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Thomas C, Ayres M, Pye K, Yassin D, Howell SJ, Alderson S. Process, structural, and outcome quality indicators to support perioperative opioid stewardship: a rapid review. Perioper Med (Lond) 2023; 12:34. [PMID: 37430326 DOI: 10.1186/s13741-023-00312-4] [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: 06/13/2022] [Accepted: 05/19/2023] [Indexed: 07/12/2023] Open
Abstract
Opioids are effective analgesics but can cause harm. Opioid stewardship is key to ensuring that opioids are used effectively and safely. There is no agreed set of quality indicators relating to the use of opioids perioperatively. This work is part of the Yorkshire Cancer Research Bowel Cancer Quality Improvement programme and aims to develop useful quality indicators for the improvement of care and patient outcomes at all stages of the perioperative journey.A rapid review was performed to identify original research and reviews in which quality indicators for perioperative opioid use are described. A data tool was developed to enable reliable and reproducible extraction of opioid quality indicators.A review of 628 abstracts and 118 full-text publications was undertaken. Opioid quality indicators were identified from 47 full-text publications. In total, 128 structure, process and outcome quality indicators were extracted. Duplicates were merged, with the final extraction of 24 discrete indicators. These indicators are based on five topics: patient education, clinician education, pre-operative optimization, procedure, and patient-specific prescribing and de-prescribing and opioid-related adverse drug events.The quality indicators are presented as a toolkit to contribute to practical opioid stewardship. Process indicators were most commonly identified and contribute most to quality improvement. Fewer quality indicators relating to intraoperative and immediate recovery stages of the patient journey were identified. An expert clinician panel will be convened to agree which of the quality indicators identified will be most valuable in our region for the management of patients undergoing surgery for bowel cancer.
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Affiliation(s)
- C Thomas
- Department of Anaesthesia, St. James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK.
| | - M Ayres
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - K Pye
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Yassin
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - S J Howell
- Leeds Institute of Health Research, University of Leeds, Leeds, UK
| | - S Alderson
- Primary Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Fagenson AM, Schleider C, Philp MM, Noonan KM, Braun PA, Cowan S, Pitt HA. Preoperative Opioid and Benzodiazepine Use: Influence on Abdominal Surgical Outcomes. J Am Coll Surg 2023; 236:925-934. [PMID: 36661320 DOI: 10.1097/xcs.0000000000000572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Preoperative opioid use has shown association with worse outcomes after surgery. However, little is known about the effect of preoperative benzodiazepines with and without opioids. The aim of this study was to determine the influence of preoperative substance use on outcomes after abdominal surgery. STUDY DESIGN Patients undergoing abdominal operations including ventral hernia, colectomy, hysterectomy, cholecystectomy, appendectomy, nephrectomy, and hiatal hernia were identified in an opioid surgical steward program by a regional NSQIP consortium between 2019 and 2021. American College of Surgeons NSQIP data were linked with custom substance use variables created by the collaborative. Univariable and multivariable analyses were performed for 30-day outcomes. RESULTS Of 4,439 patients, 64% (n = 2,847) were women, with a median age of 56 years. The most common operations performed were hysterectomy (22%), ventral hernia repair (22%), and colectomy (21%). Preoperative opioid use was present in 11% of patients (n = 472), 10% (n = 449) were on benzodiazepines, and 2.3% (n = 104) were on both. Serious morbidity was significantly (p < 0.001) increased in patients on preoperative opioids (16% vs 7.9%) and benzodiazepines (14% vs 8.3%) compared with their naïve counterpart and this effect was amplified in patients on both substances (20% vs 7.5%). Multivariable regression analyses reveal that preoperative substance use is an independent risk factor (p < 0.01) for overall morbidity and serious morbidity. CONCLUSIONS Preoperative opioid and benzodiazepine use are independent risk factors that contribute to postoperative morbidity. This influence on surgical outcomes is exacerbated when patients are on both substances.
