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Zeineddin S, Pitt JB, Carter M, Linton S, De Boer C, Ghomrawi H, Abdullah F. Rethinking hospital postoperative resource use: A national analysis of pediatric appendectomy patients admitted to children's hospitals. Surgery 2024:S0039-6060(24)00447-1. [PMID: 39048332 DOI: 10.1016/j.surg.2024.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 06/14/2024] [Accepted: 06/16/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND The increased use of remote monitoring and telemedicine support may help alleviate the need for some of the postoperative inpatient hospital care and reduce health care costs, but little is known about current postoperative hospital resource use patterns. We aim to describe hospital resources use patterns in pediatric patients postappendectomy for complicated appendicitis and to evaluate the potential of earlier discharge with remote monitoring. METHODS This was a retrospective cohort study using the Pediatric Health Information System database for patients who underwent laparoscopic appendectomy for complicated appendicitis between 2016 and 2021. Health care use/costs (antibiotics, intravenous fluids [proxy for diet], analgesics, laboratory studies, and imaging tests) were determined using administrative billing data. Potentially avoidable days were defined as nondischarge days without codes for intravenous opioid pain medication or intravenous fluids. Descriptive statistics and logistic regression were used. RESULTS In total, 24,165 patients were included: 8,300 patients (34.3%) had at least 1 potentially avoidable hospitalization day, totaling 13,970 days or 14.2% of all hospitalization days. Median hospitalization cost was $19,434 [$15,658-$25,157], with accommodation and operating room being the greatest contributors. Public insurance and minority races and ethnicities were associated with greater odds of potentially avoidable days. More than 80% of hospitalized patients had intravenous antibiotics through 10 days postoperatively. More than 20% received opioids daily. CONCLUSIONS More than one third of the patients who underwent laparoscopic appendectomy for complicated appendicitis could have had at least 1 potentially avoidable hospitalization day. Remote monitoring and telemedicine support should be explored and could help with earlier discharge and lower costs.
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Affiliation(s)
- Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, IL. https://www.twitter.com/szeineddinMD
| | - J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, IL
| | - Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, IL
| | - Samuel Linton
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, IL
| | - Christopher De Boer
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, IL
| | - Hassan Ghomrawi
- Departments of Surgery and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, IL.
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Sutherland TN, Rabbitts JA, Tasian GE, Neuman MD, Newcomb C, Hadland SE. Preoperative vs Postoperative Opioid Prescriptions and Prolonged Opioid Refills Among US Youths. JAMA Netw Open 2024; 7:e2420370. [PMID: 38967924 PMCID: PMC11227082 DOI: 10.1001/jamanetworkopen.2024.20370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 05/05/2024] [Indexed: 07/06/2024] Open
Abstract
Importance High-risk practices, including dispensing an opioid prescription before surgery when not recommended, remain poorly characterized among US youths and may contribute to new persistent opioid use. Objective To characterize changes in preoperative, postoperative, and refill opioid prescriptions up to 180 days after surgery. Design, Setting, and Participants This retrospective cohort study was performed using national claims data to determine opioid prescribing practices among a cohort of opioid-naive youths aged 11 to 20 years undergoing 22 inpatient and outpatient surgical procedures between 2015 and 2020. Statistical analysis was performed from June 2023 to April 2024. Main Outcomes and Measures The primary outcome was the percentage of initial opioid prescriptions filled up to 14 days prior to vs 7 days after a procedure. Secondary outcomes included the likelihood of a refill up to 180 days after surgery, including refills at 91 to 180 days, as a proxy for new persistent opioid use, and the opioid quantity dispensed in the initial and refill prescriptions in morphine milligram equivalents (MME). Exposures included patient and prescriber characteristics. Multivariable logistic regression models were used to estimate the association between prescription timing and prolonged refills. Results Among 100 026 opioid-naive youths (median [IQR] age, 16.0 [14.0-18.0] years) undergoing a surgical procedure, 46 951 (46.9%) filled an initial prescription, of which 7587 (16.2%) were dispensed 1 to 14 days before surgery. The mean quantity dispensed was 227 (95% CI, 225-229) MME; 6467 youths (13.8%) filled a second prescription (mean MME, 239 [95% CI, 231-246]) up to 30 days after surgery, and 1216 (3.0%) refilled a prescription 91 to 180 days after surgery. Preoperative prescriptions, increasing age, and procedures not typically associated with severe pain were most strongly associated with new persistent opioid use. Conclusions and Relevance In this retrospective study of youths undergoing surgical procedures, of which, many are typically not painful enough to require opioid use, opioid dispensing declined, but approximately 1 in 6 prescriptions were filled before surgery, and 1 in 33 adolescents filled prescriptions 91 to 180 days after surgery, consistent with new persistent opioid use. These findings should be addressed by policymakers and communicated by professional societies to clinicians who prescribe opioids.
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Affiliation(s)
- Tori N. Sutherland
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Jennifer A. Rabbitts
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Gregory E. Tasian
- Division of Urology, Department of Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Mark D. Neuman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Craig Newcomb
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Scott E. Hadland
- Division of Adolescent and Young Adult Medicine, Mass General for Children, Boston
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Stephenson KJ, Krinock DJ, Vasquez IL, Shewmake CN, Spray BJ, Ketha B, Wolf LL, Dassinger MS. Implementation of Guidelines Limiting Postoperative Opioid Prescribing at a Children's Hospital. J Patient Saf 2024; 20:299-305. [PMID: 38240645 DOI: 10.1097/pts.0000000000001209] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Variability in opioid-prescribing practices after common pediatric surgical procedures at our institution prompted the development of opioid-prescribing guidelines that provided suggested dose limitations for narcotics. The aims of this study were to improve opioid prescription practices through implementation of the developed guidelines and to assess compliance and identify barriers preventing guideline utilization. METHODS We conducted a single-center cohort study of all children who underwent the most common outpatient general surgery procedures at our institution from August 1, 2018, to February 1, 2020. We created guidelines designed to limit opioid prescription doses based on data obtained from standardized postoperative telephone interviews. Three 6-month periods were evaluated: before guideline implementation, after guideline initiation, and after addressing barriers to guideline compliance. Targeted interventions to increase compliance included modification of electronic medical record defaults and provider educations. Differences in opioid weight-based doses prescribed, filled, and taken, as well as protocol adherence between the 3 timeframes were evaluated. RESULTS A total of 1033 children underwent an outpatient procedure during the 1.5-year time frame. Phone call response rate was 72.22%. There was a significant sustained decrease in opioid doses prescribed ( P < 0.0001), prescriptions filled ( P = 0.009), and opioid doses taken ( P = 0.001) after implementation, without subsequent increase in reported pain on postoperative phone call ( P = 0.96). Protocol compliance significantly improved (62.39% versus 83.98%, P < 0.0001) after obstacles were addressed. CONCLUSIONS Implementation of a protocol limiting opioid prescribing after frequently performed pediatric general surgery procedures reduced opioids prescribed and taken postoperatively. Interventions that addressed barriers to application led to increased protocol compliance and sustained decreases in opioids prescribed and taken without a deleterious effect on pain control.
