No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Post-Discharge Pain Management After Thoracic Surgery – A Patient-Centered Approach
Abstract
Background
Postoperative analgesia is paramount to recovery following thoracic surgery, and opioids play an invaluable role in this process. Yet, current one-size-fits-all prescribing practices produce large quantities of unused opioids, increasing the risk of nonmedical use and overdose. Here, we hypothesized that patient and perioperative characteristics, including 24-hour before discharge opioid intake, could inform more appropriate post-discharge prescriptions after thoracic surgery.
Methods
We conducted a prospective observational cohort study in 200 adult thoracic surgery patients. The cohort was divided into three groups based on 24-hour before discharge opioid intake in morphine milligram equivalents (MME): 1) no (0 MME), 2) low (>0 ≤112.5 MME), or 3) high (>112.5 MME) before discharge opioid intake. Logistic regression was used to analyze the association of patient and perioperative characteristics with self-reported after discharge opioid use.
Results
Univariate analysis showed preoperative opioid use, 24-hour before discharge acetaminophen and gabapentinoid intake, and 24-hour before discharge opioid intake were associated with higher after discharge opioid use. Multivariable modeling demonstrated that 24-hour prior to discharge opioid intake was most significantly associated with after discharge opioid use. For example, compared to patients who took high amounts of opioids prior to discharge, patients who took no opioids prior to discharge were 99% less likely to take a high amount of opioids after discharge compared to taking none (OR 0.011; 95% CI 0.003-0.047; P<0.0001).
Conclusions
Assessment of 24-hour before discharge opioid intake may inform patient requirements after discharge. Opioid prescriptions after thoracic surgery can thereby be targeted based on anticipated needs.
... Among other factors, in-hospital opioid intake before discharge is a reliable predictor for opioid intake after discharge. [11][12][13][14] The choice and dose of opioid prescriptions after surgery is nonetheless often driven by local practice conventions rather than patient-specific considerations. 4,[12][13][14] In an effort to change opioid prescribing practices at discharge to reflect anticipated individual needs, we embedded a decision-support tool into electronic health records. ...
... Our previous work in three diverse samples of surgical procedures found that among available predictor variables that could be incorporated into an electronic decision-support tool, 24-h predischarge opioid intake was most associated with patient-reported postdischarge opioid intake. [11][12][13] Consistent with these findings, guidelines recommend a tiered approach to opioid prescription by categorizing in-hospital opioid intake on the day before discharge: (1) no opioids, (2) more than 0 to 22.5 milligram morphine equivalents (equivalent to three oxycodone 5-mg tablets), or (3) more than 22.5 milligram morphine equivalents. 18 Centered on these findings and with local stakeholder input, we developed a best practice alert algorithm for commonly prescribed opioids based on previous day inpatient opioid intake (table 1). ...
Background:
Over-prescription of opioids after surgery remains common. Residual and unnecessarily prescribed opioids can provide a reservoir for nonmedical use. We therefore tested the hypothesis that a decision-support tool embedded in electronic health records guides clinicians to prescribe fewer opioids at discharge after inpatient surgery.
Methods:
We studied 21,689 surgical inpatient discharges in a cluster randomized multiple crossover trial from July 2020 to June 2021 in four Colorado hospitals. Hospital-level clusters were randomized to alternating eight-week periods during which an electronic decision-support tool recommended tailored discharge opioid prescriptions based on prior inpatient opioid intake. During active alert periods, the alert was displayed to clinicians when the proposed opioid prescription exceeded recommended amounts. No alerts were displayed during inactive periods. Carryover effects were mitigated by including 4-week washout periods. The primary outcome was oral morphine milligram equivalents prescribed at discharge. Secondary outcomes included combination opioid/non-opioid prescriptions and additional opioid prescriptions until day 28 after discharge. A vigorous state-wide opioid education and awareness campaign was in place during the trial.
Results:
The total postdischarge opioid prescription was a median [quartiles] of 75 [0, 225] oral morphine milligram equivalents among 11,003 patients discharged when the alerts were active and 100 [0, 225] morphine milligram equivalents in 10,686 patients when the alerts were inactive, with an estimated ratio of geometric means of 0.95 (95% CI: 0.80, 1.13; P = 0.586). The alert was displayed in 28% (3,074/11,003) of the discharges during the active alert period. There was no relationship between the alert and prescribed opioid/non-opioid combination medications or additional opioid prescriptions written after discharge.
