ensuring optimal access for all patients. A relative lack of access to surgical services may be a contributing factor to disparities in surgical outcomes.Access is "the timely use of personal health services to achieve the best possible outcomes" (7). Utilization of services, the process of entering and staying in the system, and the actual quality of care received are all involved. Disparities in access arise when the system disproportionately under-performs for a specific group of patients relative to the historically

BackgroundThe World Health Organization Surgical Safety Checklist (SSC) has been widely implemented in an effort to decrease surgical adverse events.MethodThis systematic literature review examined the effects of the SSC on postoperative outcomes. The review included 25 studies: two randomised controlled trials, 13 prospective and ten retrospective cohort trials. A meta-analysis was not conducted as combining observational studies of heterogeneous quality may be highly biased.ResultsThe quality of the studies was largely suboptimal; only four studies had a concurrent control group, many studies were underpowered to examine specific postoperative outcomes and teamwork-training initiatives were often combined with the implementation of the checklist, confounding the results. The effects of the checklist were largely inconsistent. Postoperative complications were examined in 20 studies; complication rates significantly decreased in ten and increased in one. Eighteen studies examined postoperative mortality. Rates significantly decreased in four and increased in one. Postoperative mortality rates were not significantly decreased in any studies in developed nations, whereas they were significantly decreased in 75 % of studies conducted in developing nations.ConclusionsThe checklist may be associated with a decrease in surgical adverse events and this effect seems to be greater in developing nations. With the observed incongruence between specific postoperative outcomes and the overall poor study designs, it is possible that many of the positive changes associated with the use of the checklist were due to temporal changes, confounding factors and publication bias.

Key Points Question Can a risk score for sustained prescription opioid use after surgery be developed for a working-age population using readily available clinical information? Findings In this case-control study of 86 356 patients undergoing 1 of 10 common surgical procedures, prior opioid exposure was the factor most strongly associated with sustained opioid use. The group with the lowest Stopping Opioids After Surgery scores (<31) had a mean 4.1% risk of sustained opioid use; the group with intermediate scores (31-50) had a mean risk of 14.9%; and the group with the highest scores (>50) had a mean risk of 35.8%. Meaning The scoring system developed in this study may inform the risk of sustained prescription opioid use after surgery and be scalable to clinical practice.

Background: Prior opioid use has been shown to be associated with adverse outcomes in surgical and trauma patients. We sought to evaluate the influence of prior opioid use on prescription opioid requirements after orthopedic trauma. Materials and methods: This was a retrospective review of TRICARE claims (2006-2014). We evaluated the records of 11,752 patients treated for orthopedic injuries. Surveillance for prior opioid exposure extended to 6 mo before the traumatic event, with similar postinjury surveillance. Preinjury opioid use was categorized as unexposed, exposed without sustained use (nonsustained users), and sustained use (6 mo or longer of continuous opioid prescriptions without interruption). Multivariable Cox proportional hazard models were used to adjust for confounding and determine factors independently associated with the discontinuation of prescription opioid use after traumatic injury. Results: Prior opioid exposure among nonsustained users (hazard ratio 0.78; 95% CI 0.74, 0.83) and sustained use at the time of injury (hazard ratio 0.40; 95% CI: 0.35, 0.47) were associated with lower likelihoods of opioid discontinuation. Additional factors associated with lower likelihoods of opioid discontinuation included our proxy for lower socioeconomic status, history of depression or anxiety, injury severity, and intensive care unit admission. Conclusions: Prior opioid use is one of the strongest predictors of continued use following treatment, along with socioeconomic status, behavioral health disorders, and severity of injury. Appropriate discharge planning and early engagement of ancillary services in