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Affiliation(s)
| | - Derek J Krinock
- From the Department of Surgery, University of Arkansas for Medical Sciences
| | - Isabel L Vasquez
- Department of Surgery, Arkansas Children's Hospital Research Institute
| | | | | | - Bavana Ketha
- Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, Arizona
| | - Lindsey L Wolf
- Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, Arizona
| | - Melvin S Dassinger
- Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, Arizona
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Odegard M, Ourshalimian S, Hijaz D, Goldstein RY, Ignacio RC, Chen SY, Kim E, Kim ES, Kelley-Quon LI. Factors Associated with Postoperative Opioid Use in Adolescents. J Pediatr Surg 2024; 59:709-717. [PMID: 38097461 DOI: 10.1016/j.jpedsurg.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 10/15/2023] [Accepted: 11/20/2023] [Indexed: 04/08/2024]
Abstract
BACKGROUND We aimed to identify factors associated with postoperative prescription opioid use in adolescents. METHODS Adolescents aged 13-20 years undergoing surgery were prospectively recruited from a children's hospital. Adolescent-parent dyads completed a preoperative survey, measuring clinical and sociodemographic factors, and two postoperative surveys evaluating self-reported opioid use at 30- and 90-days. Poisson regression analysis identified factors associated with the number of pills used within 90-days, adjusting for age, gender, race/ethnicity, surgery type, and pain at discharge. RESULTS We enrolled 119 adolescents who reported postoperative opioid use following posterior spinal fusion (PSF) (50 %), arthroscopy (23 %), pectus excavatum repair (11 %), tonsillectomy (8 %), and hip reconstruction (7 %). Overall, 81 % of adolescents reported unused opioids. The median pain score at discharge was 7 (IQR:5-8). Adolescents reported using a median of 7 (IQR:2-15) opioid pills, with 20 (IQR:7-30) pills left unused. Compared to all other surgeries, adolescents undergoing PSF reported the highest median pill use (10, IQR:5-29; p = 0.004). Adolescents undergoing tonsillectomy reported the lowest median pill use (1, IQR:0-7; p = 0.03). On regression analysis, older patient age was associated with a 12 % increase in pill use (95 % CI:3%-23 %). Undergoing PSF was associated with a 63 % increase in pill use (95 % CI:15%-31 %). Each additional pain scale point reported at discharge was associated with a 13 % increase in pill use (95 % CI:5%-22 %). CONCLUSIONS Older age, surgery type, and patient-reported pain at discharge are associated with postoperative prescription opioid use in adolescents. Understanding patient and surgery-specific factors associated with opioid use may guide surgeons to minimize excess opioid prescribing. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Marjorie Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA.
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Donia Hijaz
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Rachel Y Goldstein
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Romeo C Ignacio
- Rady Children's Hospital San Diego, 3020 Children's Way, San Diego, CA, 92123, USA
| | - Stephanie Y Chen
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Eugene Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA
| | - Eugene S Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA; Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA; Department of Population and Public Health Sciences, University of Southern California, 1845 N. Soto Dr., Los Angeles, CA, 90032, USA
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Slouha E, Krumbach B, Gregory JA, Biput SJ, Shay A, Gorantla VR. Pain Management Throughout Pediatric Laparoscopic Appendectomy: A Systematic Review. Cureus 2023; 15:e49581. [PMID: 38156159 PMCID: PMC10754371 DOI: 10.7759/cureus.49581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/30/2023] Open
Abstract
Opioid-related fatalities are a leading cause of accidental death in the United States. Appendicitis is a common cause of abdominal pain in children and adolescents. The management of pain throughout the laparoscopic appendectomy (LA) in the pediatric population is a critical concern. This study aimed to evaluate trends in analgesic use and patient satisfaction following LA, with a focus on reducing the reliance on opioids for pain management. From 2003 to 2023, 18258 articles were filtered for all types of analgesic use with LA. The publications were screened using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 19 studies were included for analysis and review. The study included peer-reviewed experimental and observational studies involving individuals under 18 years. Pain management strategies varied across studies, involving a combination of analgesics, nerve blocks, and wound infiltrations. Analgesics such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids were administered before and after surgery. Some studies implemented patient-controlled analgesia (PCA) pumps. Other studies explored non-pharmacological interventions like magnetic acupuncture. The results showed a reduction in the need for postoperative analgesics in patients treated with LA, particularly when using non-opioid medications and novel analgesic techniques. Pediatric patients who received gabapentin reported lower opioid use, shorter hospital stays, and high satisfaction rates. However, the reliance on opioids remained significant in some cases, particularly among patients with peritonitis who required more morphine. Pain management in pediatric patients is multifaceted, involving preoperative and postoperative analgesics, nerve blocks, and PCA pumps. Efforts to improve pain management following pediatric LA while reducing opioid reliance are essential in the context of the ongoing opioid epidemic. The findings from this study highlight the potential benefits of non-opioid analgesics, nerve blocks, and alternative methods for managing postoperative pain in <18 appendectomy patients. Further research and standardization of pain management protocols are needed to ensure optimal patient outcomes and minimize the risk of opioid-related complications.
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Affiliation(s)
- Ethan Slouha
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Brandon Krumbach
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Jheanelle A Gregory
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Stefan J Biput
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Allison Shay
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Vasavi R Gorantla
- Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, USA
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Tyson K, Karam BS, Peppard WJ, Morris R, Murphy P, Elegbede A, Schroeder M, Somberg L, Trevino CM. Optimizing discharge opioid prescribing in trauma patients: A quasi-experimental study. Surgery 2023; 173:794-798. [PMID: 36371358 DOI: 10.1016/j.surg.2022.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/25/2022] [Accepted: 07/30/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients prescribed higher opioid dosages are at increased risk of overdose and death without added pain reduction. Increases in opioid prescribing continue to fuel the epidemic. We hypothesized a comprehensive guideline to standardize opioid prescribing would decrease postdischarge dosages for patients experiencing trauma without requiring additional refills. METHODS This quasiexperimental study compared opioid prescribing by trauma providers before and after the implementation of a departmental guideline on April 1, 2019, aimed at aligning opioid prescription patterns with Centers for Disease Control and Prevention recommendations. Patients prescribed opioids before implementation were the control group, whereas patients prescribed opioids after were the intervention group. The primary outcome was the proportion of patients receiving ≥50 morphine milligram equivalents per day. RESULTS We identified 293 and 280 patients experiencing trauma in the control and intervention groups, respectively. There were no differences between the groups' Injury Severity Score (P = .69) or the frequency of having a procedure performed (P = .80). Total morphine milligram equivalents and maximum morphine milligram equivalents per day were 16% and 25% lower, respectively, in the intervention group compared with the control group (P < .001). The proportion of trauma patients prescribed ≥50 morphine milligram equivalents per day at discharge decreased from 57% to 18% after implementation (P < .001). The proportion of trauma patients prescribed ≥90 morphine milligram equivalents per day also decreased, from 37% to 14% (P < .001). There was no significant increase in the frequency of refill requests (P = .105) or refill prescriptions (P = .099) after discharge. CONCLUSION A departmental guideline aimed at optimizing opioid prescription patterns successfully lowers the amount of morphine milligram equivalents prescribed to trauma patients and improves compliance with Centers for Disease Control and Prevention recommendations.