Conclusions:
A decision-support tool incorporated into electronic medical records did not reduce discharge opioid prescribing for postoperative patients in the context of vigorous opioid education and awareness efforts. Opioid prescribing alerts might yet be valuable in other contexts.Registered at ClinicalTrials.gov (NCT04446975).
... It was this successful collaboration that launched Dr. Bartels' career as an independent clinical researcher. Over the next 5 years, Dr. Bartels and his colleagues went on to describe the effects of opioids and other predictors, including neuromuscular blockade reversal agents, on adverse outcomes after surgery with the work published in high-impact journals such as the Annals of Thoracic Surgery, 6 British Journal of Anaesthesia, 7 Anesthesiology, 8 JAMA Surgery, 9 and Anesthesia & Analgesia. [10][11][12] Moreover, his work 13 was rapidly integrated into guidelines, including the 2022 Centers for Disease Control and Prevention Clinical Practice Guideline for Prescribing Opioids for Pain. ...
Previous work has shown that predischarge opioid use is the most reliable and practical predictor of postdischarge opioid intake after inpatient surgery. However, the most appropriate predischarge time frame for operationalizing this relationship into more individualized prescriptions is unknown. We compared the correlations between the quantity of opioids taken during 5 predischarge time frames and self-reported postdischarge opioid intake in 604 adult surgery patients. We found that the 24-hour predischarge time frame was most strongly correlated (ρ= 0.60, P < .001) with postdischarge opioid use and may provide actionable information for predicting opioid use after discharge.
Purpose:
The aim of this study was to define a threshold of minimal clinically important improvement (MCII) for interpreting patient condition following video-assisted thoracoscopic surgery (VATS).
Methods:
Patients undergoing VATS were recruited for this multicenter, prospective, observational cohort study. Symptoms were measured using the MD Anderson Symptom Inventory-Lung Cancer Module perioperatively. To define MCIIs, we first identified index symptoms, defined as the most severe symptoms showing the largest reduction from day 1 post-surgery to discharge. MCIIs for each index symptom were then obtained via an anchor-based approach. Symptom recovery was defined as an MCII after post-surgery day 1. Cox regression models were used to identify risk factors for unrecovered index symptoms.
Results:
Using 366 patients, we identified pain and fatigue as index symptoms after VATS. MCII was defined as a 30% reduction in pain or fatigue. At discharge, 22.6% of patients had not recovered from pain and 22.4% had not recovered from fatigue. Cox models found that risk factors for unrecovered pain were Charlson Comorbidity Index score ≥1 (hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.04-1.77; p = 0.02) and preoperative neoadjuvant therapy (HR 2.78, 95% CI 1.13-6.83; p = 0.02). Malignancy was a risk factor for unrecovered fatigue (HR 1.47, 95% CI 1.02-2.13; p = 0.04).
Conclusion:
Pain and fatigue can be used as index measures for symptom recovery in patients following VATS. A 30% MCII represented meaningful recovery after VATS and could identify patients who may need extensive care after discharge.
The United States is enduring a preventable opioid crisis, particularly involving a population being treated in a hospital setting, a subset of whom may escalate to illicit opioids. This project analyzed trends in distribution of opioids by hospitals in the United States. Opioids monitored included buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, powdered opium, remifentanil, and tapentadol. The Automation of Reports and Consolidated Orders System (ARCOS) reports controlled substances via the Drug Enforcement Administration (DEA). National data from ARCOS reports 5 and 7 from 2000 to 2019 were utilized for an observational study on hospital opioid distribution. Morphine milligram equivalents (MME) were calculated using oral conversion factors. The MME per person per state was calculated to compare data from the peak year, 2012, to data from 2019. Opioid use peaked in 2012 with a -46.6% decline from 2012 to 2019. Half (25) of states have seen a decrease of -50% or greater. Of the opioid compounds observed, buprenorphine has seen increased (+122.5%) hospital use from 2012 to 2019. All other opioids have been experiencing a decline (>50%), particularly hydromorphone (-49.9%), oxymorphone (-57.7%), methadone (-58.7%), morphine (-66.9%), codeine (-67.5%), and meperidine (-77.6%). There was a six-fold difference in population corrected use of opioids in 2019 between the lowest (6.8 MME/person in New Jersey) and highest (Alaska = 39.6) states. This study demonstrates the considerable progress made thus far by hospitals in curbing the US opioid crisis.
