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Candelaria A, Marek L, Kanda D, Griego J, Rutledge T. Developing and Implementing a Patient-Centered Opioid Prescribing Algorithm among Gynecological Oncology Patients. J Womens Health (Larchmt) 2024. [PMID: 38709003 DOI: 10.1089/jwh.2023.0998] [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: 05/07/2024] Open
Abstract
Background: The opioid epidemic is a public health crisis. However, opioid prescription recommendations have not been established in gynecological oncology, and guidelines that incorporate patient-reported pain are lacking. Objectives: The article aims to evaluate prescribing patterns, utilization, and patient-reported pain control in gynecological oncology patients at a large tertiary academic center. Methods: This was a two-phase, prospective cohort study. For Phase 1, patients undergoing hysterectomy through the gynecological oncology division at the University of New Mexico were enrolled. Postoperative opioid use was collected and standardized to oral morphine milligram equivalents (MMEs). The factors associated with outpatient opioid use were used to develop an opioid prescription algorithm. In Phase 2, we evaluated the implementation of the prescription algorithm. For both phases, patients completed a demographic survey, satisfaction survey, and validated pain questionnaires. Results: In Phase 1, the amount of opioids used was significantly lower than the amount of opioids prescribed. Factors that correlated with postoperative opioid use included surgical procedures and last 24-hour inpatient MME use. A standardized opioid prescription algorithm was developed by incorporating these factors. In Phase 2, the opioid prescribing algorithm there was no significant difference in pain scores between the two phases. Conclusions: Opioids were substantially overprescribed in gynecological oncology patients undergoing hysterectomy. Our study found that the surgical route and last 24-hour MME inpatient usage were reliable predictors of outpatient opioid use. We developed and implemented a standardized opioid prescription algorithm that was validated by comparing the pain control measures in the two phases.
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Affiliation(s)
- Ashlee Candelaria
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Lauren Marek
- Department of Surgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Deborah Kanda
- UNM Comprehensive Cancer Center, Albuquerque, New Mexico, USA
| | - Jamie Griego
- Rush University Medical Center, Chicago, Illinois, USA
| | - Teresa Rutledge
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico, USA
- UNM Comprehensive Cancer Center, Albuquerque, New Mexico, USA
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Huepenbecker SP, Iniesta MD, Wang XS, Cain KE, Zorrilla-Vaca A, Shen SE, Basabe MS, Suki T, Garcia Lopez JE, Mena GE, Lasala JD, Williams LA, Ramirez PT, Meyer LA. Longitudinal perioperative patient-reported outcomes in open compared with minimally invasive hysterectomy. Am J Obstet Gynecol 2024; 230:241.e1-241.e18. [PMID: 37827271 DOI: 10.1016/j.ajog.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND There are few prospective studies in the gynecologic surgical literature that compared patient-reported outcomes between open and minimally invasive hysterectomies within enhanced recovery after surgery pathways. OBJECTIVE This study aimed to compare prospectively collected perioperative patient-reported symptom burden and interference measures in open compared with minimally invasive hysterectomy cohorts within enhanced recovery after surgery pathways. STUDY DESIGN We compared patient-reported symptom burden and functional interference in 646 patients who underwent a hysterectomy (254 underwent open surgery and 392 underwent minimally invasive surgery) for benign and malignant indications under enhanced recovery after surgery protocols. Outcomes were prospectively measured using the validated MD Anderson Symptom Inventory, which was administered perioperatively up to 8 weeks after surgery. Cohorts were compared using Fisher exact and chi-squared tests, adjusted longitudinal generalized linear mixed modeling, and Kaplan Meier curves to model return to no or mild symptoms. RESULTS The open cohort had significantly worse preoperative physical functional interference (P=.001). At the time of hospital discharge postoperatively, the open cohort reported significantly higher mean symptom severity scores and more moderate or severe scores for overall (P<.001) and abdominal pain (P<.001), fatigue (P=.001), lack of appetite (P<.001), bloating (P=.041), and constipation (P<.001) when compared with the minimally invasive cohort. The open cohort also had significantly higher interference in physical functioning (score 5.0 vs 2.7; P<.001) than the minimally invasive cohort at the time of discharge with no differences in affective interference between the 2 groups. In mixed modeling analysis of the first 7 postoperative days, both cohorts reported improved symptom burden and functional interference over time with generally slower recovery in the open cohort. From 1 to 8 postoperative weeks, the open cohort had worse mean scores for all evaluated symptoms and interference measures except for pain with urination, although scores indicated mild symptomatic burden and interference in both cohorts. The time to return to no or mild symptoms was significantly longer in the open cohort for overall pain (14 vs 4 days; P<.001), fatigue (8 vs 4 days; P<.001), disturbed sleep (2 vs 2 days; P<.001), and appetite (1.5 vs 1 days; P<.001) but was significantly longer in the minimally invasive cohort for abdominal pain (42 vs 28 days; P<.001) and bloating (42 vs 8 days; P<.001). The median time to return to no or mild functional interference was longer in the open than in the minimally invasive hysterectomy cohort for physical functioning (36 vs 32 days; P<.001) with no difference in compositive affective functioning (5 vs 5 days; P=.07) between the groups. CONCLUSION Open hysterectomy was associated with increased symptom burden in the immediate postoperative period and longer time to return to no or mild symptom burden and interference with physical functioning. However, all patient-reported measures improved within days to weeks of both open and minimally invasive surgery and differences were not always clinically significant.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xin S Wang
