Orthopedics

Feature Article 

Continuous Peripheral Nerve Blocks Are Associated With Increased Rates of Emergency Department Visits After Arthroscopic Rotator Cuff Repair Surgery

Andrew R. Jensen, MD, MBE; Abhinav K. Sharma, BS; Blake Formanek, BS; Christopher Wang, BS; Zorica Buser, PhD; Jeffrey C. Wang, MD; Frank A. Petrigliano, MD

Abstract

The purpose of this study was to assess trends in the use of perioperative single and continuous peripheral nerve blocks (PNBs) and their associations with emergency department (ED) visits after arthroscopic rotator cuff repair (RCR) surgery. The authors used a large database from a private insurer to identify patients who received perioperative PNBs for arthroscopic RCR surgeries from 2007 to 2015. They analyzed patient demographics as well as trends in perioperative PNB use. They also assessed rates of single shot vs continuous PNB use and compared rates of postoperative ED visits according to PNB type. The rate of perioperative PNB for arthroscopic RCR was higher than previously reported (65.9%) and increased over time (52.8% in 2007 to 64.6% in 2015; P=.029). Single shot PNBs were more common than continuous, catheter-mediated PNBs (60.0% vs 6.6%; P<.001), although the use of continuous blocks increased at a greater rate during the study period. Patients who received a perioperative continuous PNB were significantly more likely to visit an ED within 7 days of their surgery than those who received a single shot PNB or no PNB (6.71% vs 4.78% vs 4.74%; P<.02). The rates of ED visits within each group did not change significantly over time. Continuous PNBs are increasingly common for patients undergoing arthroscopic RCR surgery but are associated with increased rates of postoperative ED visits. Studies are needed to identify the reasons for this increased rate of ED visits and strategies to decrease ED use. [Orthopedics. 2020; 43(2): 127–131.]

Abstract

The purpose of this study was to assess trends in the use of perioperative single and continuous peripheral nerve blocks (PNBs) and their associations with emergency department (ED) visits after arthroscopic rotator cuff repair (RCR) surgery. The authors used a large database from a private insurer to identify patients who received perioperative PNBs for arthroscopic RCR surgeries from 2007 to 2015. They analyzed patient demographics as well as trends in perioperative PNB use. They also assessed rates of single shot vs continuous PNB use and compared rates of postoperative ED visits according to PNB type. The rate of perioperative PNB for arthroscopic RCR was higher than previously reported (65.9%) and increased over time (52.8% in 2007 to 64.6% in 2015; P=.029). Single shot PNBs were more common than continuous, catheter-mediated PNBs (60.0% vs 6.6%; P<.001), although the use of continuous blocks increased at a greater rate during the study period. Patients who received a perioperative continuous PNB were significantly more likely to visit an ED within 7 days of their surgery than those who received a single shot PNB or no PNB (6.71% vs 4.78% vs 4.74%; P<.02). The rates of ED visits within each group did not change significantly over time. Continuous PNBs are increasingly common for patients undergoing arthroscopic RCR surgery but are associated with increased rates of postoperative ED visits. Studies are needed to identify the reasons for this increased rate of ED visits and strategies to decrease ED use. [Orthopedics. 2020; 43(2): 127–131.]

Perioperative pain management following arthroscopic rotator cuff repair (RCR) surgery is increasingly recognized as a key factor in patient satisfaction and clinical outcomes.1–3 Inadequate pain control following RCR surgery has been identified as the most common reason for postoperative emergency department (ED) visits.4,5

Traditionally, pain following orthopedic surgery has been treated with oral medications, such as narcotics. These medications have significant side effect profiles, including the risk of addiction, and often are inadequate in treating postoperative pain.6 Peripheral nerve blocks (PNBs) have been increasingly used in the perioperative setting as an adjunct to decrease postoperative pain.7,8 One study found that, as of 2006, 23.9% of patients undergoing arthroscopic shoulder surgery received a perioperative PNB.7 Perioperative PNBs have been associated with improved postoperative pain control, decreased time in post-anesthesia care units, and increased patient satisfaction following arthroscopic shoulder surgery.9,10

In performing a PNB for shoulder surgery, local anesthetics are injected in close proximity to the brachial plexus, providing intraoperative and postoperative pain relief that can last for 24 to 72 hours.9 Peripheral nerve blocks may be administered as a single shot or as a continuous block via an indwelling catheter that remains inserted postoperatively until removed by the patient or the provider.11

It has been suggested that continuous PNBs allow for increased duration of analgesia compared with single shot PNBs.12 Although complications have been reported following PNBs, including hemidiaphragmatic paresis,13–16 persistent hiccups,17 and pneumothorax,11 both single shot and continuous PNBs have repeatedly been found to be safe procedures.11,13,18 Furthermore, continuous PNBs have been shown to have complication rates similar to those of single shot PNBs.11,12

Although previous studies have evaluated the rates of PNBs in general for shoulder surgery, the rates of single shot and continuous PNBs for arthroscopic RCR surgery are currently unknown. Similarly, the effect of these two procedures on the rates of postoperative ED visits has not previously been investigated.

