Adults age 65 and older ("older adults") are the fastest growing segment of the United States population, and their number is expected to double to 89 million between 2010 and 2050. 1 Based on these evolving demographics, it is expected that there will be a concurrent rise in the demand for a variety of surgical services, including vascular surgery (with a projected growth of 31%) and general surgery (with a projected growth of 18%). 2 Older adult surgical patients often require a different level of care than younger patients during the perioperative period. Many have multiple chronic illnesses other than the one for which surgery is required, and therefore are prone to developing postoperative complications, functional decline, loss of independence, and other untoward outcomes. In order to provide optimal care for the older surgical patient, a thorough assessment of the individual's health status and a plan of care during the perioperative period designed to look for and address any identified deficits is essential. To assist clinicians with this assessment and subsequent care, in 2010, the American College of Surgeons (ACS) partnered with the American Geriatrics Society (AGS) and the John A Hartford Foundation to develop guidelines for the optimal surgical care of older adults. The first part of these guidelines, the American College of Surgeons National Surgical Quality Improvement Program (NSQIP)/American Geriatrics Society (AGS) Best Practices Guidelines: Optimal Preoperative Assessment of the Geriatric Surgical Patient 3 was published in 2012. This resource defined 9 assessment categories: cognitive/behavioral disorders, cardiac evaluation, pulmonary evaluation, functional/performance status, frailty, nutritional status, medication management, patient counseling, and preoperative testing. The second part of these guidelines, presented here, targets the rest of the perioperative period, beginning in the immediate preoperative period and extending through the postoperative period and discharge transition. These guidelines build on the domains of geriatric care and proposed geriatric competencies established by previous work and are designed to provide a framework for thinking about the complex issues around perioperative care in this patient population. 4,5 GERIATRIC SURGERY EXPERT PANEL, LITERATURE REVIEW, AND GUIDELINES DEVELOPMENT Similar to the preoperative assessment guidelines, the optimal perioperative management guidelines leveraged the expertise of a 28-member, multidisciplinary panel representing the American College of Surgeons (ACS), American Society of Anesthesiologists, American Geriatrics Society (AGS), the ACS Geriatric Surgery Task Force, and the AGS Geriatrics for Specialists Initiative. This document is divided conceptually into 3 domains: the immediate preoperative, intraoperative, and postoperative periods. A literature review of MEDLINE was performed for each domain in order to identify systematic reviews, metaanalyses, practice guidelines, and clinical trials between

Healthcare workers involved in aerosol-generating procedures, such as tracheal intubation, may be at elevated risk of acquiring COVID-19. However, the magnitude of this risk is unknown. We conducted a prospective international multicentre cohort study recruiting healthcare workers participating in tracheal intubation of patients with suspected or confirmed COVID-19. Information on tracheal intubation episodes, personal protective equipment use and subsequent provider health status was collected via self-reporting. The primary endpoint was the incidence of laboratory-confirmed COVID-19 diagnosis or new symptoms requiring selfisolation or hospitalisation after a tracheal intubation episode. Cox regression analysis examined associations between the primary endpoint and healthcare worker characteristics, procedure-related factors and personal protective equipment use. Between 23 March and 2 June 2020, 1718 healthcare workers from 503 hospitals in 17 countries reported 5148 tracheal intubation episodes. The overall incidence of the primary endpoint was 10.7% over a median (IQR [range]) follow-up of 32 (18-48 [0-116]) days. The cumulative incidence within 7, 14

Worldwide, the use of prescription opioid analgesics more than doubled between 2001 and 2013, with several countries, including the USA, Canada, and Australia, experiencing epidemics of opioid misuse and abuse over this period. In this context, excessive prescribing of opioids for pain treatment after surgery has been recognised as an important concern for public health and a potential contributor to patterns of opioid misuse and related harm. In the second paper in this Series we review the evolution of prescription opioid use for pain treatment after surgery in the USA, Canada, and other countries. We summarise evidence on the extent of opioid overprescribing after surgery and its potential association with subsequent opioid misuse, diversion, and the development of opioid use disorder. We discuss evidence on patient, physician, and system-level predictors of excessive prescribing after surgery, and summarise recent work on clinical and policy efforts to reduce such prescribing while ensuring adequate pain control.

oral morphine equivalents prescribed. Although a limited supply of opioids may be required for some patients following tooth extraction, these data suggest that disproportionally large amounts of opioids are frequently prescribed given the expected intensity and duration of postextraction pain, particularly as nonopioid analgesics may be more effective in this setting. 5 This study has limitations. Findings based on data from Medicaid claims may not generalize to a commercially insured population. Also, the final year of the study was 2010, and it is possible that dental prescribing practices have changed somewhat since that time.This common dental procedure may represent an important area of excessive opioid prescribing in the United States. As the nation implements programs to reduce excessive prescribing of opioid medications, it will be important to include dental care in these approaches.

