Impact of a tiered discharge opioid algorithm on prescriptions and patient-reported outcomes after open gynecologic surgery.
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ABSTRACT: Objective
To compare discharge opioid refills, prescribed morphine equivalent dose and quantity, and longitudinal patient-reported outcomes before and after implementation of a tiered opioid prescribing algorithm among women undergoing open gynecologic surgery within an enhanced recovery after surgery program.Methods
We compared opioid prescriptions, clinical outcomes, and patient-reported outcomes among 273 women. Post-discharge symptom burden was collected up to 42 days after discharge using the validated 27-item MD Anderson Symptom Inventory and analyzed using linear mixed effects models and Kaplan-Meier curves for symptom recovery.Results
Among 113 pre-implementation and 160 post-implementation patients there was no difference in opioid refills (9.7% vs 11.3%, p=0.84). The post-implementation cohort had a significant reduction in median morphine equivalent dose (112.5 mg vs 225 mg, p<0.01), with no difference in median hospital length of stay (3 days vs 3 days, p=1.0) or 30-day readmission rate (9.4% vs 7.1%, p=0.66). There was no difference in patient-reported pain between the pre- and post-implementation cohorts on the day of discharge (severity 4.93 vs 5.14, p=0.53) or in any patient-reported symptoms, interference measures, or composite scores by post-discharge day 7. The median recovery time for most symptoms was 7 days, except for pain (14 days), fatigue (18 days), and physical interference (21 days), with no differences between cohorts.Conclusions
After implementation of a tiered opioid prescribing algorithm, the quantity and dose of discharge opioids prescribed decreased with no change in post-operative refills and without negatively impacting patient-reported symptom burden or interference, which can be used to educate and reassure patients and providers.
SUBMITTER: Huepenbecker S
PROVIDER: S-EPMC8328052 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundLittle is known about the electronic collection and clinical feedback of patient-reported outcomes (ePROs) following surgical discharge. This systematic review summarized the evidence on the collection and uses of electronic systems to collect PROs after discharge from hospital after surgery.MethodSystematic searches of MEDLINE, Embase, PsycINFO, CINAHL and Cochrane Central were undertaken from database inception to July 2019 using terms for 'patient reported outcomes', 'electronic', 'surgery' and 'at home'. Primary research of all study designs was included if they used electronic systems to collect PRO data in adults after hospital discharge following surgery. Data were collected on the settings, patient groups and specialties, ePRO systems (including features and functions), PRO data collected, and integration with health records.ResultsFourteen studies were included from 9474 records, including two RCTs and six orthopaedic surgery studies. Most studies (9 of 14) used commercial ePRO systems. Six reported types of electronic device were used: tablets or other portable devices (3 studies), smartphones (2), combination of smartphones, tablets, portable devices and computers (1). Systems had limited features and functions such as real-time clinical feedback (6 studies) and messaging service for patients with care teams (3). No study described ePRO system integration with electronic health records to support clinical feedback.ConclusionThere is limited reporting of ePRO systems in the surgical literature, and ePRO systems lack integration with hospital clinical systems. Future research should describe the ePRO system and ePRO questionnaires used, and challenges encountered during the study, to support efficient upscaling of ePRO systems using tried and tested approaches.