Therefore, to better understand the changing use of single shot and continuous PNBs for arthroscopic RCR surgery, the authors analyzed trends in perioperative PNBs using a large patient database. They compared rates of single shot and continuous PNBs as well as rates of postoperative ED visits according to type of PNB. Due to the documented complication rates of single shot and continuous PNBs being similar, the authors hypothesized that there would be no difference in the rate of postoperative ED visits between patients receiving single shot and patients receiving continuous PNBs.

Materials and Methods

A retrospective review of the Pearl-Diver Patient Record Database (Pearl-Diver [ www.pearldiverinc.com], Warsaw, Indiana) was conducted. The database was queried to identify patients who had undergone arthroscopic RCR (Current Procedural Terminology [CPT] code 29827) from 2007 through 2015. PearlDiver is a commercially available database with orthopedic records compiled from the billing data of more than 76 million patients. Only patients from the private health insurance cohort were included in this analysis. All patient records are Health Insurance Portability and Accountability Act compliant and all data are de-identified.

This arthroscopic RCR patient cohort was then queried for the use of either a single injection to the brachial plexus (CPT 64415), a continuous injection with catheter placement to the brachial plexus (CPT 64416), a single or a continuous injection to the brachial plexus (CPT 64415 and/or 64416), or no injection to the brachial plexus (neither CPT 64415 nor 64416) on the day of surgery. From these data, the authors calculated the overall incidence of perioperative PNBs for arthroscopic RCR surgery. They also evaluated trends in PNB use over time. To assess for changes in the distribution of single shot and continuous PNBs over time, the authors calculated the annual percentages of PNBs that were single shot vs continuous and compared them.

The authors assessed demographic data (sex and geographic region) of patients who received PNBs. To determine whether surgery location affected rates of perioperative PNB use, they used billing location to compare the rates of PNBs for patients undergoing RCR performed in an outpatient hospital setting (service location 22) vs an ambulatory surgery center (ASC; service location 24).

Finally, to evaluate the effect of PNBs on perioperative ED visits, the authors queried the annual incidence of ED visits for each of the 4 patient groups. They compared these rates between groups and the trends over time. Data on ED visits were only available starting in 2011.

Statistical Analysis

The Student's two-sample t test was used to compare means between two groups, one-way analysis of variance was used to compare means from three or more groups, and the Mann–Kendall trend test was used to determine the significance of trends in data over time (StatPlus:mac; AnalystSoft Inc, Walnut, California). Statistical significance for all analyses was set at P<.05.

Results

From 2007 to 2015, a total of 41,356 RCRs were performed in the patient population. Overall, the authors found that 65.9% of these patients received a perioperative PNB. The rates of PNB use did not vary according to patient sex. There were minor geographic differences in the rates of PNBs for RCRs, with the lowest rates seen in the West region of the United States. Surgeries performed in ASCs were associated with higher rates of PNB use than those performed in the outpatient hospital setting (Table 1).

Rates of Perioperative Peripheral Nerve Blocks (Single Shot or Continuous) for Arthroscopic Rotator Cuff Repairs by Select Characteristics

Table 1:

Rates of Perioperative Peripheral Nerve Blocks (Single Shot or Continuous) for Arthroscopic Rotator Cuff Repairs by Select Characteristics

The percentage of patients receiving a perioperative PNB increased significantly over time, from 52.8% in 2007 to 64.6% in 2015 (P=.029; Figure 1). Single shot PNBs were approximately tenfold more commonly performed than continuous PNBs during the study period (60.0% vs 6.6%; P<.001). However, the percentage of PNBs that were continuous increased significantly over time, from 3.6% in 2007 to 11.7% in 2015 (P<.01; Figure 2).

Trend in the rates of peripheral nerve blocks (PNB) (single shot or continuous) used for arthroscopic rotator cuff repair surgery, 2007–2015. The increase in PNB use was statistically significant (P=.029).

Figure 1:

Trend in the rates of peripheral nerve blocks (PNB) (single shot or continuous) used for arthroscopic rotator cuff repair surgery, 2007–2015. The increase in PNB use was statistically significant (P=.029).

Trend in the percentage of peripheral nerve blocks (PNB) used for arthroscopic rotator cuff repair surgery that were continuous. The increase in continuous PNB use was significant (P=.009).

