No abstract

Objective To compare adherence to opioid prescribing guidelines and potential opioid misuse in patients of resident versus attending physicians. Design Retrospective cross-sectional study. Setting Large primary care practice at a safety-net hospital in New England. Subjects Patients 18–89 years old, with at least one visit to the primary care clinic within the past year and were prescribed long-term opioid treatment for chronic non-cancer pain. Methods Data were abstracted from the EMR by a trained data analyst through a clinical data warehouse. The primary outcomes were adherence to any one of two American Pain Society Guidelines; 1) documentation of at least one opioid agreement (contract) ever, and 2) any urine drug testing in the past year; and 3) evidence of potential prescription misuse defined as ≥2 early refills. We employed logistic regression analysis to assess whether patients’ physician status predicts guideline adherence and/or potential opioid misuse. Results Similar proportions of resident and attending patients had a controlled substance agreement (45.1% of resident patients vs. 42.4% of attending patient, p=0.47) or urine drug testing (58.6% of resident patients vs. 63.6% of attending patients, p=0.16). Resident patients were more likely to have two or more early refills in the past year relative to attending patients (42.8% vs. 32.5%; p=0.004). In the adjusted regression analysis, resident patients were more likely to receive early refills (OR 1.82, 95% CI 1.26–2.62) than attending patients. Conclusions With some variability, residents and attending physicians were only partly compliant with national guidelines. Residents were more likely to manage patients with a higher likelihood of opioid misuse.

Reinterventions after F/B-EVAR were necessary in 26% of patients, most commonly for type III endoleaks and target artery complications. Whereas all but one reintervention was successful, many of these required complex procedures with significant morbidity and mortality. Development of strategies to eliminate type III endoleaks by improving component junction integrity and to ensure target artery primary patency are key next steps in the evolution of F/B-EVAR.

In this single-institution experience of fenestrated endovascular aneurysm repair, the primary differences between PMEG and CMD related only to operative metrics and the need for postoperative reinterventions. No statistically significant advantage was found for one approach over the other; we therefore cannot conclude that one approach is better than the other. Both remain viable options that may compare favorably with open repair of complex aortic aneurysms. Further studies are necessary to determine whether this relative equivalence represents a type II error or lack of long-term durability data or whether true equivalence between PMEG and CMD approaches exists.