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Affiliation(s)
- Katherine Tyson
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Basil S Karam
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - William J Peppard
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Rachel Morris
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Patrick Murphy
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Anuoluwapo Elegbede
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Mary Schroeder
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Lewis Somberg
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Colleen M Trevino
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
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Chen SY, Ourshalimian S, Kim E, Russell CJ, Kelley-Quon LI. Tramadol Use in Pediatric Surgery: Trends After the Food and Drug Administration Black-Box Warning. J Surg Res 2022; 280:10-18. [PMID: 35944445 DOI: 10.1016/j.jss.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION The U.S. Food and Drug Administration (FDA) issued a black-box warning in 2017 contraindicating tramadol in children <12 y. Longitudinal trends and factors associated with perioperative tramadol use in children remain unclear. METHODS A retrospective, multi-institutional cohort study utilizing the Pediatric Health Information System database was performed for children 2-18 y who underwent one of ten common surgeries from 1/2009-2/2020. Temporal trends correlated with the FDA tramadol contraindication were evaluated. Hierarchical multivariable logistic regression analysis identified factors associated with tramadol use. RESULTS Of 477,153 children undergoing surgery, 5857(1.2%) received tramadol during hospitalization. Tramadol use occurred in 942 (16.1%) children after the black-box warning, 390 of whom were <12 y. For children <12 y, annual tramadol use peaked at 1.87% (2016) and decreased to 0.66% (2019). Female sex (odds ratio OR 1.32; 95% confidence interval CI:1.24,1.40), age ≥12 y (OR 2.79; 95%CI: 2.62,2.97), and Midwest location (OR 4.07; 95% CI:1.64,10.11) increased likelihood of receiving tramadol. Tramadol use was more likely after cholecystectomy (OR 1.17; 95% CI:1.04,1.32) and in children with gastrointestinal (OR 2.39; 95% CI: 2.19,2.60), metabolic (OR 1.39; 95% CI:1.26,1.53) or transplant-related (OR 1.82; 95% CI: 1.57,2.10) comorbidities. Children of Hispanic/Latino ethnicity and those with public insurance had decreased likelihood of receiving tramadol. Adjusting for patient and hospital characteristics, children <12 y were less likely to receive tramadol following the black-box warning (OR 0.65; 95% CI: 0.59,0.70). CONCLUSIONS Despite the FDA contraindication, tramadol prescribing continues among children <12 y undergoing surgery, with use varying by patient and institutional factors. Interventions are required to reduce perioperative tramadol use in children.
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Affiliation(s)
- Stephanie Y Chen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Eugene Kim
- Division of Pain Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California.
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8
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Odegard M, Kelley-Quon LI. Postoperative Opioid Prescribing, Use, and Disposal in Children. Adv Pediatr 2022; 69:259-271. [PMID: 35985715 DOI: 10.1016/j.yapd.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article provides an overview of postoperative opioid prescribing, use, and disposal patterns in children and also identifies gaps in knowledge and areas for improvement. We present evidence that there is a need to tailor prescriptions to specific procedures to reduce the number of excess, unused prescription opioid pills in the home. We also explain the need to provide culturally competent care when managing a child's pain after surgery. Finally, we discuss the need for widespread provider and caregiver education about safe prescription opioid use, storage, and disposal.
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Affiliation(s)
- Marjorie Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #100, Los Angeles, CA 90027, USA.
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #100, Los Angeles, CA 90027, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA 90033, USA
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9
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Lo HYA, Yang C, Rettig RL, Chung J, Shaul D, Sydorak R. Same day discharge after pediatric laparoscopic appendectomy in community hospitals. J Pediatr Surg 2022; 57:1242-1248. [PMID: 35379493 DOI: 10.1016/j.jpedsurg.2022.02.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/23/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Same-day discharge (SDD) protocols after pediatric laparoscopic appendectomy have not been well studied in a community hospital setting, especially when hospitals with low inpatient pediatric censuses are increasingly closing their pediatric units. This study evaluates the outcomes of a SDD protocol after pediatric appendectomy that was implemented across an integrated healthcare system in which hospitals experienced closure of pediatric units. METHODS Patients between ages 6 to 13 years-old who underwent laparoscopic appendectomy for uncomplicated appendicitis from January 1st 2015 to December 31st 2020 were reviewed. During the study period, an inter-hospital SDD protocol was introduced at nine hospitals, four of which closed their pediatric units. RESULTS There were 1293 patients in the pre-protocol cohort and 953 patients in the post-protocol cohort. There were 588 (45.5%) patients who underwent SDD in the pre-protocol cohort, compared with 804 (84.4%) patients in the post-protocol cohort (p<0.00001). Postoperative narcotics were prescribed to 358 (27.7%) patients in the pre-protocol cohort, compared to 482 (50.6%) patients in the post-protocol cohort (P<0.00001). There was no difference in the 30-day emergency department visit rate or 30-day readmission rate between the two cohorts. A subgroup analysis comparing the surgical outcomes at community hospitals with and without pediatric units after implementation of the SDD protocol showed no difference. CONCLUSION Same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis in community hospitals, even after pediatric unit closure, is safe and feasible. The decrease in postoperative LOS and the increase in SDD are not associated with higher complication rates.
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Affiliation(s)
- Hoi Yee Annie Lo
- General Surgery Department, Kaiser Permanente Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA 90027, United States
| | - Claire Yang
- General Surgery Department, Kaiser Permanente Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA 90027, United States
| | - Robert Luke Rettig
- General Surgery Department, Kaiser Permanente Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA 90027, United States
| | - Joanie Chung
- Kaiser Permanente Research and Evaluation, 100 S Los Robles Ave #2, Pasadena, CA 91101, United States
| | - Donald Shaul
- Children's Hospital of Orange County, CHOC Children's Commerce Tower, 505 S Main St UNIT 225, Orange, CA 92868, United States
| | - Roman Sydorak
- General Surgery Department, Kaiser Permanente Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA 90027, United States.