Figure 2:

Trend in the percentage of peripheral nerve blocks (PNB) used for arthroscopic rotator cuff repair surgery that were continuous. The increase in continuous PNB use was significant (P=.009).

Patients who received continuous PNBs had significantly higher rates of postoperative ED visits within 7 days of surgery compared with patients who received single shot PNBs or those who did not receive PNBs (Table 2). There was no difference in the rate of ED visits between patients who had no PNB and those who had a single shot PNB (Table 2).

Rates of Postoperative Emergency Department Visits Within 7 Days of Arthroscopic Rotator Cuff Repair Surgery According to Use of Perioperative Peripheral Nerve Block

Table 2:

Rates of Postoperative Emergency Department Visits Within 7 Days of Arthroscopic Rotator Cuff Repair Surgery According to Use of Perioperative Peripheral Nerve Block

The incidence of ED visits for the no PNB, single shot PNB, and continuous PNB groups did not change significantly over time (P>.05 for all 3 groups; Figure 3).

Trends in the rates of emergency department (ER) visits within 7 days following arthroscopic rotator cuff repair surgery according to peripheral nerve block (PNB) use. There was no significant change in emergency department visit rate for any of the 3 groups (P>.05 for all 3 groups).

Figure 3:

Trends in the rates of emergency department (ER) visits within 7 days following arthroscopic rotator cuff repair surgery according to peripheral nerve block (PNB) use. There was no significant change in emergency department visit rate for any of the 3 groups (P>.05 for all 3 groups).

Discussion

Pain control following arthroscopic RCR surgery is an important factor in patient outcomes and satisfaction1–3 and has been shown to be the most common reason for ED visits.4,5 Perioperative PNBs present an attractive option for postoperative pain control, and continuous PNBs have been found to be particularly promising due to longer duration of pain relief and the same complication rate as single shot PNBs.11,12 In this study, the authors analyzed the rates of single and continuous PNBs for patients undergoing arthroscopic RCR surgery in a large database of a private insurer. They found that continuous PNBs are increasing in frequency but are associated with a significantly higher rate of postoperative ED visits than either single shot PNBs or no PNB at all.

Perioperative PNBs for arthroscopic RCR surgery, whether single shot or continuous, are much more common than previously reported.8,19 More than 65% of the patients undergoing arthroscopic RCR in the authors' private insurance population received a perioperative PNB. In contrast, a study of the National Survey of Ambulatory Surgery indicated that the rate of perioperative PNBs for shoulder arthroscopies was 11.5% in 1996 and 23.9% in 2006.7 This survey involved self-reported information from Medicare-participating ASCs and hospitals across the United States.7 The discrepancy in PNB rates between this study and the current study partly reflects the increase in PNB use over time, as that study preceded the current study, and also differences in study design and patient populations. The current study was based on billing codes, which may be more accurate than self-reported information. Additionally, the current study only evaluated privately insured patients, and it is possible that there are lower rates of perioperative PNB use for Medicare patients compared with privately insured patients. Large differences exist between the rates at which privately insured patients and Medicare patients are prescribed postoperative physical therapy,20 for instance, and this may be true for other perioperative modalities, such as PNBs, as well.

Overall, there were no large demographic differences between the patients who did and did not receive a perioperative PNB. There were no differences in the rates of PNB use for RCR surgery according to sex. This is interesting in that a previous study, which evaluated rates of PNBs for patients undergoing total shoulder arthroplasty, found higher rates of PNBs for women compared with men.8 Regional variability in the incidence of PNB use did exist, but was small. The Western region had lower rates of PNB use than the South or Midwest. Ambulatory surgery centers were found to have greater rates of PNBs than hospitals, which likely reflects differences in anesthesia perioperative care practices in outpatient vs inpatient settings.

In this study, continuous PNBs were approximately 10 times less common than single shot PNBs. Although initially described in 1946, continuous PNBs have only been in use in the US ASC setting since 199812; therefore, it is perhaps not surprising that their use still lags behind that of single shot PNBs. Multiple recent studies have indicated that continuous PNBs result in improved analgesic time without an increase in complication rate compared with single shot PNBs.9,11,12,21 Accordingly, the percentage of PNBs that were continuous rose significantly over time in the current study. This likely indicates a growing familiarity and comfort with continuous PNBs and this increasingly supportive literature.

The most promising aspect of continuous PNBs is the longer period of analgesia following shoulder surgery compared with single shot PNBs.21 Knowing that pain is the most common presenting complaint for patients visiting the ED after arthroscopic RCR surgery, it is reasonable to hypothesize that continuous PNBs would lead to lower rates of ED visits than single shot and no PNBs. However, the current study found that the opposite was true. Patients who received continuous PNBs were significantly more likely to present to the ED within 7 days of surgery.