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Affiliation(s)
- Alexander M Fagenson
- From the Department of Surgery, Temple University Hospital, Philadelphia, PA (Fagenson, Philp)
| | - Christine Schleider
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA (Schleider, Cowan)
| | - Matthew M Philp
- From the Department of Surgery, Temple University Hospital, Philadelphia, PA (Fagenson, Philp)
| | - Kristin M Noonan
- Department of Surgery, Jefferson Health-Abington Hospital, Thomas Jefferson University, Abington, PA (Noonan)
| | - Pamela A Braun
- Health Care Improvement Foundation, Philadelphia, PA (Braun)
| | - Scott Cowan
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA (Schleider, Cowan)
| | - Henry A Pitt
- the Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (Pitt)
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Josephs CA, Shaffer VO, Kucera WB. Impact of Mental Health on General Surgery Patients and Strategies to Improve Outcomes. Am Surg 2022:31348221109469. [PMID: 35730505 DOI: 10.1177/00031348221109469] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Mental Health Disorders (MHD) are a growing concern nationwide. The significant impact MHD have on surgical outcomes has only recently started to be understood. This literature review investigated how mental health impacts the outcomes of general surgery patients and what can be done to make improvements. Patients with schizophrenia had the poorest surgical outcomes. Mental health disorders increased post-surgical pain, hospital length of stay, complications, readmissions, and mortality. Mental health disorders decreased wound healing and quality of care. Optimizing outcomes will be best accomplished through integrating more effective perioperative screening tools and interventions. Screenings tools can incorporate artificial intelligence, MHD data, resilience and its biomarkers, and patient mental health questionnaires. Interventions include cognitive behavioral therapy, virtual reality, spirituality, pharmacology, and resilience training.
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Affiliation(s)
- Cooper A Josephs
- 364432Campbell University School of Osteopathic Medicine, Lillington, NC, USA
| | - Virginia O Shaffer
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Walter B Kucera
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
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Szabo A, Szabo D, Toth K, Szecsi B, Sandor A, Szentgroti R, Parkanyi B, Merkely B, Gal J, Szekely A. Effect of Preoperative Chronic Opioid Use on Mortality and Morbidity in Vascular Surgical Patients. Cureus 2021; 13:e20484. [PMID: 35047302 PMCID: PMC8760026 DOI: 10.7759/cureus.20484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction Opioid derivates are an essential part of everyday clinical pain management practice. They have excellent analgesic, sedative, and sympatholytic effects and are widely used in various conditions. Beyond advantageous aspects, there are numerous problems with the chronic use of these agents. Dependency and life-threatening complications are the biggest problems with both illegal and prescribed opioid derivates. In our current study, effects of chronic opioid use were observed on mortality and life quality in the case of vascular surgery. Methods This prospective, observational study was conducted between 2014 and 2017. After obtaining informed consent, all participants were asked to fill a questionnaire containing different psychological tests. Perioperative data, chronic medical therapy, and anthropometric data were also collected. Opioid user and non-user patients’ psychological results were compared with non-parametrical tests. The effect of chronic opioid administration was investigated with logistic regression method with bootstrapping. Results Finally, the data of 164 patients were analyzed. 64.0% of participants were male, the mean age was 67.05 years, and the standard deviation was 9.48 years. The median follow-up time was 1312 days [interquartile range (IQR): 930-1582 days]. During the follow-up time, 42 patients died (25.6%). In the examined patient cohort, the frequency of opioid derivate use was 3.7% (only six patients). In the non-survived group, opioid use was significantly higher (1.6% vs. 9.5%, p=0.019). Significant differences were found in the aspect of cognitive performance measured by Mini-Mental State Examination (MMSE), opioid users have had lower points [25.5 (IQR: 24.5-26.0) vs. 28.0 (IQR: 27.0-29.0) p=0.008]. Opioid users have showed higher score on Beck Depression Inventory (BDI) [15.5 (IQR: 10.0-18.0) vs. 6.0 (IQR: 3.0-11.0), p=0.030). In a multivariate Cox regression model built up from registered preoperative medical treatment, opioids were found as a risk factor for all-cause mortality [adjusted hazard ratio (AHR): 4.31, 95% CI: 1.77-10.55, p=0.001]. Conclusion Our current findings suggest that chronic, preoperative use of opioids could associate with increased mortality. Furthermore, both decrease in cognitive performance and increased depression symptoms were found in the opioid user cohorts which emphasize the importance of further risk stratification of these patients.