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Project description:Purpose: Nonmedical use of prescription opioids continues to be a public health crisis in the United States that disproportionately affects rural communities with diversion of pills from friends and family being the most common source. The primary goal of the study was to identify current opioid prescription practices, and to assess the discrepancy in amount of opioids prescribed by surgeons versus the amount needed post-operatively by patients. Patient factors that may influence postoperative analgesia needs and their management of leftover prescription opioids were also evaluatedMethods: Patients ≥18 years-of-age who underwent a surgery between July and December 2018 by the subspecialty departments of Acute Care and General Surgery at a tertiary care facility in the rural Midwest were surveyed at their first post-operative visit to assess their postoperative analgesic needs. Resident and attending surgeons in the above departments were also surveyed to identify different factors that influenced their narcotic prescription practices.Results: Surveys from 252 patients, 12 attending surgeons, and 14 general surgery residents met inclusion criteria. Of patients who received a narcotic prescription, 19.9% did not fill their prescription, 64.1% of whom were >60 years old, and 72.1% resided within an hour of the hospital. Average reported prescription size was 11-40 pills; however, most used more than 5 pills regardless of the type of operation (P=0.59) and history of chronic pain (P=0.07). Inability to call in narcotic prescriptions and patients' distance from care influenced providers' prescription practices, with 77.9% of resident physicians and 68.3% of attending surgeons stating they would prescribe fewer if given the ability to call in a narcotic prescription.Conclusions: Regardless of the operation complexity, a majority of patients required fewer than five opioid pills after discharge and would be willing to return leftover pills. Development of opioid stewardship programs within the healthcare sector may reduce the number of opioids available for diversion and misuse.
| S-EPMC9242732 | biostudies-literature
Project description:Background Many patients use opioids for nonmalignant pain, and opioid use in the general population has been associated with poor long-term outcomes. The use of high-risk medications, including opioid analgesics, may increase the risk of unplanned healthcare utilization. Methods and Results We performed a nested evaluation in the VICS (Vanderbilt Inpatient Cohort Study) (N=3000) on patients with an admitting diagnosis of acute coronary syndrome and/or acute decompensated heart failure. Patient enrollment occurred from October 2011 until December 2015 and involved a single investigational site, Vanderbilt University Medical Center (Nashville, TN). Of the 2495 eligible patients, 501 (20%) were discharged with an opioid prescription and were predominantly white and men, with a median age of 59 (interquartile range, 53-67) years. Our primary outcome was unplanned healthcare utilization, which included emergency department presentation or readmission. Secondary outcomes included mortality and a composite of planned utilization behaviors: cardiac rehabilitation and provider follow-up within 30 days. Cox proportional hazards models did not show a statistically significant association with increased unplanned utilization (adjusted hazard ratio, 1.06; 95% CI, 0.87-1.28) or mortality (adjusted hazard ratio, 1.08; 95% CI , 0.84-1.39), compared with those without opioids at discharge. Patients discharged with opioids were less likely to complete planned healthcare utilization (adjusted odds ratio, 0.69; 95% CI , 0.52-0.91). Conclusions There are decreased odds of planned healthcare utilization among patients with acute coronary syndrome and acute decompensated heart failure discharged with opioid medication. It is imperative to understand how opioid use can affect a patient's relationship with the healthcare system.
| S-EPMC6405584 | biostudies-literature
Project description:BACKGROUND:Opioids and multimodal analgesia are widely administered to manage postoperative pain. However, little is known on how improvements in inpatient pain control are correlated with high-risk (> 90 daily OME) discharge opioid prescriptions for opioid naïve surgical patients. METHODS:We conducted a retrospective observational study of adult opioid-naïve patients undergoing surgery from June 2012 through December 2018 at a large academic medical center. We used multivariate logistic regression to assess whether multimodal analgesic drugs consumed in the 24 h prior to discharge was associated with a reduction in high-risk opioid discharge prescriptions. We identified other risk factors for receiving a high-risk discharge opioid prescription. RESULTS:Among the 32,511 patients, 83% of patients were discharged with an opioid prescription. In 2013, 34.1% of patients with a discharge opioid prescription received a high-risk prescription and this declined to 17.7% by 2018. Use of multimodal analgesic agents during the final 24 h of hospitalization increased each year, with over 80% receiving at least one multimodal analgesic agent by 2018. The median OME consumed in the 24 h prior to discharge peaked in 2013 at 31 and steadily decreased to 19.8 by 2018. There was a significant association between the use of acetaminophen in the 24 h prior to discharge and a high-risk prescription at discharge (p < 0.01). OMEs consumed in the 24 h prior to discharge was a significant predictor of receiving a high-risk discharge prescription, even at low doses. Other factors associated with receipt of a high-risk discharge opioid prescription included male gender, race, history of anxiety disorder, and discharge service. DISCUSSION:Use of multimodal analgesia regimens in hospitalized surgical patients in the 24 h prior to hospital discharge increased between 2012 and 2018. Simultaneously, opioid use prior to hospital discharge decreased. Despite these gains, approximately one in five discharge prescriptions was high-risk (> 90 daily OME). In addition, we found that prescribing of discharge opioids above inpatient opioid requirements remains common in opioid naive surgical patients. CONCLUSION:Providers should account for pre-discharge opioid consumption and use of multimodal analgesia when considering the total and daily OME's that may be appropriate for an individual surgical patient on the discharge opioid prescription.