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Kelley-Quon LI, Ourshalimian S, Lee J, Russell KW, Kling K, Shew SB, Mueller C, Jensen AR, Vu L, Padilla B, Ostlie D, Smith C, Inge T, Roach J, Ignacio R, Lofberg K, Radu S, Rohan A, Wang KS. Multi-Institutional Quality Improvement Project to Minimize Opioid Prescribing in Children after Appendectomy Using NSQIP-Pediatric. J Am Coll Surg 2022; 234:290-298. [PMID: 35213491 DOI: 10.1097/xcs.0000000000000056] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND There is wide variation in opioid prescribing after appendectomy in children and adolescents, with recent increases noted in opioid-related pediatric deaths from prescription and illicit opioids. The goal of this project was to minimize opioid prescribing at the time of discharge for children undergoing appendectomy by using Quality Improvement (QI) methodology. STUDY DESIGN Children (18 years of age or less) who underwent appendectomy were evaluated from January to December 2019 using NSQIP-Pediatric at 10 children's hospitals within the Western Pediatric Surgery Research Consortium. Before project initiation, 5 hospitals did not routinely prescribe opioids after appendectomy (protocol). At the remaining 5 hospitals, prescribing was not standardized and varied by surgeon (no-protocol). A prospective multi-institutional QI project was used to minimize outpatient opioid prescriptions for children after appendectomy. The proportion of children at each hospital receiving an opioid prescription at discharge was compared for 6 months before and after the intervention using chi-square analysis. RESULTS Overall, 1,524 children who underwent appendectomy were evaluated from January to December 2019. After the QI intervention, overall opioid prescribing decreased from 18.2% to 4.0% (p < 0.001), with significant decreases in protocol hospitals (2.7% vs 0.8%, p = 0.038) and no-protocol hospitals (37.9% vs 8.8%, p < 0.001). The proportion of 30-day emergency room visits did not change after the QI intervention (8.9% vs 9.9%, p = 0.54) and mean postintervention pain management satisfaction scores were high. CONCLUSION Opioid prescribing can be minimized in children after appendectomy without increasing emergency room visits or decreasing patient satisfaction. Furthermore, NSQIP-Pediatric can be used as a platform for multi-institutional collaboration for successful implementation of QI projects.
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Affiliation(s)
- Lorraine I Kelley-Quon
- From the Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourhsalimian, Wang)
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA (Kelley-Quon)
| | - Shadassa Ourshalimian
- From the Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourhsalimian, Wang)
| | - Justin Lee
- Division of Surgery, Phoenix Children's Hospital, Phoenix, AZ (Lee, Padilla, Ostlie)
| | - Katie W Russell
- Division of Pediatric Surgery, University of Utah and Primary Children's Hospital, Salt Lake City, UT (Russell, Rohan)
| | - Karen Kling
- Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, CA; Department of Surgery, University of California San Diego School of Medicine, San Diego, CA (Kling, Ignacio)
| | - Stephen B Shew
- Division of Pediatric Surgery, Lucile Packard Children's Hospital, Palo Alto, CA; Department of Surgery, Stanford University School of Medicine, Palo Alto, CA (Shew, Mueller)
| | - Claudia Mueller
- Division of Pediatric Surgery, Lucile Packard Children's Hospital, Palo Alto, CA; Department of Surgery, Stanford University School of Medicine, Palo Alto, CA (Shew, Mueller)
| | - Aaron R Jensen
- Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, and Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA (Jensen, Vu)
| | - Lan Vu
- Division of Pediatric Surgery, UCSF Benioff Children's Hospitals, and Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA (Jensen, Vu)
| | - Benjamin Padilla
- Division of Surgery, Phoenix Children's Hospital, Phoenix, AZ (Lee, Padilla, Ostlie)
| | - Daniel Ostlie
- Division of Surgery, Phoenix Children's Hospital, Phoenix, AZ (Lee, Padilla, Ostlie)
| | - Caitlin Smith
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle WA; Department of Surgery, University of Washington School of Medicine, Seattle, WA (Smith)
| | - Thomas Inge
- Children's Hospital Colorado, University of Colorado, Aurora, CO (Inge, Roach)
| | - Jonathan Roach
- Children's Hospital Colorado, University of Colorado, Aurora, CO (Inge, Roach)
| | - Romeo Ignacio
- Division of Pediatric Surgery, Rady Children's Hospital San Diego, San Diego, CA; Department of Surgery, University of California San Diego School of Medicine, San Diego, CA (Kling, Ignacio)
| | - Katrine Lofberg
- the Division of Pediatric Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR (Lofberg, Radu)
| | - Stephanie Radu
- the Division of Pediatric Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR (Lofberg, Radu)
| | - Autumn Rohan
- Division of Pediatric Surgery, University of Utah and Primary Children's Hospital, Salt Lake City, UT (Russell, Rohan)
| | - Kasper S Wang
- From the Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Kelley-Quon, Ourhsalimian, Wang)
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11
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Hayes D, Tan M, Wang M, Weinsheimer R. A multi-institutional approach for decreasing narcotic prescriptions after laparoscopic appendectomy. Surg Endosc 2022; 36:6250-6254. [PMID: 35169880 PMCID: PMC8853128 DOI: 10.1007/s00464-022-09107-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 02/07/2022] [Indexed: 11/27/2022]
Abstract
Background Appendicitis is a common indication for surgical hospital admission. Uncomplicated appendicitis is typically treated with surgical intervention, most commonly a laparoscopic appendectomy. As with many procedures, narcotic utilization is highly varied among surgeons for postoperative pain control. With the opioid epidemic and a demonstrated link between excessive narcotic prescriptions paving the way to dependence and addiction, it is more important than ever to decrease the circulation of these medications. We hypothesized that a perioperative, multimodal analgesia strategy coupled with monthly feedback reports comparing hospitals narcotic prescribing habits would decrease, and in some cases eliminate, the use of outpatient narcotics in adults after laparoscopic appendectomy. Methods A quality improvement project was initiated to provide monthly feedback to surgeons on narcotic prescribing habits after adult laparoscopic appendectomies. A multi-hospital database was created to include adult patients that were diagnosed with acute appendicitis, treated with laparoscopic appendectomy, and discharged within 48 h of surgery. The database provided information regarding the number of narcotic doses prescribed on discharge. Participating hospitals selected a site champion who distributed monthly prescribing reports. A protocol was created and distributed to participating sites that provided a guideline for preoperative and postoperative pain medication management. The intervention period was 10/1/2019–3/31/2020. We utilized the preceding year’s data (October 1, 2018–September 30, 2019) as the pre-intervention control group. We also compared results between local and distant sites to see if personal connection to surgeons influenced the results. Results A total of 1785 appendectomies were performed during the study period at participating hospitals. The average number of prescribed narcotics decreased from 23.6 doses during the control period to 14.2 during the intervention (p < 0.001). There was no change in the number of total narcotic prescriptions (8.9 vs 7.9%, p = 0.52). Overall, the average number of narcotics prescribed decreased by 40% with similar decrease in average prescribed narcotics for local and distant hospitals, respectively (47.7% vs 42.1%). Average narcotic dose during the first 2 months of intervention at the local hospitals was 9.7 and 11.1 for the last 2 months of intervention (p = 0.69). Average narcotic dose during the first 2 months of intervention at the distant hospitals was 19.5 and 13.4 for the last 2 months of intervention (p = 0.005). Conclusion A multimodal pain regimen combined with a monthly narcotic prescription report provided to prescribers decreases the average number of narcotic prescriptions after laparoscopic appendectomy. Local sites demonstrated immediate decrease in narcotic utilization compared to distant sites whose change occurred more gradually. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-022-09107-y.