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Caring for the opioid-dependent patient. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Teng CY, Myers S, Kenkre TS, Doney L, Tsang WL, Subramaniam K, Esper SA, Holder-Murray J. Targets for Intervention? Preoperative Predictors of Postoperative Ileus After Colorectal Surgery in an Enhanced Recovery Protocol. J Gastrointest Surg 2021; 25:2065-2075. [PMID: 33205308 PMCID: PMC8126638 DOI: 10.1007/s11605-020-04876-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/10/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative ileus occurs in up to 30% of colorectal surgery patients and is associated with increased length of stay, costs, and morbidity. While Enhanced Recovery Protocols seek to accelerate postoperative recovery, data on modifiable preoperative factors associated with postoperative ileus in this setting are limited. We aimed to identify preoperative predictors of postoperative ileus following colorectal surgery in Enhanced Recovery Protocols, to determine new intervention targets. METHODS We performed a retrospective single-center cohort study of patients ≥ 18 years old who underwent colorectal surgery via Enhanced Recovery Protocols (7/2015-7/2017). Postoperative ileus was defined as nasogastric tube insertion postoperatively or nil-per-os by postoperative day 4. Preoperative risk factors including comorbidities and medication use were identified using multivariable stepwise logistic regression. RESULTS Of 530 patients, 14.9% developed postoperative ileus. On univariate analysis of perioperative and postoperative factors, postoperative ileus patients had increased psychiatric illness, antidepressant and antipsychotic use, American Society of Anesthesiologists classification, ileostomy creation, postoperative opioid use, complications, surgery duration, and length of stay (p < 0.05). Multivariable logistic regression model for preoperative factors identified psychiatric illness, preoperative antipsychotic use, and American Society of Anesthesiologists classification ≥ 3 as significant predictors of postoperative ileus (p < 0.05). DISCUSSION Postoperative ileus remains a common complication following colorectal surgery under Enhanced Recovery Protocols. Patients with pre-existing psychiatric comorbidities and preoperative antipsychotic use may be a previously overlooked cohort at increased risk for postoperative ileus. Additional research and preoperative interventions within Enhanced Recovery Protocols to reduce postoperative ileus for this higher-risk population are needed.
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Affiliation(s)
- Cindy Y. Teng
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sara Myers
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tanya S. Kenkre
- University of Pittsburgh Epidemiology Data Center Graduate School of Public Health, Pittsburgh, PA
| | - Luke Doney
- Department of Anesthesiology and Pain Management, Cleveland Clinic, Cleveland, OH
| | - Wai Lok Tsang
- Department of Anesthesiology, Cleveland Clinic Florida, Weston, FL
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh PA
| | - Stephen A. Esper
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh PA
| | - Jennifer Holder-Murray
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA,Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh PA
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Perlmutter B, Wynia E, McMichael J, Tu C, Scheman J, Simon R, Walsh RM, Augustin T. Effect of pre-operative opioid exposure on surgical outcomes in elective laparoscopic cholecystectomy. Am J Surg 2021; 223:764-769. [PMID: 34193351 DOI: 10.1016/j.amjsurg.2021.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/15/2021] [Accepted: 06/20/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND The effects of varying levels of pre-operative opioids on post-operative outcomes following elective laparoscopic cholecystectomy is largely unknown. METHODS Patients who underwent elective laparoscopic cholecystectomy from 2012 to 2019 were reviewed and categorized by the number of outpatient opioid prescriptions received in the 90 days preceding surgery: none (Naïve), one (1 Rx), two (2 Rx), or three or more (Chronic). Operative time, hospital length of stay, and 30-day readmission rate were analyzed. RESULTS Of the 11911 patients identified, 2958 (24.8%) used opioids pre-operatively. Among patients with an overnight admission, the Naïve, 1 Rx, and 2 Rx cohorts had a shorter length of stay compared to the Chronic cohort. The Naïve group had the lowest 30-day readmission rate (5.0%) followed by the 1 Rx (5.9%), 2 Rx and Chronic groups (9.1% and 8.7%, respectively) (p < 0.001). CONCLUSIONS Prevalence of pre-operative opioid use is high and warrants surgeon assessment to minimize adverse post-operative outcomes.
