The Perioperative Use of Benzodiazepines for Major Orthopedic Surgery in the United States
Authors: Cozowicz Crispiana , Zhong Haoyan , Illescas Alex , Athanassoglou Vassilis , Poeran Jashvant , Reichel Julia Frederica , Poultsides Lazaros A. , Liu Jiabin , Memtsoudis Stavros G. 
Published: February 2022

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.