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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; 176:1226-1232. [PMID: 39048332 DOI: 10.1016/j.surg.2024.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [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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Scalise PN, Koo DC, Durgin JM, Truche BS, Staffa SJ, Greco C, Solodiuk J, Lee EJ, Demehri FR, Kim HB. Cold Therapy for Pain Control in Pediatric Appendectomy Patients: A Randomized Controlled Trial. J Pediatr Surg 2024; 59:1304-1308. [PMID: 38570264 DOI: 10.1016/j.jpedsurg.2024.02.036] [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: 02/06/2024] [Accepted: 02/26/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE Topical ice has been shown to reduce pain scores and opioid use in adults with midline abdominal incisions. This study was designed to evaluate the efficacy of a cold therapy system in children following laparoscopic appendectomy. METHODS Patients 7 years and older who underwent laparoscopic appendectomy at our institution from December 2021-September 2022 were eligible. Patients were randomized to standard pain therapy (control) or standard plus cold therapy (treatment) utilizing a modified ice machine system with cool abdominal pad postoperatively. Pain scores on the first 3 postoperative days (PODs), postoperative narcotic consumption, and patient satisfaction were analyzed. RESULTS Fifty-eight patients were randomized, 29 to each group. Average survey response rate was 74% in control and 89% in treatment patients. There was no significant difference in median pain scores or narcotic use between groups. Cold therapy contributed to subjective pain improvement in 71%, 74%, and 50% of respondents on PODs 1, 2, and 3 respectively. CONCLUSION A majority of patients reported cold therapy to be a helpful adjunct in pain control after appendectomy, though it did not reduce postoperative pain scores or narcotic use in our cohort - likely due to this population's naturally expedient recovery and low baseline narcotic requirement. TYPE OF STUDY Randomized Controlled Trial. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- P Nina Scalise
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.
| | - Donna C Koo
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Jonathan M Durgin
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Brianna Slatnick Truche
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Christine Greco
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Jean Solodiuk
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Eliza J Lee
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
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Keane OA, Motley T, Robinson J, Smith A, Short HL, Santore MT. Standardization of Antibiotic Management and Reduction of Opioid Prescribing in Pediatric Complicated Appendicitis: A Quality Improvement Initiative. J Pediatr Surg 2024; 59:1058-1065. [PMID: 38030531 DOI: 10.1016/j.jpedsurg.2023.11.001] [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: 09/01/2023] [Revised: 10/27/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Appendicitis is one of the most common pediatric surgical procedures in the United States. However, wide variation remains in antibiotic prescribing and pain management across and within institutions. We aimed to minimize variation in antibiotic usage and decrease opioid prescribing at discharge for children with complicated appendicitis by implementation of a quality improvement (QI) initiative. METHODS On December 1st, 2021, a QI initiative standardizing postoperative care for complicated appendicitis was implemented across a tertiary pediatric healthcare system with two main surgical centers. QI initiative focused on antibiotic and pain management. An extensive literature search was performed and a total of 20 articles matching our patient population were critically appraised to determine the best evidence-based interventions to implement. Antibiotic regimen included: IV or PO ceftriaxone/metronidazole immediately post-operatively and transition to PO amoxicillin-clavulanic acid for completion of 7-day total course at discharge. Discharge pain control regimen included acetaminophen, ibuprofen, as needed gabapentin, and no opioid prescription. Guideline compliance were closely monitored for the first six months following implementation. RESULTS In the first 6-months post-implementation, compliance with use of ceftriaxone/metronidazole as initial post-operative antibiotics was 75.6 %. Transition to PO amoxicillin-clavulanic acid prior to discharge increased from 13.7 % pre-implementation to 73.7 % 6-months post-implementation (p < 0.001). Compliance with a 7-day course of antibiotics within the first 6-months post-implementation was 60 % across both sites. After QI intervention, overall opioid prescribing remained at 0 % at one surgical site and decreased from 17.6 % to 0 % at the second surgical site over the study timeframe (p < 0.001). CONCLUSION Antibiotic use can be standardized and opioid prescribing minimized in children with complicated appendicitis using QI principles. Continued monitoring of the complicated appendicitis guideline is needed to assess for further progress in the standardization of post-operative care. STUDY TYPE Quality improvement. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Olivia A Keane
- Department of Surgery, Emory University, Atlanta, GA, USA.