| S-EPMC8672612 | biostudies-literature
Project description:ObjectiveTo compare outcomes after surgery between patients who were not prescribed opioids and patients who were prescribed opioids.Summary of background dataPostoperative opioid prescriptions carry significant risks. Understanding outcomes among patients who receive no opioids after surgery may inform efforts to reduce these risks.MethodsWe performed a retrospective study of adult patients who underwent surgery between January 1, 2019 and October 31, 2019. The primary outcome was the composite incidence of an emergency department visit, readmission, or reoperation within 30 days of surgery. Secondary outcomes were postoperative pain, satisfaction, quality of life, and regret collected via postoperative survey. A multilevel, mixed-effects logistic regression was performed to evaluate differences between groups.ResultsIn a cohort of 22,345 patients, mean age (standard deviation) was 52.1 (16.5) years and 13,269 (59.4%) patients were female. About 3175 (14.2%) patients were not prescribed opioids, of whom 422 (13.3%) met the composite adverse event endpoint compared to 2255 (11.8%) of patients not prescribed opioids ( P = 0.015). Patients not prescribed opioids had a similar probability of adverse events {11.7% [95% confidence interval (CI) 10.2%-13.2%] vs 11.9% (95% CI 10.6%-13.3%]}. Among 12,872 survey respondents, patients who were not prescribed an opioid had a similar rate of high satisfaction [81.7% (95% CI 77.3%-86.1%) vs 81.7% (95% CI 77.7%- 85.7%)] and no regret [(93.0% (95% CI 90.8%-95.2%) vs 92.6% (95% CI 90.4%-94.7%)].ConclusionsPatients who were not prescribed opioids after surgery had similar clinical and patient-reported outcomes as patients who were prescribed opioids. This suggests that minimizing opioids as part of routine postoperative care is unlikely to adversely affect patients.
| S-EPMC8787466 | biostudies-literature
Project description:Importance:In 2014, the US Drug Enforcement Administration moved hydrocodone-containing analgesics from schedule III to the more restrictive schedule II to limit prescribing and decrease nonmedical opioid use. The association of this policy change with postoperative prescribing is not well understood. Objective:To examine the hypothesis that the amount of opioids prescribed following surgery is associated with the rescheduling of hydrocodone. Design, Setting, and Participants:An interrupted time series analysis of outpatient opioid prescriptions was conducted to examine the trends in the amount of postoperative opioids filled before and after the schedule change. Opioid prescriptions filled between January 2012 and October 2015 were analyzed using insurance claims data from the Michigan Value Collaborative, which includes data from 75 hospitals across Michigan. A total of 21 955 adult inpatients 18 to 64 years of age who underwent 1 of 19 common elective surgical procedures and filled an opioid prescription within 14 days of discharge to home were eligible for inclusion. Main Outcomes and Measures:The primary outcome was the trends in the mean amount of opioids filled in oral morphine equivalents (OMEs) for the initial postoperative prescriptions before and after the schedule change date of October 6, 2014, compared using interrupted time series and multivariable regression analyses. Secondary outcomes included the total amount of opioids filled and the refill rate for the 30-day postoperative period. Subgroup analyses were performed by hydrocodone prescriptions, nonhydrocodone prescriptions, surgical procedure, and prior opioid use. Results:Data from 21 955 patients undergoing surgical procedures across 75 hospitals and 5120 prescribers were analyzed. Cohorts before and after the schedule change were equivalent with respect to sex (10 197 of 15 791 [64.6%] vs 3966 of 6169 [64.3%] female; P = .69) and mean (SE) age (47.9 [11.2] vs 47.7 [11.3] years; P = .19). After the schedule change, the mean OMEs filled in the initial opioid prescription increased by approximately 35 OMEs (β = 35.1 [13.2]; P < .01), equivalent to 7 tablets of hydrocodone (5 mg). There were no significant differences in the total OMEs filled during the 30-day postoperative period before and after the schedule change (β = 18.3 [30.5]; P = .55), but there was a significant decrease in the refill rate (β = -5.2% [1.3%]; P < .001). Conclusions and Relevance:Changing hydrocodone from schedule III to schedule II was associated with an increase in the amount of opioids filled in the initial prescription following surgery. Opioid-related policies require close follow-up to identify and address early unintended effects given the multitude of competing factors that influence health care professional prescribing behaviors.