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Affiliation(s)
- Danielle Hayes
- Department of General Surgery, Swedish Medical Center First Hill, Seattle, WA, USA. .,Department of General Surgery, Swedish Medical Center First Hill, 747 Broadway, Heath Tenth Floor, Seattle, WA, 98122-4307, USA.
| | - Mimi Tan
- Department of General Surgery, Swedish Medical Center First Hill, Seattle, WA, USA
| | - Mansen Wang
- Medical Data Research Center, Providence Health & Services, Portland, OR, USA
| | - Robert Weinsheimer
- Department of Pediatric Surgery, Swedish Medical Center First Hill, Seattle, WA, USA
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12
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Baker CE, Larson AN, Ubl DS, Shaughnessy WJ, Rutledge JD, Stans AA, Habermann EB, Milbrandt TA. Tiered Guidelines in a Pediatric Orthopaedic Practice Reduce Opioids Prescribed at Discharge. J Pediatr Orthop 2022; 42:e83-e90. [PMID: 34560763 DOI: 10.1097/bpo.0000000000001974] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Data regarding opioid prescribing patterns following pediatric orthopaedic procedures is limited. The aim of this work was to evaluate the effects of tiered guidelines for discharge opioid prescriptions following common pediatric orthopaedic procedures. METHODS Quality improvement project conducted at a single academic institution. Guidelines for discharge opioid prescriptions were implemented January 2018 and established 4 tiers of increasing invasiveness for 28 common pediatric orthopaedic procedures. Patients who underwent these procedures in 2017 comprised the preguideline cohort (N=258), while patients treated in 2019 comprised the postguideline cohort (N=212). Opioid prescriptions were reported as oral morphine equivalents (OMEs). Univariate tests were performed to assess statistically significant differences before and after implementation of the guidelines. RESULTS There was a significant decrease in OME prescribed between preguideline and postguideline cohorts (median OME 97.5 vs. 37.5). When analyzed according to procedure tiers, tiers 1, 2, and 4 showed significant decreases in OME prescribed between 2017 and 2019. The rate of no opioids prescribed at discharge increased from 13% to 23% between preguideline and postguideline cohorts. The 30-day refill rate did not significantly change. After implementation of guidelines, 91% of all prescriptions were within the guideline parameters, and there was a significant reduction in prescription variability. In tier 4 procedures, median OME prescribed decreased from 375 preguideline to 188 postguideline, but was associated with greater opioid refills within 30 days of discharge (10.2% preguideline vs. 28.8% postguideline). CONCLUSIONS Tiered guidelines for discharge opioid prescriptions following pediatric orthopaedic procedures can significantly decrease the quantity of opioids prescribed. Furthermore, we noted excellent adherence and no overall increase in the rates of narcotic refills. Such guidelines may improve pediatric orthopaedists' ability to responsibly treat postoperative pain while limiting the distribution of unneeded opioids. LEVEL OF EVIDENCE Level IV-quality improvement project.
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Affiliation(s)
| | | | - Daniel S Ubl
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | | | | | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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13
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Stokes SC, Theodorou CM, Brown EG, Saadai P. Variations in Perceptions of Postoperative Opioid Need for Pediatric Surgical Patients. JAMA Surg 2021; 156:885-887. [PMID: 34160611 DOI: 10.1001/jamasurg.2021.2076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Sarah C Stokes
- Department of Surgery, University of California, Davis, Sacramento
| | | | - Erin G Brown
- Department of Surgery, University of California, Davis, Sacramento.,Shriners Hospital for Children Northern California, Sacramento
| | - Payam Saadai
- Department of Surgery, University of California, Davis, Sacramento.,Shriners Hospital for Children Northern California, Sacramento
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14
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Mahdi EM, Ourshalimian S, Darcy D, Russell CJ, Kelley-Quon LI. The impact of intravenous acetaminophen pricing on opioid utilization and outcomes for children with appendicitis. Surgery 2021; 170:932-938. [PMID: 33985768 PMCID: PMC8405541 DOI: 10.1016/j.surg.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND In 2014, the price of intravenous acetaminophen more than doubled. This study determined whether increased intravenous acetaminophen cost was associated with decreased utilization and increased opioid use for children undergoing appendectomy. METHODS A multicenter retrospective cohort study using the Pediatric Health Information System database between 2011 and 2017 was performed. Healthy children 2 to 18 years undergoing appendectomy at 46 children's hospitals in the United States were identified. Intravenous acetaminophen use, opioid use, and pharmacy costs were assessed. Multivariable mixed-effects modeling was used to determine the association between postoperative opioid use, intravenous acetaminophen use, and postoperative length-of-stay. RESULTS Overall, 110,019 children undergoing appendectomy were identified, with 22.5% (N = 24,777) receiving intravenous acetaminophen. Despite the 2014 price increase, intravenous acetaminophen use increased from 3% in 2011 to 40.1% in 2017 (P < .001), but at a significantly reduced rate. After 2014, adjusted median pharmacy charges decreased from $3,326.5 (interquartile range: $1,717.5-$6,710.8) to $3,264.1 (interquartile range: $1,782.8-$5,934.7, P < .001) for children who received intravenous acetaminophen. In 94,745 children staying ≥1 day after surgery, postoperative opioid use decreased from 73.6% in 2011 to 58.6% in 2017 (P < .001). Use of intravenous acetaminophen alone compared to opioids alone after surgery resulted in similar predicted mean postoperative length-of-stay. CONCLUSION In children undergoing appendectomy, intravenous acetaminophen use continued to rise, but at a slower rate after a price increase. Furthermore, adjusted pharmacy charges were lower for children receiving intravenous acetaminophen, possibly secondary to a concurrent decrease in postoperative opioid use. These findings suggest intravenous acetaminophen may be more broadly used regardless of perceived costs to minimize opioid use after surgery.
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Affiliation(s)
- Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - David Darcy
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Christopher J Russell
- Division of Pediatric Hospital Medicine, Children's Hospital Los Angeles, CA Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, CA Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA; Department of Preventive Medicine, University of Southern California, Los Angeles, CA.