Background
The effects of video-assisted thoracoscopic surgery (VATS) and traditional thoracotomy with respect to patient-reported outcomes (PROs) have only been assessed for early-stage lung cancer. This study was a longitudinal PRO assessment to compare the effects of these surgeries for locally advanced (stage II and III) lung cancer from the patients’ perspective.Methods
We investigated lung cancer patients from a previous prospective, multicentre study. Longitudinal data of clinical characteristics and PROs were collected. PROs were obtained preoperatively, daily in the hospital postoperatively, and weekly up to 4 weeks after discharge or the beginning of postoperative adjuvant therapy. Symptoms and impact on daily functioning and quality of life (QOL) were assessed by using the MD Anderson Symptom Inventory for lung cancer and a single-item QOL scale. Trajectories of PROs over the investigation period were compared.ResultsOverall, 117 primary lung cancer patients (stage II or III), including 63 and 54 patients who underwent VATS and traditional thoracotomy, respectively, were included. During postoperative hospitalization, VATS patients reported milder disturbed sleep (p = 0.048), drowsiness (p = 0.008), and interference with activity (p = 0.001), as well as better work ability (p < 0.0001), walking ability (p < 0.0001), and life enjoyment (p = 0.004). Post-discharge, VATS patients had less distress (p = 0.039), milder pain (p = 0.006), better work ability (p = 0.001), and better QOL (p = 0.047).Conclusions
Locally advanced lung cancer patients who underwent VATS had lower postoperative symptom burden, less daily function interference, and better QOL than those who underwent thoracotomy.
Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September, 2004, with methodologists, researchers, and journal editors to draft a che-cklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed explanation and elaboration document is published separately and is freely available on the websites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE statement will contribute to improving the quality of reporting of observational studies.
There is an epidemic of opioid abuse. This article discusses the history of opioid use. Abusers of opioids are at great risk of harm. There have been increasing legislative efforts to curb this abuse and we present a review of the current state of these laws. Naloxone has made a profound impact in the care of these patients if they present for medical care early enough. This paper discusses naloxone pharmacodynamics, its use in the medical setting, and how its use is now being expanded to include nontraditional providers with take home naloxone programs.
Unlabelled:
Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence.
Perspective:
This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations.
To describe rates and risk factors for prolonged postoperative use of opioids in patients who had not previously used opioids and undergoing major elective surgery.
Population based retrospective cohort study.
Acute care hospitals in Ontario, Canada, between 1 April 2003 and 31 March 2010.
39 140 opioid naïve patients aged 66 years or older who had major elective surgery, including cardiac, intrathoracic, intra-abdominal, and pelvic procedures.
Prolonged opioid use after discharge, as defined by ongoing outpatient prescriptions for opioids for more than 90 days after surgery.
Of the 39 140 patients in the entire cohort, 49.2% (n=19 256) were discharged from hospital with an opioid prescription, and 3.1% (n=1229) continued to receive opioids for more than 90 days after surgery. Following risk adjustment with multivariable logistic regression modelling, patient related factors associated with significantly higher risks of prolonged opioid use included younger age, lower household income, specific comorbidities (diabetes, heart failure, pulmonary disease), and use of specific drugs preoperatively (benzodiazepines, selective serotonin reuptake inhibitors, angiotensin converting enzyme inhibitors). The type of surgical procedure was also highly associated with prolonged opioid use. Compared with open radical prostatectomies, both open and minimally invasive thoracic procedures were associated with significantly higher risks (odds ratio 2.58, 95% confidence interval 2.03 to 3.28 and 1.95 1.36 to 2.78, respectively). Conversely, open and minimally invasive major gynaecological procedures were associated with significantly lower risks (0.73, 0.55 to 0.98 and 0.45, 0.33 to 0.62, respectively).
Approximately 3% of previously opioid naïve patients continued to use opioids for more than 90 days after major elective surgery. Specific patient and surgical characteristics were associated with the development of prolonged postoperative use of opioids. Our findings can help better inform understanding about the long term risks of opioid treatment for acute postoperative pain and define patient subgroups that warrant interventions to prevent progression to prolonged postoperative opioid use.
Objectives To determine the prevalence of medical and nonmedical use of prescription opioids among high school seniors in the United States and to assess substance use behaviors based on medical and nonmedical use of prescription opioids.