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Project description:BackgroundOpioid addiction is endemic in the United States. We developed a standardized opioid-prescribing schedule (SOPS) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and evaluated opioid usage alongside Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference scores. We hypothesized that opioid usage would be less than prescribed and reducing prescription would decrease consumption without negatively impacting the PROMIS scores.MethodsA prospective observational study was performed on all patients undergoing primary THA and TKA from April 7, 2018, to August 10, 2019. Opioid consumption and pain interference were determined 2 weeks after discharge via telephone and email surveys. SOPSs were implemented during the study. Outcomes were compared in patients before and after the SOPS.ResultsA total of 715 patients met inclusion criteria; 201 patients completed surveys. Before the SOPS, the mean opioid prescription was 81.2 ± 15.3 tablets for THA and 82.9 ± 10.6 for TKA. The mean usage was 35.1 ± 29.4 tablets and 35.4 ± 33.4, respectively. After the SOPS, the mean usage decreased to 19.4 ± 16.8 (P = .04) and 31.6 ± 20.9 (P = .52), respectively. After implementation of a second SOPS for THA, the mean number of tablets consumed was 21.5 ± 18.6 (P = .05 compared with pre-SOPS). The PROMIS 6B responses in patients who underwent THA demonstrated no significant changes. PROMIS 6B responses for TKA showed an increase in interference with recreational activities (P = .04) and tasks away from home (P = .04), but otherwise had no significant impact on reported scores.ConclusionsImplementation of the SOPS reduced postoperative opioid prescription and consumption without significantly impacting the reported pain interference, supporting the need to decrease opioid prescription after THA and TKA.
| S-EPMC7653012 | biostudies-literature
Project description:BackgroundRecent literature suggests that state-level legislation is effective in reducing postoperative opioid prescribing after total joint arthroplasty but has not addressed the effect on opioid antagonist coprescribing. This study aims to describe the change in postoperative opioid and opioid antagonist prescribing patterns after total joint arthroplasty following passage of state-level opioid-limiting legislation and to determine the comorbidities associated with increased opioid prescribing in this population.MethodsBilling data were used to identify all patients who underwent primary total hip or knee arthroplasty admitted between March 2016 and March 2018 at our institution. The data were divided into 2 cohorts comprising the year before (671 subjects) and after (713 subjects) the legislation. Discharge prescriptions were reviewed, and the median morphine milligram equivalents (MME) per day and naloxone prescriptions were recorded. International Classification of Diseases codes were used to identify comorbid conditions of interest present during previous inpatient or outpatient encounters.ResultsThere was a significant reduction in both the minimum and maximum median MME per day after introduction of state legislation and a substantial increase in opioid antagonist coprescription. Total knee arthroplasty, younger age, male sex, chronic pain disorders, post-traumatic stress disorder, and prior opioid abuse were correlated with increased opioid prescribing.ConclusionOur findings suggest that state-level legislation is effective in decreasing the MME per day prescribed and increasing opioid antagonist coprescription in the postoperative period for patients undergoing total hip and knee arthroplasties at our institution. These changes may lead to a decrease in opioid-related morbidity and mortality in the patient population undergoing total hip and knee arthroplasties.
