The Perioperative Use of Benzodiazepines for Major Orthopedic Surgery in the United States

Abstract

BACKGROUND: Despite numerous indications for perioperative benzodiazepine use, associated risks may be exacerbated in elderly and comorbid patients. In the absence of national utilization data, we aimed to describe utilization patterns using national claims data from total hip/knee arthroplasty patients (THA/TKA), an increasingly older and vulnerable surgical population. METHODS: We included data on 1,863,996 TKAs and 985,471 THAs (Premier Healthcare claims data, 2006–2019). Benzodiazepine utilization (stratified by long- and short-acting agents) was assessed by patient- and health care characteristics, and analgesic regimens. Given the large sample size, standardized differences instead of P values were utilized to signify meaningful differences between groups (defined by value >0.1). RESULTS: Among 1,863,996 TKA and 985,471 THA patients, the utilization rate of benzodiazepines was 80.5% and 76.1%, respectively. In TKA, 72.6% received short-acting benzodiazepines, while 7.9% received long-acting benzodiazepines, utilization rates 68.4% and 7.7% in THA, respectively. Benzodiazepine use was particularly more frequent among younger patients (median age [interquartile range {IQR}]: 66 [60–73]/64 [57–71] among short/long-acting compared to 69 [61–76] among nonusers), White patients (80.6%/85.4% short/long-acting versus 75.7% among nonusers), commercial insurance (36.5%/34.0% short/long-acting versus 29.1% among nonusers), patients receiving neuraxial anesthesia (56.9%/56.5% short/long-acting versus 51.5% among nonusers), small- and medium-sized (≤500 beds) hospitals (68.5% in nonusers, and 74% and 76.7% in short- and long-acting benzodiazepines), and those in the Midwest (24.6%/25.4% short/long-acting versus 16% among nonusers) in TKA; all standardized differences ≥0.1. Similar patterns were observed in THA except for race and comorbidity burden. Notably, among patients with benzodiazepine use, in-hospital postoperative opioid administration (measured in oral morphine equivalents [OMEs]) was substantially higher. This was even more pronounced in patients who received long-acting agents (median OME with no benzodiazepines utilization 192 [IQR, 83–345] vs 256 [IQR, 153–431] with short-acting, and 329 [IQR, 195–540] with long-acting benzodiazepine administration). Benzodiazepine use was also more frequent in patients receiving multimodal analgesia (concurrently 2 or more analgesic modes) and regional anesthesia. Trend analysis showed a persistent high utilization rate of benzodiazepines over the last 14 years. CONCLUSIONS: Based on a representative sample, 4 of 5 patients undergoing major orthopedic surgery in the United States receive benzodiazepines perioperatively, despite concerns for delirium and delayed postoperative neurocognitive recovery. Notably, benzodiazepine utilization was coupled with substantially increased opioid use, which may project implications for perioperative pain management.

Association of Patient Race and Hospital with Utilization of Regional Anesthesia for Treatment of Postoperative Pain in Total Knee Arthroplasty: A Retrospective Analysis Using Medicare Claims

“…Approximately 5% of our study population was identified as Black, which is slightly lower than reported Black patient populations in similar studies including patients with commercial or Medicare Advantage insurance. 10,27 The table presents our primary unadjusted and adjusted models estimating the association between race and regional anesthesia utilization for postoperative pain, along with selected sensitivity analyses. The primary adjusted model was specified as a multivariable logistic regression that accounted for age, sex, elixhauser comorbidities, preoperative opioid, anticoagulant, and antiplatelet utilization, and year and hospital fixed effects.…”

“…Approximately 5% of our study population was identified as Black, which is slightly lower than reported Black patient populations in similar studies including patients with commercial or Medicare Advantage insurance. 10,27 Given that the Black and White race categories have been validated, it is unlikely that this difference is due to misclassification bias; rather, this difference in the proportion of Black patients potentially stems from varied enrollment patterns of minoritized populations in fee-for-service versus Medicare Advantage ( i.e. , managed care) plans.…”

The Burden of Postoperative Delirium After Shoulder Arthroplasty and Modifiable Pharmacological Perioperative Risk Factors: A Retrospective Nationwide Cohort Study

“…The use of benzodiazepines in elderly patients is surprising, given the known risk of benzodiazepine use in the elderly. Benzodiazepine use—regardless of short or long half-life—has been linked to an increased risk of falls, hip fracture, and cognitive impairment; thus, the association with postoperative delirium is of particular importance [ 3 , 8 ]. Indeed, the 2019 edition of the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults recommends that benzodiazepines be avoided in elderly patients [ 2 , 3 ].…”

Evaluation of a behavioural intervention to reduce perioperative midazolam administration to older adults

“… 7 Despite this, a majority of older surgical patients in the US receive benzodiazepines during anaesthesia care. 8 , 9 …”