Design Nationally representative samples of high school seniors (modal age 18 years) were surveyed during the spring of their senior year via self-administered questionnaires.
Setting Data were collected in public and private high schools.
Participants The sample consisted of 7374 students from 3 independent cohorts (2007, 2008, and 2009).
Outcome Measures Self-reports of medical and nonmedical use of prescription opioids and other substance use.
Results An estimated 17.6% of high school seniors reported lifetime medical use of prescription opioids, while 12.9% reported nonmedical use of prescription opioids. Sex differences in the medical and nonmedical use were minimal, while racial/ethnic differences were extensive. More than 37% of nonmedical users reported intranasal administration of prescription opioids. An estimated 80% of nonmedical users with an earlier history of medical use had obtained prescription opioids from a prescription they had previously. The odds of substance use behaviors were greater among individuals who reported any history of nonmedical use of prescription opioids relative to those who reported medical use only.
Conclusions Nearly 1 in every 4 high school seniors in the United States has ever had some exposure to prescription opioids either medically or nonmedically. The quantity of prescription opioids and number of refills prescribed to adolescents should be carefully considered and closely monitored to reduce subsequent nonmedical use of leftover medication.
G*Power is a free power analysis program for a variety of statistical tests. We present extensions and improvements of the version introduced by Faul, Erdfelder, Lang, and Buchner (2007) in the domain of correlation and regression analyses. In the new version, we have added procedures to analyze the power of tests based on (1) single-sample tetrachoric correlations, (2) comparisons of dependent correlations, (3) bivariate linear regression, (4) multiple linear regression based on the random predictor model, (5) logistic regression, and (6) Poisson regression. We describe these new features and provide a brief introduction to their scope and handling.
Background:
New persistent opioid use occurs in 3% to 14% of patients after elective surgery, but is poorly described after cardiothoracic surgery. We examined the association of prescription size with new persistent opioid use after cardiothoracic surgery.
Methods:
Opioid-naive Medicare patients undergoing cardiothoracic surgery between 2009 and 2015 were identified. Patients who filled an opioid prescription between 30 days before surgery and 14 days after discharge and with continuous Medicare enrollment 12 months before and 6 months after surgery were selected (n = 24,549). New persistent use was defined as continued prescription fills 91 to 180 days after surgery. Prescription size was reported in oral morphine equivalents. Multivariable regression was performed for risk adjustment, and new persistent use rate was estimated.
Results:
Patient age was 71 ± 8 years, 9222 (38%) were female, and 20,898 (85%) were white. Overall new persistent use was 12.8% (3153 of 24,549), and declined yearly from 17% in 2009 to 7.1% in 2015 (P < .001). Prescription size, preoperative prescription fills, black race, gastrointestinal complications, disability status, open lung resection, dual eligibility (Medicare and Medicaid), drug and substance abuse, female sex, tobacco use, high comorbidity, pain disorders, longer hospital stay, and younger age were associated with new persistent use. Adjusted new persistent use was 19.6% (95% confidence interval, 18.7% to 20.4%) among patients prescribed more than 450 oral morphine equivalents, compared with 10.4% (95% confidence interval, 9.9% to 10.8%) among those prescribed 200 oral morphine equivalents or less (P < .001).
Conclusions:
Size and timing of perioperative opioid prescriptions were the strongest predictors of new persistent opioid use after cardiothoracic surgery. Modifiable risk factors such as prescription size should be targeted to reduce new persistent use.
Background:
Opioid dependence, misuse, and abuse in the United States continue to rise. Prior studies indicate an important risk factor for persistent opioid use includes elective surgical procedures, though the probability following thoracic procedures remains unknown. We analyzed the incidence and factors associated with new persistent opioid use after lung resection.
Methods:
We evaluated data from opioid-naïve cancer patients undergoing lung resection between 2010 and 2014 using insurance claims from the Truven Health MarketScan Databases. New persistent opioid usage was defined as continued opioid prescription fills between 90 and 180 days following surgery. Variables with a p value less than 0.10 by univariate analysis were included in a multivariable logistic regression performed for risk adjustment. Multivariable results were each reported with odds ratio (OR) and confidence interval (CI).