| | - Theresa Motley
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jenny Robinson
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Alexis Smith
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Matthew T Santore
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Lascano D, Zamora AK, Mahdi E, Ourshalimian S, Russell CJ, Kim E, Kelley-Quon LI. Gabapentin is Associated With Decreased Postoperative Opioid Use and Length of Stay After Appendectomy in Children With Perforated Appendicitis: A Propensity Score-Matched Analysis. J Pediatr Surg 2023; 58:1935-1941. [PMID: 37029026 PMCID: PMC10771856 DOI: 10.1016/j.jpedsurg.2023.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/17/2023] [Accepted: 03/13/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Gabapentin is increasingly used as an off-label, opioid-sparing pain medication in children. We investigated perioperative gabapentin administration and postoperative opioid use in children who underwent appendectomy for perforated appendicitis. METHODS A retrospective cohort study of healthy children ages 2-18 years undergoing appendectomy for perforated appendicitis from 2014 to 2019 was performed using the Pediatric Health Information System®. Propensity score matched (PSM) analysis was conducted with 1:1 matching based on patient and hospital characteristics. Multivariable linear regression analysis was used to evaluate an association between gabapentin, postoperative opioid use, and postoperative length of stay. RESULTS Of 29,467 children with perforated appendicitis who underwent appendectomy, 236 (0.8%) received gabapentin. In 2014, <10 children received gabapentin, but by 2019, 110 children received gabapentin. On univariate analysis of the PSM cohort, children receiving gabapentin had decreased total postoperative opiate use (2.3 SD ± 2.3 versus 3.0 SD ± 2.5 days, p < 0.001). On adjusted analysis, children receiving gabapentin had 0.65 fewer days of postoperative total opioid use (95% CI: -1.09, -0.21) and spent 0.69 fewer days in the hospital after surgery (95% CI: -1.30, -0.08). CONCLUSION While overall use is infrequent, gabapentin is increasingly administered to children with perforated appendicitis who undergo an appendectomy and is associated with decreased postoperative opioid use and reduced postoperative length of stay. Multimodal pain management strategies incorporating gabapentin may reduce postoperative opioid consumption, but further studies of drug safety are needed for this off-label use in children undergoing surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Danny Lascano
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Abigail K Zamora
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Elaa Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA; Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Eugene Kim
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, 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 of the University of Southern California, Los Angeles, CA, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA.
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Keane OA, Zamora AK, Ourshalimian S, Mahdi EM, Song AY, Kim E, Lakshmanan A, Kim ES, Kelley-Quon LI. Opioid and Methadone Use for Infants With Surgically Treated Necrotizing Enterocolitis. JAMA Netw Open 2023; 6:e2318910. [PMID: 37347485 PMCID: PMC10288332 DOI: 10.1001/jamanetworkopen.2023.18910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/02/2023] [Indexed: 06/23/2023] Open
Abstract
Importance Necrotizing enterocolitis (NEC) requiring surgical intervention is the most common reason for surgical procedures in preterm neonates. Opioids are used to manage postoperative pain, with some infants requiring methadone to treat physiologic opioid dependence or wean from nonmethadone opioid treatment during recovery. Objective To describe postoperative opioid use and methadone treatment for infants with surgically treated NEC and evaluate postoperative outcomes. Design, Setting, and Participants A cohort study of infants with surgically treated NEC admitted from January 1, 2013, to December 31, 2022, to 48 Children's Hospital Association hospitals contributing data to the Pediatric Health Information System (PHIS) was performed. Infants who received methadone preoperatively, were aged 14 days or less at the time of the operation, had a congenital heart disease-related operation, or died within 90 days of the operation were excluded. Mixed-effects multivariable logistic regression was used to evaluate thresholds for duration of opioid use after the operation associated with methadone treatment and clinical outcomes associated with methadone use were enumerated. Exposure Postoperative administration of nonmethadone opioids. Main Outcomes and Measures Methadone use and postoperative length of stay, ventilator days, and total parenteral nutrition (TPN) days. Results Of the 2037 infants with surgically treated NEC identified, the median birth weight was 920 (IQR, 700.0-1479.5) g; 1204 were male (59.1%), 911 were White (44.7%), and 343 were Hispanic (16.8%). Infants received nonmethadone opioids for a median of 15 (IQR, 6-30) days after the operation and 231 received methadone (11.3%). The median first day of methadone use was postoperative day 18 (IQR, days 9-64) and continued for 28 days (IQR, 14-73). Compared with infants who received nonmethadone opioids for 1 to 5 days, infants receiving 16 to 21 days of opioids were most likely to receive methadone treatment (odds ratio, 11.45; 95% CI, 6.31-20.77). Methadone use was associated with 21.41 (95% CI, 10.81-32.02) more days of postoperative length of stay, 10.80 (95% CI, 3.63-17.98) more ventilator days, and 16.21 (95% CI, 6.34-26.10) more TPN days. Conclusions and Relevance In this cohort study of infants with surgically treated NEC, prolonged use of nonmethadone opioids after the operation was associated with an increased likelihood of methadone treatment and increased postoperative length of stay, ventilation, and TPN use. Optimizing postoperative pain management for infants requiring an operation may decrease the need for methadone treatment and improve health care use.