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Katherine E Cain
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Andres Zorrilla-Vaca
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shu-En Shen
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M Sol Basabe
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tina Suki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Juan E Garcia Lopez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Javier D Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Loretta A Williams
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Basabe MS, Suki TS, Munsell MF, Iniesta MD, Garcia Lopez JE, Hillman RT, Cain K, Huepenbecker S, Mena G, Taylor JS, Ramirez PT, Meyer LA. Evaluation of a tiered opioid prescription algorithm in an ERAS pathway: exploring opportunities for further refinement. Int J Gynecol Cancer 2023; 34:ijgc-2023-004948. [PMID: 38123191 PMCID: PMC11186977 DOI: 10.1136/ijgc-2023-004948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Opioid over-prescription is wasteful and contributes to the opioid crisis. We implemented a personalized tiered discharge opioid protocol and education on opioid disposal to minimize over-prescription. OBJECTIVE To evaluate the intervention by investigating opioid use post-discharge for women undergoing abdomino-pelvic surgery, and patient adherence to opioid disposal education. METHODS We analyzed post-discharge opioid consumption among 558 patients. Eligible patients included those who underwent elective gynecologic surgery, were not taking scheduled opioids pre-operatively, and received discharge opioids according to a tiered prescribing algorithm. A survey assessing discharge opioid consumption and disposal safety knowledge was distributed on post-discharge day 21. Over-prescription was defined as >20% of the original prescription left over. Descriptive statistics were used for analysis. RESULTS The survey response rate was 61% and 59% in the minimally invasive surgery and open surgery cohorts, respectively. Overall, 42.8% of patients reported using no opioids after hospital discharge, 45.2% in the minimally invasive surgery and 38.6% in the open surgery cohort. Furthermore, 74.9% of respondents were over-prescribed, with median age being statistically significant for this group (p=0.004). Finally, 46.4% of respondents expressed no knowledge regarding safe disposal practices, with no statistically significant difference between groups (p>0.99). CONCLUSION Despite implementation of the tiered discharge opioid algorithm aimed to personalize opioid prescriptions to estimated need, we still over-prescribed opioids. Additionally, despite targeted education, nearly half of all patients who completed the survey did not know how to dispose of their opioid tablets. Additional efforts are needed to further refine the algorithm to reduce over-prescription of opioids and improve disposal education.
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Affiliation(s)
- M Sol Basabe
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tina S Suki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark F Munsell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juan E Garcia Lopez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert Tyler Hillman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katherine Cain
- Department of Pharmacy Clinical Programs, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sarah Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Nelson G, Fotopoulou C, Taylor J, Glaser G, Bakkum-Gamez J, Meyer LA, Stone R, Mena G, Elias KM, Altman AD, Bisch SP, Ramirez PT, Dowdy SC. Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges - 2023 update. Gynecol Oncol 2023; 173:58-67. [PMID: 37086524 DOI: 10.1016/j.ygyno.2023.04.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Despite evidence supporting its use, many Enhanced Recovery After Surgery (ERAS) recommendations remain poorly adhered to and barriers to ERAS implementation persist. In this second updated ERAS® Society guideline, a consensus for optimal perioperative care in gynecologic oncology surgery is presented, with a specific emphasis on implementation challenges. METHODS Based on the gaps identified by clinician stakeholder groups, nine implementation challenge topics were prioritized for review. A database search of publications using Embase and PubMed was performed (2018-2023). Studies on each topic were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded by an international panel according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS implementation challenge topics are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendations for stakeholder derived ERAS implementation challenges in gynecologic oncology are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- G Nelson
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - C Fotopoulou
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - J Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - J Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - L A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R Stone
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - G Mena
- Department of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K M Elias
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - A D Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S P Bisch
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, TX, USA
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
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