Few studies have evaluated ED visitation rates after continuous PNBs. In a large retrospective Canadian study of perioperative PNBs for inpatient total knee arthroplasty, a significant decrease in postoperative ED visits was found for patients who had received a continuous PNB.22 This study differed from the current study in many ways that may affect ED visitation, such as PNB location, in-patient vs outpatient surgery, and patient population. Additionally, as the average inpatient hospital stay after total knee arthroplasty was 4.6 days in that study, it is likely that many of the continuous PNB catheters had been removed prior to discharge from the hospital.

Identifying the reasons for this increased rate of ED visits among patients with continuous PNBs for RCR surgery is important for improving patient care and decreasing medical costs. Currently, $4.4 billion is spent annually in the United States on avoidable ED visits.23 In the current study, approximately 1 in 15 patients who received a continuous PNB visited an ED postoperatively, despite the improved analgesia associated with continuous PNBs. This finding presents an important opportunity to decrease costs associated with avoidable ED visits after arthroscopic shoulder surgery.

That multiple studies have demonstrated no differences in complication rates between single shot and continuous PNBs suggests that ED visits after continuous PNBs are not due to serious medical complications. Therefore, some possible explanations are that the visits may be due to rebound pain when the block ultimately wears off, difficulties or concerns with removing the catheter at home, catheter leakage, concerns about persistent numbness and lack of motor function, or inadvertent catheter removal. Many of these factors could potentially be addressed preoperatively with improved patient education. Studies are needed to determine the etiology of ED visits after continuous PNBs and to identify strategies to decrease them.

Limitations

This study had several limitations. First, only patients from a private health insurance cohort in the United States were analyzed, limiting external validity. Further, patient records in the database are not equally distributed across the United States; only 6.9% of the patient records were from the Northeast, which prevented accurate evaluation of this region. Additionally, although this study evaluated rates of postoperative ED visits according to PNB use, it was not designed to evaluate rates of post-procedural complications per se. Complications due to upper extremity PNBs remain a significant concern, although certain procedural interventions, such as the use of ultrasound guidance or the use of the interscalene as opposed to the supraclavicular PNB location, have been shown to decrease them.14,16,24 Finally, the current study was unable to control for certain variables, such as anesthesiologist experience, type of dressing or catheter used, or location of PNB, that may influence postoperative ED visitation rates.

Conclusion

This study indicated that PNBs for arthroscopic RCR surgery are used more frequently than previously reported and that their use continues to grow in the US privately insured population. Single shot PNBs are currently more common than continuous PNBs, but the use of the latter is becoming more frequent. Despite studies indicating no difference in complication rates between single shot and continuous PNBs, the current study suggests that continuous PNBs are associated with higher rates of postoperative ED visits. Given that continuous PNBs hold great promise in providing prolonged analgesia for patients following arthroscopic RCR surgery, future studies should evaluate the reasons for this increase in postoperative ED visits to identify opportunities for improved perioperative care delivery.

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Rates of Perioperative Peripheral Nerve Blocks (Single Shot or Continuous) for Arthroscopic Rotator Cuff Repairs by Select Characteristics

CharacteristicReceived Peripheral Nerve BlockP
Total65.9%
Sex.88
  Male66.2%
  Female65.6%
Geographic location.02
  Midwest67.9%
  South66.3%
  West59.5%
Surgical location.04
  Ambulatory surgery center70.7%
  Hospital63.7%

Rates of Postoperative Emergency Department Visits Within 7 Days of Arthroscopic Rotator Cuff Repair Surgery According to Use of Perioperative Peripheral Nerve Block

Peripheral Nerve BlockEmergency Department VisitsP
None4.74%
Single shot4.78%
Continuous6.71%<.02a
Authors

The authors are from the Department of Orthopaedic Surgery (ARJ, AKS, FAP), University of California, Los Angeles, and the Department of Orthopaedic Surgery (BF, CW, ZB, JCW), University of Southern California, Los Angeles, California.

Dr Jensen, Mr Sharma, Mr Formanek, Mr Wang, Dr Buser, and Dr Petrigliano have no relevant financial relationships to disclose. Dr Wang has private investments in Promethean Spine, Paradigm Spine, Benevenue, NexGen, Vertiflex, ElectroCore, Surgitech, Expanding Orthopaedics, Osprey, Bone Biologics, Curative Biosciences, and PearlDiver; receives royalties from Aesculap, Biomet, Amedica, Seaspine, and Synthes; and holds stock in Fziomed.

Correspondence should be addressed to: Andrew R. Jensen, MD, MBE, 1250 16th St, Ste 2100, Santa Monica, CA 90404 ( ajensen@mednet.ucla.edu).

Received: August 18, 2018
Accepted: January 14, 2019
Posted Online: December 16, 2019

10.3928/01477447-20191212-06

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