Results:
A total of 3,026 patients (44.8% men, 55.2% women) were identified as opioid-naïve undergoing lung resection. Mean age was 64 ± 11 years and mean postoperative length of stay was 5.2 ± 3.3 days. A total of 6.5% underwent neoadjuvant therapy, while 21.7% underwent adjuvant therapy. Among opioid-naïve patients, 14% continued to fill opioid prescriptions following lung resection. Multivariable analysis showed that age less than or equal to 64 years (OR, 1.28; 95% CI, 1.03 to 1.59; p = 0.028), male sex (OR, 1.40; 95% CI, 1.13 to 1.73; p = 0.002), postoperative length of stay (OR, 1.32; 95% CI, 1.05 to 1.65; p = 0.016), thoracotomy (OR, 1.58; 95% CI, 1.24 to 2.02; p < 0.001), and adjuvant therapy (OR, 2.19; 95% CI, 1.75 to 2.75; p < 0.001) were independent risk factors for persistent opioid usage.
Conclusions:
The greatest risk factors for persistent opioid use (14%) following lung resection were adjuvant therapy and thoracotomy. Future studies should focus on reducing excess prescribing, perioperative patient education, and safe opioid disposal.
Background:
There is a paucity of data to inform appropriate opioid prescribing for patients who are discharged after a hospital admission for a surgical procedure.
Study design:
We studied 333 inpatients discharged to home after bariatric, benign foregut, liver, pancreas, ventral hernia, and colon surgery. Chronic opioid users or patients who had complications were excluded. Home opioid usage was quantified in 90% of the remaining patients by questionnaires and phone surveys.
Results:
Eighty-five percent of patients were prescribed an opioid and 38% of prescribed opioid pills were taken. Fifteen opioid pills satisfied the opioid needs of 88% of patients discharged on postoperative day (POD) 1. For patients discharged after POD 1, in multivariate analysis, the number of opioid pills used at home was associated with the number taken the day before discharge (p < 0.0001) and patient age (p = 0.006), but not the type of surgery. Forty-one percent of patients took no opioids the day before discharge, 33% took 1 to 3, and 26% took more than 4 pills. Eighty-five percent of patients' home opioid requirements would be satisfied using the following guideline: if no opioid pills are taken the day before discharge, no prescription is needed; if 1 to 3 opioid pills are taken the day before discharge, then a prescription for 15 opioid pills is given at discharge; and if 4 or more pills are taken the day before discharge, then a prescription for 30 opioid pills is given at discharge. If these guidelines were used, the number of opioid pills prescribed would decrease by 40%.
Conclusions:
For patients admitted after surgical procedures, post-discharge opioid use is best predicted by usage the day before discharge. Use of this guideline could decrease opioid prescriptions substantially and effectively treat patients' pain.
Importance
Prescription opioid analgesics play an important role in the treatment of postoperative pain; however, unused opioids may be diverted for nonmedical use and contribute to opioid-related injuries and deaths.
Objective
To quantify how commonly postoperative prescription opioids are unused, why they remain unused, and what practices are followed regarding their storage and disposal.
Evidence Review
MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched from database inception to October 18, 2016, for studies describing opioid oversupply for adults after a surgical procedure. The primary outcome—opioid oversupply—was defined as the number of patients with either filled but unused opioid prescriptions or unfilled opioid prescriptions. Two reviewers independently screened studies for inclusion, extracted data, and assessed the study quality.
Findings
Six eligible studies reported on a total of 810 unique patients (range, 30-250 patients) who underwent 7 different types of surgical procedures. Across the 6 studies, 67% to 92% of patients reported unused opioids. Of all the opioid tablets obtained by surgical patients, 42% to 71% went unused. Most patients stopped or used no opioids owing to adequate pain control, and 16% to 29% of patients reported opioid-induced adverse effects. In 2 studies examining storage safety, 73% to 77% of patients reported that their prescription opioids were not stored in locked containers. All studies reported low rates of anticipated or actual disposal, but no study reported US Food and Drug Administration–recommended disposal methods in more than 9% of patients.
Conclusions and Relevance
Postoperative prescription opioids often go unused, unlocked, and undisposed, suggesting an important reservoir of opioids contributing to nonmedical use of these products, which could cause injuries or even deaths.
Perspective:
This study shows that characteristics of the first opioid prescription, particularly duration of the prescription, are significant predictors of continued opioid use irrespective of the indication for an opioid prescription. These data should encourage prescribers to initiate patients on the minimum effective opioid dose and duration to reduce unintended long-term use and could motivate policies that restrict the initial supply of opioids.