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15
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Chua KP, Brummett CM, Conti RM, Bohnert AS. Opioid Prescribing to US Children and Young Adults in 2019. Pediatrics 2021; 148:peds.2021-051539. [PMID: 34400571 PMCID: PMC8778996 DOI: 10.1542/peds.2021-051539] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Recent national data are lacking on the prevalence, safety, and prescribers of opioid prescriptions dispensed to children and young adults aged 0 to 21 years. METHODS We identified opioid prescriptions dispensed to children and young adults in 2019 in the IQVIA Longitudinal Prescription Database, which captures 92% of US pharmacies. We calculated the proportion of all US children and young adults with ≥1 dispensed opioid prescription in 2019. We calculated performance on 6 metrics of high-risk prescribing and the proportion of prescriptions written by each specialty. Of all prescriptions and those classified as high risk by ≥1 metric, we calculated the proportion written by high-volume prescribers with prescription counts at the ≥95th percentile. RESULTS Analyses included 4 027 701 prescriptions. In 2019, 3.5% of US children and young adults had ≥1 dispensed opioid prescription. Of prescriptions for opioid-naive patients, 41.8% and 3.8% exceeded a 3-day and 7-day supply, respectively. Of prescriptions for young children, 8.4% and 7.7% were for codeine and tramadol. Of prescriptions for adolescents and young adults, 11.5% had daily dosages of ≥50 morphine milligram equivalents; 4.6% had benzodiazepine overlap. Overall, 45.6% of prescriptions were high risk by ≥1 metric. Dentists and surgeons wrote 61.4% of prescriptions. High-volume prescribers wrote 53.3% of prescriptions and 53.1% of high-risk prescriptions. CONCLUSIONS Almost half of pediatric opioid prescriptions are high risk. To reduce high-risk prescribing, initiatives targeting high-volume prescribers may be warranted. However, broad-based initiatives are also needed to address the large share of high-risk prescribing attributable to other prescribers.
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Affiliation(s)
- Kao-Ping Chua
- Division of General Pediatrics, Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Chad M. Brummett
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI,Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Rena M. Conti
- Department of Markets, Public Policy, And Law, Institute for Health System Innovation and Policy, Questrom School of Business, Boston University, Boston, MA
| | - Amy S. Bohnert
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI,VA Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, MI
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16
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The impact of patient age and procedure type on postoperative opioid use following ambulatory pediatric urologic procedures. Pediatr Surg Int 2021; 37:1127-1133. [PMID: 33904987 DOI: 10.1007/s00383-021-04912-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The aim of this study is to determine whether patient age and procedure type are associated with duration of opioid use in pediatric patients undergoing ambulatory urologic procedures. METHODS We retrospectively reviewed pediatric patients who underwent outpatient urologic procedures from 2013 to 2017. At postoperative visits, parents reported the number of days their child took opioid pain medication. Factors associated with duration of opioid use were evaluated using negative binomial regression models. RESULTS 805 patients were included: 320 infants (39.8%), 430 children (53.4%), and 55 adolescents (6.8%). Overall mean length of opioid use was 1.7 (± 2.6) days. On average, infants used opioids for the shortest duration: 1.5 (± 2.3) days, followed by children: 1.7 (± 2.5) days, and adolescents: 3.1 (± 4.6) days. In adjusted models, adolescents used opioids for 85.2% longer (95% CI 13.1-161.8%; p < 0.001) than children and infants used opioids for 19.4% shorter duration (95% CI 0.4-34.7%; p = 0.05) than children. Each 1-year increase in age was associated with 6.1% increased duration of opioid use (95% CI 3.9-8.5%; p < 0.0001). Patients who underwent circumcision, hypospadias repair, and penile reconstruction took opioids for 75.9% (95% CI 42.6-117.1%; p < 0.001), 144.2% (95% CI 76.4-238.0%; p < 0.001), and 126.7% (95% CI 48.8-245.3%; p < 0.001) longer respectively than patients who underwent inguinal procedures. CONCLUSIONS Increasing age, circumcision, hypospadias repair, and penile reconstruction are associated with increased duration of opioid use.
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Rodriguez-Merchan EC, De la Corte-Rodriguez H. Pain management in people with hemophilia in childhood and young adulthood. Expert Rev Hematol 2021; 14:525-535. [PMID: 34042011 DOI: 10.1080/17474086.2021.1935852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: People with hemophilia (PWH) commonly experience acute and chronic musculoskeletal pain during childhood and young adulthood, but their treatment is often inadequate.Areas covered: From 1 September 2020 to 15 April 2021, authors performed a literature search in PubMed and the Cochrane Library using 'hemophilia AND pain' as keywords. Authors found 1082 articles, 51 of which were chosen because we considered them to be intimately connected with the topic of this report. Multimodal pain treatment, including multimodal analgesia, physical and rehabilitation medicine (PRM), and psychological therapies (imagery or relaxation, hypnosis), is currently the most recommended treatment for PWH. In acute hemarthrosis, in addition to hematologic treatment and joint aspiration, paracetamol/acetaminophen should be prescribed if the pain is mild, metamizole if the pain is moderate, and soft opioids (codeine or tramadol) if the pain is severe. In cases of chronic musculoskeletal pain due to hemophilic arthropathy, paracetamol/acetaminophen, COX-2 inhibitors, PRM, intra-articular injections of some drugs (corticosteroids, hyaluronic acid, platelet-rich plasma, mesenchymal stem cells), radiosynovectomy and behavioral therapies are advised.Expert opinion: Management of musculoskeletal pain in children and young adults with hemophilia should employ multimodal pain treatment (multimodal analgesia, PRM, and psychological strategies).
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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18
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Hunsberger JB, Monitto CL, Hsu A, Yenokyan G, Jelin E. Pediatric surgeon opioid prescribing behavior: A survey of the American Pediatric Surgery Association membership. J Pediatr Surg 2021; 56:875-882. [PMID: 33039104 DOI: 10.1016/j.jpedsurg.2020.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/04/2020] [Accepted: 08/21/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The opioid crisis has led to increasing numbers of overdose fatalities in teens and young adults. Surgery, as a common cause of acute pain in children, drives much of the opioid prescribing in pediatrics. Therefore, we sought to characterize opioid prescribing practices of pediatric surgeons by surveying members of the American Pediatric Surgery Association (APSA). STUDY DESIGN After receiving approval from our institutional review board, we sent an online survey to the entire APSA membership. The survey included four vignettes of common pediatric surgical procedures with questions regarding analgesic prescribing practices, the rationale for these practices, and knowledge about opioid risk mitigation. RESULTS Of 1127 APSA members contacted, 327 (29%) provided survey responses. For all vignettes, opioid prescribing was within standard ranges for 83% of respondents. Eighty-eight percent of respondents prescribed nonopioid pain medicine. Additionally, 25% reported routinely utilizing a prescription drug monitoring program, 64% did not tell patients how to dispose of opioids, and 37% did not know themselves how to dispose of leftover opioids. CONCLUSIONS Prescribing by APSA surgeons is largely within standard ranges, but improvement is needed, particularly regarding opioid disposal. Procedure-specific consensus guidelines for opioid prescribing and opioid risk mitigation strategies are warranted. LEVEL OF EVIDENCE Observational study, level III.