IMPORTANCE Little is known regarding outcomes after hip fracture among long-term nursing home residents.OBJECTIVE To describe patterns and predictors of mortality and functional decline in activities of daily living (ADLs) among nursing home residents after hip fracture. DESIGN, SETTING, AND PARTICIPANTSRetrospective cohort study of 60 111 Medicare beneficiaries residing in nursing homes who were hospitalized with hip fractures between

IMPORTANCE More than 300 000 hip fractures occur each year in the United States. Recent practice guidelines have advocated greater use of regional anesthesia for hip fracture surgery. OBJECTIVE To test the association of regional (ie, spinal or epidural) anesthesia vs general anesthesia with 30-day mortality and hospital length of stay after hip fracture. DESIGN, SETTING, AND PATIENTS We conducted a matched retrospective cohort study involving patients 50 years or older who were undergoing surgery for hip fracture at general acute care hospitals in New York State between July 1, 2004, and December 31, 2011. Our main analysis was a near-far instrumental variable match that paired patients who lived at different distances from hospitals that specialized in regional or general anesthesia. Supplementary analyses included a within-hospital match that paired patients within the same hospital and an across-hospital match that paired patients at different hospitals. EXPOSURES Spinal or epidural anesthesia; general anesthesia. MAIN OUTCOMES AND MEASURES Thirty-day mortality and hospital length of stay. Because the distribution of length of stay had long tails, we characterized this outcome using the Huber M estimate with Huber weights, a robust estimator similar to a trimmed mean. RESULTS Of 56 729 patients, 15 904 (28%) received regional anesthesia and 40 825 (72%) received general anesthesia. Overall, 3032 patients (5.3%) died. The M estimate of the length of stay was 6.2 days (95% CI, 6.2 to 6.2). The near-far matched analysis showed no significant difference in 30-day mortality by anesthesia type among the 21 514 patients included in this match: 583 of 10 757 matched patients (5.4%) who lived near a regional anesthesia– specialized hospital died vs 629 of 10 757 matched patients (5.8%) who lived near a general anesthesia–specialized hospital (instrumental variable estimate of risk difference, −1.1%; 95% CI, −2.8 to 0.5; P = .20). Supplementary analyses of within and across hospital patient matches yielded mortality findings to be similar to the main analysis. In the near-far match, regional anesthesia was associated with a 0.6-day shorter length of stay than general anesthesia (95% CI, −0.8 to −0.4, P < .001). Supplementary analyses also showed regional anesthesia to be associated with shorter length of stay, although the observed association was smaller in magnitude than in the main analysis. CONCLUSIONS AND RELEVANCE Among adults in acute care hospitals in New York State undergoing hip repair, the use of regional anesthesia compared with general anesthesia was not associated with lower 30-day mortality but was associated with a modestly shorter length of stay. These findings do not support a mortality benefit for regional anesthesia in this setting.

A large number of postoperative pulmonary outcome measures have been used, but most are poorly defined. Our four recommended outcome measures include a new definition of postoperative pulmonary complications, incorporating an assessment of severity. These definitions will meet the needs of most clinical effectiveness trials of treatments to improve postoperative pulmonary outcomes.

Importance Hospital readmissions are common, costly, and potentially preventable. Little is known about the association between available SNF performance measures and the risk of hospital readmission. Objective To measure the association between SNF performance measures and hospital readmissions among Medicare beneficiaries receiving post-acute care at U.S. SNFs. Design Using national Medicare data, we examined the association between SNF performance on publicly available metrics (SNF staffing intensity, performance on required facility site inspections, and the percentages of SNF patients with delirium, moderate-to-severe pain, and new or worsening pressure ulcers) and the risk of readmission or death 30 days after discharge to a SNF. Adjusted analyses controlled for patient case-mix, SNF facility factors, and the discharging hospital. Participants Fee-for-service Medicare beneficiaries discharged to a SNF following an acute-care hospitalization between September 1, 2009 and August 31, 2010. Main outcomes and measures Readmission to an acute-care hospital or death within 30 days of the index hospital discharge. Results Out of 1,530,824 discharges, 357,752 (23.4%;99% CI: 23.3%, 23.5%) were readmitted or died within 30 days; 4.7% (72,472 discharges) died within 30 days (99% CI: 4.7%, 4.8%), and 21.0%(N=321,709) were readmitted (99% CI: 20.9%, 21.1%). The unadjusted risk of readmission or death was lower at SNFs with better staffing ratings (lowest (19.2% of SNFs) vs. highest (6.7% of SNFs): 25.5%; 99% CI: 25.3%, 25.8% vs 19.8%; 99% CI: 19.5%, 20.1%, p<0.001) and better facility inspection ratings (lowest (20.1% of SNFs) vs. highest (9.8% of SNFs): 24.9%; 99% CI: 24.7%,25.1%; vs. 21.5%; 99% CI: 21.2%, 21.7%; p<0.001). Adjustment for patient factors, SNF facility factors, and the discharging hospital attenuated these associations; we observed small differences in the adjusted risk of readmission or death according to SNF facility inspection ratings (lowest vs. highest rating: 23.7%; 99% CI: 23.7%, 23.7%; vs 23.0%; 99% CI:23.0%, 23.1%; p<0.001). Other measures did not predict clinically meaningful differences in the adjusted risk of readmission or death. Conclusions and relevance Among fee-for-service Medicare beneficiaries discharged to a SNF following an acute care hospitalization, available performance measures were not consistently associated with differences in the adjusted risk of readmission or death.