| S-EPMC7593266 | biostudies-literature
Project description:BackgroundOverprescribing of opioids after surgery contributes to long-term abuse. Evaluating opioid prescription patterns and patient-reported opioid use offers an evidence-based method to identify potential overprescription. This quality improvement initiative aimed to reduce and standardize opioid prescriptions upon discharge from an ambulatory oncologic surgery center and evaluate the effect of this change on patients' subsequent opioid use and reported pain.MethodsBetween March 2018 and January 2019, consecutive opioid-naïve patients aged ≥ 18 years who underwent robotic or laparoscopic hysterectomy, radical prostatectomy, or partial nephrectomy, or total mastectomy with or without immediate reconstruction were surveyed 7-10 days postoperatively. Data collected in the pre- (n = 551) and post-standardization (n = 480) cohorts included perception of pain relief, opioids prescribed (verified by electronic medical record review) and consumed, and refills received.ResultsPre-standardization, the median opioid prescription at discharge was 20 pills (interquartile range [IQR] 20-28) or 140 oral morphine milligram equivalents (MME) (IQR 100-150). Median opioid consumption was 2 pills (IQR 0-7) or 10 MME (IQR 0-40) among all services. Opioid prescriptions were later standardized to 7, 8, and 10 pills (35, 40, and 75 MME), in the gynecology, urology, and breast services, respectively. The change was not associated with an increase in reported pain. Refill requests increased postintervention across all surgeries from 4.4% to 7.7%, with the largest increase among patients who underwent breast surgery.ConclusionThe number of opioid pills given at discharge to patients undergoing ambulatory or short-stay cancer surgery can safely be reduced.
| S-EPMC8290876 | biostudies-literature
Project description:ObjectiveTo evaluate the feasibility of an electronic symptom-tracking platform for patients recovering from ambulatory surgery.MethodWe assessed user response to an electronic system designed to self-report symptoms. Endpoints included compliance, postoperative symptoms, patient satisfaction. An 8-item symptom inventory (pain, nausea, vomiting, shortness of breath, fever, swelling, discharge, redness) was developed and made available on postoperative days (POD) 2-6. Responses exceeding defined thresholds of severity triggered alerts to healthcare providers. Symptoms, alerts, actions taken, urgent care center (UCC) visits, hospital admissions were tracked until POD 30. Patient satisfaction was evaluated on POD 7. A patient was defined as "responder" if at least 5/8 items on at least 3 PODs were completed. The assessment method was deemed successful if 64/100 patients responded.Results97/102 patients were evaluable; 65 met "responder" criteria (67% responder rate; 95% CI 57-76%). 321 surveys were completed (median 4/patient), 248 (77%) in ≤2 min. Involving caregivers and allowing additional symptom-reporting improved the responder rate to 72% (95% CI 58-84%). Most commonly-reported moderate, severe, very severe symptoms were pain, nausea, swelling; 71% reported moderate to very severe pain on POD 2. Phone calls and adjustment of medications adequately addressed most symptoms. Two patients (2%) presented at UCC before, 6 (6%) after, POD 6; 1 (1%) was admitted. Most agreed or strongly agreed that electronic symptom-tracking was helpful, easy to use, and would recommend it to others.ConclusionElectronic symptom-tracking is feasible for patients undergoing ambulatory gynecologic cancer surgery. Symptom burden is high in the early postoperative period. Addressing patient-reported symptoms in a timely, automated manner may prevent severe downstream adverse events, reduce UCC visits and admission rates, and improve outcomes.
| S-EPMC7380930 | biostudies-literature