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Affiliation(s)
- Joann B Hunsberger
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21287.
| | - Constance L Monitto
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21287
| | - Aaron Hsu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21287
| | - Gayane Yenokyan
- Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Eric Jelin
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins University, Baltimore, MD 21287
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19
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Cartmill RS, Yang DY, Walker BJ, Bradfield YS, Kille TL, Su RR, Kohler JE. Opioid prescribing to preteen children undergoing ambulatory surgery in the United States. Surgery 2021; 170:925-931. [PMID: 33902922 DOI: 10.1016/j.surg.2021.03.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Overuse and misuse of opioids is a continuing crisis. The most common reason for children to receive opioids is postoperative pain, and they are often prescribed more than needed. The amount of opioids prescribed varies widely, even for minor ambulatory procedures. This study uses a large national sample to describe filled opioid prescriptions to preteen patients after all ambulatory surgical procedures and common standard procedures. METHODS We analyzed Truven Health MarketScan data for July 2012 through December 2016 to perform descriptive analyses of opioid fills by age and geographic area, change over time, second opioid fills in opioid-naïve patients, and variation in the types and amount of medication prescribed for 18 common and standard procedures in otolaryngology, urology, general surgery, ophthalmology, and orthopedics. RESULTS Over 10% of preteen children filled perioperative opioid prescriptions for ambulatory surgery in the period 2012 to 2016. The amount prescribed varied widely (median 5 days' supply, IQR 3-8, range 1-90), even for the most minor procedures, for example, frenotomy (median 4 days' supply, IQR 2-5, range 1-60). Codeine fills were common despite safety concerns. Second opioid prescriptions were filled by opioid-naïve patients after almost all procedures studied. The rate of prescribing declined significantly over time and varied substantially by age and across census regions. CONCLUSIONS We identified opioid prescribing outside of the norms of standard practice in all of the specialties studied. Standardizing perioperative opioid prescribing and developing guidelines on appropriate prescribing for children may reduce the opioids available for misuse and diversion.
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Affiliation(s)
- Randi S Cartmill
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, WI; Department of Surgery, University of Wisconsin, Madison, WI.
| | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin, Madison, WI
| | | | - Yasmin S Bradfield
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI
| | - Tony L Kille
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Ruthie R Su
- Department of Urology, University of Wisconsin, Madison, WI
| | - Jonathan E Kohler
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, WI; Department of Surgery, University of Wisconsin, Madison, WI
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20
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Manworren RCB, Kaduwela N, Mishra T, Cooper J. Children's Opioid Use at Home After Laparoscopic Appendectomy. Pain Manag Nurs 2021; 22:708-715. [PMID: 33812791 DOI: 10.1016/j.pmn.2021.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/08/2021] [Accepted: 02/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND To combat the opioid epidemic, prescribers need accurate information about pediatric home opioid requirements to manage acute pain after surgery. Current opioid use estimates come from retrospective surveys; this study used medication adherence technology (eCAP) to track home opioid use. PURPOSE To describe children's pain treatment at home after laparoscopic appendectomy, and to compare self-reported opioid analgesic use to eCAP data and counts of returned pills. DESIGN Prospective exploratory and descriptive study METHODS: A convenience sample of 96 patients, 10-17 years of age, from a single urban nonprofit children's hospital consented to self-report pain treatment in 14-day diaries and use eCAP to monitor prescribed opioid use at home after laparoscopic appendectomy. RESULTS Patients were prescribed 5-45 opioid-containing pills (mean ± standard deviation 15 ± 7.2). Of 749 opioid-containing pills prescribed to 49 patients who returned data, 689 pills were dispensed, 167.5 were used for the reason prescribed, 488 were returned to families for disposal, and 53.5 were missing. The majority of the 49 patients were opioid naïve (72%), Caucasian (64%), and male (56%), with a mean age of 14 years. Patients used 6.6 ± 6.3 opioid-containing pills by pill count and 5.6 ± 5.1 by self-report, a significant difference (p = .004). Unreported eCAP-enabled pill bottle openings typically occurred on weekends. CONCLUSION Medication adherence technology (eCAP) is a more rigorous method than self-report to estimate opioid needs and detect early opioid misuse. Additional rigorously designed studies of postoperative opioid use are needed to guide opioid prescribing.
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Affiliation(s)
- Renee C B Manworren
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | | | | | - Jessica Cooper
- KaviGlobal, Barrington, Illinois; University of North Carolina Health, Chapel Hill, North Carolina
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21
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Manworren RCB, Cooper J, Mishra T, Kaduwela N. Children's Pain at Home After Laparoscopic Appendectomy. Pain Manag Nurs 2021; 22:623-630. [PMID: 33744106 DOI: 10.1016/j.pmn.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/02/2021] [Accepted: 02/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Hospitalized children experience moderate-to-severe pain after laparoscopic appendectomy, but knowledge of children's pain experiences after discharge home is limited. Accurate pain assessments are needed to guide appropriate pain treatment. AIMS To describe children's pain at home after laparoscopic appendectomy. DESIGN Prospective exploratory and descriptive METHODS: A convenience sample of 100 patients, aged 10-17 years, who spoke or wrote in English or Spanish, volunteered to complete 14-day pain diaries at home after laparoscopic appendectomy. Visual analytic techniques were used to analyze patterns of pain experiences. RESULTS Diaries were returned by 45 patients/parents, the majority of whom were White (64%), male (56%), adolescents (mean age 14 years) with no previous surgical history (70%), and whose appendix was inflamed (87%) but not perforated. More than 50% reported severe pain (4 or 5 on a 0-5 scale) on the first full day home after laparoscopic appendectomy. On day 7, 40% reported pain and on day 14, 16% were still reporting pain. Only rarely were pain scores not clinically significantly lower 1 hour after pain treatment, regardless of treatment type (e.g., nondrug, nonopioid, opioid). Reported pain intensity steadily decreased over time as did frequency of recorded pain scores. CONCLUSION Adolescents experience severe pain at home after laparoscopic appendectomy and some experience pain for 7 to 14 days after hospital discharge. Visual analytics better represent the dynamics of pain experiences than measures of central tendency.
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Affiliation(s)
- Renee C B Manworren
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago 60611, Illinois; Northwestern University Feinberg School of Medicine, Chicago 60611, Illinois.
| | - Jessica Cooper
- University of North Carolina Health, Chapel Hill, North Carolina
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22
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Calderon T, Hedges E, Livingston MH, Gitzelmann C, Pegoli W, Wakeman D. Opioid stewardship in pediatric surgery: Approaching zero. J Pediatr Surg 2021; 56:573-579. [PMID: 33008639 DOI: 10.1016/j.jpedsurg.2020.08.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/07/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION In response to the opioid epidemic, we hypothesized that adequate pain control can be achieved with few, if any, opioid prescriptions at discharge following pediatric surgical procedures. METHODS All records for patients 0-15 years old who underwent pediatric surgical operations from December 2017 through May 2018 were reviewed. Opioids prescriptions, emergency department (ED) visits, and hospital readmissions were recorded. Postoperative pain was assessed on a scale from 0 to 10 via phone call within three days of discharge. RESULTS 352 patients underwent 394 surgical procedures. Three patients were prescribed opioids at discharge. There were no pain-related readmissions. One patient returned to the ED owing to pain. 116 unique pain scores were obtained from 114 patients: score 0 (n = 69, 59%), 1-3 (n = 31, 27%), 4-5 (n = 11, 9%), 6-8 (n = 5, 4%), and 9-10 (n = 0, 0%). There was a positive association between pain and increasing age (r = 0.26, p = 0.005). No patients who underwent hernia repair reported a pain score greater than 3. CONCLUSIONS Adequate pain control at discharge after pediatric general surgical procedures can be achieved for most children with scheduled nonopioid medications only. A limited supply of opioids for analgesia after discharge may benefit small subset of patients. This strategy would help reduce opioid prevalence in the community. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Thais Calderon
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Elizabeth Hedges
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Michael H Livingston
- Division of Pediatric Surgery, Department of Surgery, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY
| | - Christopher Gitzelmann
- Division of Pediatric Surgery, Rutgers Robert Wood Johnson Medical School, Saint Barnabas Medical Center, Livingston, NJ
| | - Walter Pegoli
- Division of Pediatric Surgery, Department of Surgery, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY
| | - Derek Wakeman
- Division of Pediatric Surgery, Department of Surgery, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY.