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Affiliation(s)
- Olivia A. Keane
- 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
| | - Abigail K. Zamora
- 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
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Elaa M. Mahdi
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Ashley Y. Song
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Eugene Kim
- Department of Anesthesia, Children’s Hospital Los Angeles, Los Angeles, California
| | - Ashwini Lakshmanan
- Division of Neonatology, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles
| | - Eugene S. Kim
- Department of Surgery, Cedars-Sinai Health System, 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
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles
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Kingston P, Lascano D, Ourshalimian S, Russell CJ, Kim E, Kelley-Quon LI. Ketorolac use and risk of bleeding after appendectomy in children with perforated appendicitis. J Pediatr Surg 2022; 57:1487-1493. [PMID: 34893309 PMCID: PMC9133265 DOI: 10.1016/j.jpedsurg.2021.11.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 11/18/2021] [Accepted: 11/21/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ketorolac is an opioid sparing agent commonly used in children. However, ketorolac may be avoided in children with peritonitis owing to a possible increased risk of bleeding. METHODS A retrospective cohort study of healthy children 2-18 years who underwent appendectomy for perforated appendicitis was performed using the Pediatric Health Information System (2009-2019). Multivariable logistic regression was used to evaluate the association between perioperative ketorolac use and postoperative blood transfusions within 30 days of surgery, adjusting for patient and hospital level factors. An interaction between ketorolac and ibuprofen was evaluated to identify synergistic effects. RESULTS Overall, 55,603 children with perforated appendicitis underwent appendectomy and 82.3% (N = 45,769) received ketorolac. Of those, 32% (N = 14,864) also received ibuprofen. Receipt of a blood transfusion was infrequent (N = 189, 0.3%). On multivariable logistic regression analysis, perioperative ketorolac administration was associated with decreased odds of a blood transfusion (OR 0.53, 95% CI: 0.35-0.79). However, children receiving ketorolac and ibuprofen were more likely to require a blood transfusion (OR 1.99, 95% CI: 1.42-2.79). In a subset of children receiving ketorolac, each additional day of ketorolac was associated with an increase odds of blood transfusion (OR 1.39, 95% CI: 1.30-1.49). CONCLUSION Perioperative ketorolac alone is not associated with an increased risk of significant bleeding in children undergoing appendectomy for perforated appendicitis. However, use of both ketorolac and ibuprofen during hospitalization was associated with increased risk of bleeding, although precise timing of administration of these medications was unable to be determined. Extended ketorolac use was also associated with increased risk of bleeding requiring blood transfusion. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Paige Kingston
- Division of Pediatric Surgery, Children’s Hospital of Los Angeles, Department of Surgery, Keck School of Medicine of the University of Southern California. 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Danny Lascano
- Division of Pediatric Surgery, Children’s Hospital of Los Angeles, Department of Surgery, Keck School of Medicine of the University of Southern California. 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children’s Hospital of Los Angeles, Department of Surgery, Keck School of Medicine of the University of Southern California. 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Christopher J. Russell
- Division of Hospital Medicine, Children’s Hospital of Los Angeles, Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles. 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Eugene Kim
- Children’s Hospital of Los Angeles, Division of Pain Medicine. 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Lorraine I. Kelley-Quon
- Division of Pediatric Surgery, Children’s Hospital of Los Angeles, Department of Surgery, Keck School of Medicine of the University of Southern California. 4650 Sunset Blvd, Los Angeles, CA 90027, United States.,Department of Preventive Medicine, University of Southern California. 2001 N Soto St, Los Angeles, CA 90032, United States.,Corresponding Author. Lorraine Kelley-Quon, Assistant Professor of Clinical Surgery and Preventive Medicine, Division of Pediatric Surgery, Children’s Hospital Los Angeles, Department of Surgery and Preventive Medicine, Keck School of Medicine of University of Southern California, 4650 Sunset Blvd. MS #100, Los Angeles, CA 90027, Phone: 323-361-1628, Fax: 323-361-3534, Cell: 323- 397-8539, Twitter Handles: @LKelley_Quon, @HOPE_sci_lab, @ChildrensLA,
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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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