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Affiliation(s)
- Breanna Perlmutter
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Elisabeth Wynia
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA; United States Air Force. The Views Expressed in This Paper are Those of the authors and do not Reflect the Official Policy Or Stance of the Department of the Air Force, Department of Defense, Or the U.S. Government, USA
| | - John McMichael
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Chao Tu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Judith Scheman
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Robert Simon
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Toms Augustin
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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Jackson NA, Gan T, Davenport DL, Oyler DR, Ebbitt LM, Evers BM, Bhakta AS. Preoperative opioid, sedative, and antidepressant use is associated with increased postoperative hospital costs in colorectal surgery. Surg Endosc 2020; 35:5599-5606. [PMID: 33034774 PMCID: PMC7545805 DOI: 10.1007/s00464-020-08062-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/29/2020] [Indexed: 11/30/2022]
Abstract
Background Opioid (OPD), sedative (SDT), and antidepressant (ADM) prescribing has increased dramatically over the last 20 years. This study evaluated preoperative OPD, SDT, and ADM use on hospital costs in patients undergoing colorectal resection at a single institution. Methods This study was a retrospective record review. The local ACS-NSQIP database was queried for adult patients (age ≥ 18 years) undergoing open/laparoscopic, partial/total colectomy, or proctectomy from January 1, 2013 to December 31, 2016. Individual patient medical records were reviewed to determine preoperative OPD, SDT, and AD use. Hospital cost data from index admission were captured by the hospital cost accounting system and matched to NSQIP query-identified cases. All ACS-NSQIP categorical patient characteristic, operative risk, and outcome variables were compared in medication groups using chi-square tests or Fisher’s exact tests, and continuous variables were compared using Mann–Whitney U tests. Results A total of 1185 colorectal procedures were performed by 30 different surgeons. Of these, 27.6% patients took OPD, 18.5% SDT, and 27.8% ADM preoperatively. Patients taking OPD, SDT, and ADM were found to have increased mean total hospital costs (MTHC) compared to non-users (30.8 vs 23.6 for OPD, 31.6 vs 24.4 for SDT, and 30.7 vs 23.8 for ADM). OPD and SDT use were identified as independent risk factors for increased MTHC on multivariable analysis. Conclusion Preoperative OPD and SDT use can be used to predict increased MTHC in patients undergoing colorectal resections.
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Affiliation(s)
- Nicholas A Jackson
- Graduate Medical Education, General Surgery Residency Program, University of Kentucky, Lexington, KY, USA
| | - Tong Gan
- Graduate Medical Education, General Surgery Residency Program, University of Kentucky, Lexington, KY, USA
| | | | - Doug R Oyler
- Department of Surgery, University of Kentucky, Lexington, KY, USA
- Division of General Surgery, University of Kentucky, Lexington, KY, USA
| | - Laura M Ebbitt
- Department of Pharmacy Services, University of Kentucky, Lexington, KY, USA
| | - B Mark Evers
- Department of Surgery, University of Kentucky, Lexington, KY, USA
- Division of General Surgery, University of Kentucky, Lexington, KY, USA
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Avinash S Bhakta
- Department of Surgery, University of Kentucky, Lexington, KY, USA.
- Division of General Surgery, University of Kentucky, Lexington, KY, USA.
- Section of Colorectal Surgery, University of Kentucky, Lexington, KY, USA.
- University of Kentucky Medical Center, 800 Rose St., C-233, Lexington, KY, 40536, USA.
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