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23
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Mansfield SA, Kimble A, Rodriguez L, Murphy AJ, Gorantla S, Huang EY, Anghelescu DL, Davidoff AM. Validating an opioid prescribing algorithm in post-operative pediatric surgical oncology patients. J Pediatr Surg 2020; 56:S0022-3468(20)30689-8. [PMID: 34756373 DOI: 10.1016/j.jpedsurg.2020.09.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/22/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE We developed an algorithm to decrease opioid prescriptions for pediatric oncology patients at discharge following surgery, based on a retrospective analysis to decrease variability and over-prescribing. The aim of this study was to prospectively test the algorithm. METHODS Opioid-naïve patients undergoing surgery for tumor resection at a single institution were included. A prescribing algorithm was developed based on surgical approach, day of discharge, and inpatient opioid use. Prospectively collected data included outpatient opioid consumption and patient/family satisfaction. Total home dose prescribed was equal to that used in the 8 or 24 h, depending on length of stay and operative approach, prior to discharge, divided into 0.15 mg/kg doses. RESULTS The algorithm was used in 121 patients and correctly predicted outpatient opioid requirements for 102 patients (84.3%). For 15 (12.4%) patients, the algorithm over-estimated opioid need by an average of 0.38 OME/kg. Four (3.3%) patients required additional opioids. Using this algorithm, we decreased overall opioid prescriptions from 6.17 to 0.21 OME/kg (p < 0.001), and all but one patient/family reported being satisfied with post-operative pain control. CONCLUSION Using an algorithm based on inpatient opioid use, outpatient opioid needs can be accurately predicted, thereby reducing excess opioid prescriptions without detriment to patient satisfaction. TYPE OF STUDY Prospective Quality Initiative Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Sara A Mansfield
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN.
| | - Amy Kimble
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN
| | - Lynn Rodriguez
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN
| | - Andrew J Murphy
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN; Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Shilpa Gorantla
- Quality and Patient Care, St. Jude Children's Research Hospital, Memphis, TN
| | - Eunice Y Huang
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Doralina L Anghelescu
- Division of Anesthesiology, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN; Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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24
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Pergolizzi JV, Magnusson P, Raffa RB, LeQuang JA, Coluzzi F. Developments in combined analgesic regimens for improved safety in postoperative pain management. Expert Rev Neurother 2020; 20:981-990. [PMID: 32749896 DOI: 10.1080/14737175.2020.1806058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: Fixed-dose combination analgesic regimens may be similarly effective to opioid monotherapy but with potentially less risk. A number of individualized combination regimens can be created, including nonopioid agents such as acetaminophen and nonsteroidal anti-inflammatory drugs, opioids, and adjunctive agents such as gabapentin, pregabalin, and muscle relaxants. Areas covered: When such combinations have a synergistic effect, analgesic benefits may be enhanced. Many combination analgesic regimens are opioid sparing, which sometimes but not always results in reduced opioid-associated side effects. Safety concerns for all analgesics must be considered but postoperative analgesia is typically administered for a brief period (days), reducing risks that may occur with prolonged exposure. Expert opinion: Judiciously considered combination analgesic regimens can be effective postoperative analgesics that reduce opioid consumption without compromising pain control, which are important factors for patient recovery and satisfaction. The specific combinations used must be based on the patient, the type and duration of the surgical procedure, and complementary mechanisms of action of the agents used. In opioid-sparing combination analgesic regimens, the short-term use of small doses of opioids in this setting may be helpful for appropriate patients.
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Affiliation(s)
| | - Peter Magnusson
- Centre for Research and Development, Uppsala/Region Gävleborg , Gävle, Sweden.,Department of Medicine, Cardiology Research Unit, Karolinska Institutet , Stockholm, Sweden
| | - Robert B Raffa
- Professor Emeritus and past Chair, Temple University School of Pharmacy , Philadelphia, Pennsylvania, USA.,Department of Pharmacology, University of Arizona College of Pharmacy , Tucson, Arizona, USA.,CSO, Neumentum , Palo Alto, California, USA
| | - Jo Ann LeQuang
- Pain Medicine, NEMA Research, Inc , Naples, Florida, USA
| | - Flaminia Coluzzi
- Department Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome , Rome, Italy
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25
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Lazar DJ, Zaveri S, Khetan P, Nobel TB, Divino CM. Variations in postoperative opioid prescribing by day of week and duration of hospital stay. Surgery 2020; 169:929-933. [PMID: 32684334 DOI: 10.1016/j.surg.2020.05.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/29/2020] [Accepted: 05/27/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Studies demonstrate wide variation in postoperative opioid prescribing and that patients are at risk of chronic opioid abuse after surgery. The factors that influence prescribing, however, remain obscure. This study investigates whether day of the week or the postoperative day at the time of discharge impacts prescribing patterns. METHODS We identified patients who underwent commonly performed procedures at our institution from January 2014 through April 2019 and analyzed the relationship between postoperative opioids prescribed (oral morphine milligram equivalents) and both the day of the week and the postoperative day at discharge. RESULTS In ambulatory operations (n = 13,545), each day progressing from Monday was associated with increased morphine milligram equivalents prescribed on discharge (P = .0080). For inpatient cases (n = 10,838), surgeons prescribed more morphine milligram equivalents at discharge in the latter half of the week and during the weekend (P = .0372). Every additional postoperative day at discharge was associated with a +19.25 morphine milligram equivalent prescribed (P < .0001). CONCLUSION More opioids were prescribed on discharges later in the week and after prolonged hospital stays perhaps to avoid patients running out of medication. Providers may unintentionally allow such non-clinical factors to influence postoperative opioid prescribing. Increased awareness of these inadvertent biases may help decrease excess prescribing of potentially addicting opioids after an operation.
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Affiliation(s)
- Damien J Lazar
- Department of Surgery, The Mount Sinai Hospital, New York, NY.
| | - Shruti Zaveri
- Department of Surgery, The Mount Sinai Hospital, New York, NY
| | - Prerna Khetan
- Department of Surgery, The Mount Sinai Hospital, New York, NY
| | - Tamar B Nobel
- Department of Surgery, The Mount Sinai Hospital, New York, NY
| | - Celia M Divino
- Department of Surgery, The Mount Sinai Hospital, New York, NY
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