Objective:
To assess whether a shared decision-making intervention decreases the quantity of oxycodone tablets prescribed after cesarean delivery.
Technique:
A tablet computer-based decision aid formed the basis of a shared decision-making session to guide opioid prescribing after cesarean delivery. Women first received information on typical trajectories of pain resolution and expected opioid use after cesarean delivery and then chose the number of tablets of 5 mg oxycodone they would be prescribed up to the institutional standard prescription of 40 tablets.
Experience:
From April 11, 2016, to June 10, 2016, 105 women were screened, 75 were eligible, and 51 consented to participate; one patient was excluded after enrollment as a result of prolonged hospitalization. The median number of tablets (5 mg oxycodone) women chose for their prescription was 20.0 (interquartile range 15.0-25.0), which was less than the standard 40-tablet prescription (P<.001).
Conclusion:
A shared decision-making approach to opioid prescribing after cesarean delivery was associated with approximately a 50% decrease in the number of opioids prescribed postoperatively in this cohort compared with our institutional standard prescription. This approach is a promising strategy to reduce the amount of leftover opioid medication after treatment of acute postcesarean pain.
Clinical trial registration:
ClinicalTrials.gov, NCT02770612.
Background:
Surgeons recognize the importance of patient reported outcomes in the evaluation of healthcare. Documenting health related quality of life (HRQOL) can enhance surgical quality improvement efforts. Systematic documentation of HRQOL began in 1963. Currently multiple, varied and unstandardized instruments make it difficult to compare quality of life measures across studies. The National Institutes of Health (NIH) developed the Patient Reported Outcomes Measurement Information System (PROMIS) to provide a standardized assessment designed to complement traditional outcome measures.
Methods:
We used Systematic Scoping Methodology to investigate the characteristics of PROMIS utilization in studies assessing quality of life measures as surgical outcomes.
Results:
A systematic search of PubMed revealed 21 publications describing the use of PROMIS to assess surgical outcomes. The 121 study publications reported observations on 2561 patients. Twenty nine percent of patients had injuries, 33% had neoplasms, and 38% included other patients having neither injuries nor neoplasms. General Surgery/Gynecology/Plastic Surgery had 8 publications, Orthopedic Surgery had 9 publications, and Neurosurgery had 4 publications. Most studies included additional measures. There were 25 instruments used in addition to PROMIS.
Conclusions:
This study revealed that PROMIS performed efficiently, accurately, and reliably in assessing patient reported HRQOL in multidisciplinary surgical publications.
Objective:
To examine opioid prescribing patterns after general surgery procedures and to estimate an ideal number of pills to prescribe.
Background:
Diversion of prescription opioids is a major contributor to the rising mortality from opioid overdoses. Data to inform surgeons on the optimal dose of opioids to prescribe after common general surgical procedures is lacking.
Methods:
We evaluated 642 patients undergoing 5 outpatient procedures: partial mastectomy (PM), partial mastectomy with sentinel lymph node biopsy (PM SLNB), laparoscopic cholecystectomy (LC), laparoscopic inguinal hernia repair (LIH), and open inguinal hernia repair (IH). Postoperative opioid prescriptions and refill data were tabulated. A phone survey was conducted to determine the number of opioid pills taken.
Results:
There was a wide variation in the number of opioid pills prescribed to patients undergoing the same operation. The median number (and range) prescribed were: PM 20 (0-50), PM SLNB 20 (0-60), LC 30 (0-100), LIH 30 (15-70), and IH 30 (15-120). Only 28% of the prescribed pills were taken. This percentage varied by operation: PM 15%, PM SLNB 25%, LC 33%, LIH 15%, and IH 31%. Less than 2% of patients obtained refills.We identified the number of pills that would fully supply the opioid needs of 80% of patients undergoing each operation: PM 5, PM SLNB 10, LC 15, LIH 15, and IH 15. If this number were prescribed, the number of opioid initially prescribed would be 43% of the actual number prescribed.
Conclusions:
There is wide variability in opioid prescriptions for common general surgery procedures. In many cases excess pills are prescribed. Using our ideal number, surgeons can adequately treat postoperative pain and markedly decrease the number of opioids prescribed.
This cohort study measures opioid use between 90 days and 1 year after major surgery.. Exposure to opioids is largely unavoidable after major surgery because they are routinely used to treat postoperative pain. Nonetheless, continued long-term opioid use has negative health consequences including opioid dependence.¹ Patients and health care professionals are therefore concerned about long-term postoperative opioid use.² There are limited data on the risk of previously opioid-naive individuals developing persistent postoperative opioid use. In a 2014 population-based cohort study, we found that 3% of previously opioid-naive patients continued to use opioids 3 months after major elective surgery in Ontario, Canada.³ Importantly, the risk of persistent opioid use over longer periods after surgery remains unclear. We therefore conducted a follow-up study to measure rates of ongoing opioid use up to 1 year after major surgery.
The use of prescription opioid medications has increased greatly in the United States during the past two decades; in 2010, there were 16,651 opioid-related deaths. In response, hundreds of federal, state, and local interventions have been implemented. We describe trends in the diversion and abuse of prescription opioid analgesics using data through 2013.
We used five programs from the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System to describe trends between 2002 and 2013 in the diversion and abuse of all products and formulations of six prescription opioid analgesics: oxycodone, hydrocodone, hydromorphone, fentanyl, morphine, and tramadol. The programs gather data from drug-diversion investigators, poison centers, substance-abuse treatment centers, and college students.
Prescriptions for opioid analgesics increased substantially from 2002 through 2010 in the United States but then decreased slightly from 2011 through 2013. In general, RADARS System programs reported large increases in the rates of opioid diversion and abuse from 2002 to 2010, but then the rates flattened or decreased from 2011 through 2013. The rate of opioid-related deaths rose and fell in a similar pattern. Reported nonmedical use did not change significantly among college students.
Postmarketing surveillance indicates that the diversion and abuse of prescription opioid medications increased between 2002 and 2010 and plateaued or decreased between 2011 and 2013. These findings suggest that the United States may be making progress in controlling the abuse of opioid analgesics. (Funded by the Denver Health and Hospital Authority.).
Context:
The Eastern Cooperative Oncology Group/World Health Organization Performance Status (ECOG/WHO PS) is a prognostic factor. It should be used in analyzing health outcomes such as risk-adjusted hospital performance models in cancer populations. Performance status is rarely recorded in surgery, often the place where cancer is first diagnosed. Could a universally collected preoperative measure be substituted for ECOG/WHO PS?
Objectives:
The aim of this study was to assess whether the American Society of Anesthesiologists (ASA) score could be used as a proxy for ECOG/WHO PS in risk adjustment models predicting extended length of stay (LOS) after cancer surgery.
Methods:
Data were obtained from the BioGrid Colorectal Cancer Database for 2540 treatment episodes (2528 patients) at five hospitals in Victoria and Tasmania, Australia, from 2003 to 2012. Using extended LOS as the index outcome measure, a risk adjustment model was developed using patient demographic and clinical variables. The ECOG/WHO PS and ASA score were added to this model, and the relative percentage change in hospital coefficients were examined. Model fit was compared using Akaike's information criterion (AIC) and concordance statistic (c).
Results:
Adding ECOG/WHO PS or ASA score to the model resulted in relative changes in the hospital coefficients of up to 27%. The ECOG/WHO PS and ASA score performed similarly, with addition of either improving the AIC from 988.2 to 976.3. Inclusion of both measures further improved AIC to 972.4.
Conclusion:
The ASA score can be used as a proxy for ECOG/WHO PS in risk adjustment models predicting cancer surgery. Further studies should assess its broader application for other outcomes and in other settings.
This paper asks which sub-groups of the population are affected by the payment of a small cash incentive to respond to a telephone survey. We find that an incentive improves response rates primarily amongst those individuals with the longest history of income support receipt. Importantly, these individuals are least likely to respond to the survey in the absence of an incentive. The incentive thus improves both average response rates and acts to equalize response rates across different socio-economic groups, potentially reducing non-response bias. Interestingly, the main channel through which the incentive appears to increase response rates is in improving the probability of making contact with individuals in the group with heavy exposure to the income support system.
Current developments in automating the processes to author technical information and deliver it using microcomputers are described
in this article. The Department of Defense (DoD) has directed that the entire logistics support system (including technical
information now contained in printed manuals) be computer-based for new major systems entering production during the 1990s.
Addressed are issues relating to authoring efficiency, information access, user acceptance, and screen formats. The article
also reviews several ongoing projects and discusses implications for making the transition from paper to computer-based technical
manuals.
Prescription narcotic abuse is a significant social problem. Surplus medication following surgery is 1 source of prescription diversion. We assessed prescribing practices, consumption and disposal of prescribed narcotics after urological surgery.
Surveys were administered to a 3-month consecutive sample of adult patients who underwent surgery performed by full and adjunct University of Utah Urology faculty. Surveys were performed 2 to 4 weeks postoperatively. With the exception of the investigators, prescribing physicians had no prior knowledge of the study. Data collected included perception of pain control, type and quantity of medication prescribed, quantity of leftover medication, refills needed, disposal instructions and surplus medication disposition.
Overall 47% of 586 patients participated in the study. Hydrocodone was prescribed most commonly (63%), followed by oxycodone (35%), and 86% of the patients were satisfied with pain control. Of the dispensed narcotics 58% was consumed and 12% of patients requested refills. A total of 67% of patients had surplus medication from the initial prescription and 92% received no disposal instructions for surplus medication. Of those patients with leftover medication 91% kept the medication at home while 6% threw it in the trash, 2% flushed it down the toilet and less than 1% returned it to a pharmacy.
Overprescription of narcotics is common and retained surplus medication presents a readily available source of opioid diversion. It appears that no entity on the prescribing or dispensing ends of prescription opioid delivery is fulfilling the responsibility to accurately educate patients on proper surplus medication disposal. Surgeons should analyze prescribing practices and consider decreasing the quantity of postoperative narcotics prescribed.
Long-term pain is a common sequela of thoracotomy, occurring in approximately 50% of patients 2 years after thoracic surgery. Despite this alarming statistic, little is known about the factors responsible for the transition of acute to chronic pain. The aim of the present study is to identify predictors of long-term post-thoracotomy pain.
Follow-up was for 1.5 years for patients who had participated in a prospective, randomized, controlled trial of preemptive, multimodal analgesia.
Subjects were recruited from a tertiary care center.
Thirty patients who had undergone lateral thoracotomy were followed up by telephone, administered a structured interview, and classified according to long-term pain status.
Present pain status was measured by a verbal rating scale (VAS). Measures obtained within the first 48 h after surgery were compared between patients with and without pain 1.5 years later. These include VAS pain scores at rest and after movement, McGill Pain Questionnaire data, patient-controlled morphine consumption (mg), and pain thresholds to pressure applied to a rib contralateral to the thoracotomy incision.
Fifty-two percent of patients reported long-term pain. Early postoperative pain was the only factor that significantly predicted long-term pain. Pain intensity 24 h after surgery, at rest, and after movement was significantly greater among patients who developed long-term pain compared with pain-free patients. A significant predictive relationship was also found at 24 and 48 h using the McGill Pain Questionnaire. Cumulative morphine was comparable for the two groups. Pain thresholds to pressure applied to a rib contralateral to the incision did not differ significantly between the groups.
Aggressive management of early postoperative pain may reduce the likelihood of long-term post-thoracotomy pain.
Management of thoracotomy pain can be difficult, but the benefits of effective pain control are significant. A variety of modalities for treating postoperative pain after thoracotomy are available, including systemic opiates, regional analgesics, and new oral and parenteral agents. This work provides a review of the literature and recommendations for the clinician.
To many clinicians, the assessment of health-related quality of life (HRQL) seems more art than science. This belief is due in part to the lack of formal training available to clinicians regarding HRQL measurement and interpretation. When HRQL is used systematically, it has been shown to improve patient-physician communication, clinical decision making, and satisfaction with care. Nevertheless, clinicians rarely use formal HRQL data in their practices. One major reason is unfamiliarity with the interpretation and potential utility of the data. This unfamiliarity causes a lack of appreciation for the reliability of data generated by formal HRQL assessment and a tendency to regard HRQL data as having insufficient precision for individual use. This article discusses HRQL in the larger context of health indicators and health outcome measurement and is targeted to the practicing clinician who has not had the opportunity to understand and use HRQL data. The concept and measurement of reliability are explained and applied to HRQL and common clinical measures simultaneously, and these results are compared with one another. By offering a juxtaposition of common medical measurements and their associated error with HRQL measurement error, we note that HRQL instruments are comparable with commonly used clinical data. We further discuss the necessary requirements for clinicians to adopt formal, routine HRQL assessment into their practices.