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Cronin WA, Nealeigh MD, Harry NM, Kerr C, Cyr KL, Velosky AG, Highland KB. Appendectomy Pain Medication Prescribing Variation in the U.S. Military Health System. Mil Med 2024; 189:1497-1504. [PMID: 37951595 DOI: 10.1093/milmed/usad419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/14/2023] [Accepted: 10/12/2023] [Indexed: 11/14/2023] Open
Abstract
INTRODUCTION Post-appendectomy opioid prescription practices may vary widely across and within health care systems. Although guidelines encourage conservative opioid prescribing and prescribing of non-opioid pain medications, the variation of prescribing practices and the probability of opioid refill remain unknown in the U.S. Military Health System. MATERIALS AND METHODS This retrospective observational cohort study evaluated medical data of 11,713 patients who received an appendectomy in the Military Health System between January 2016 and June 2021. Linear-mixed and generalized linear-mixed models evaluated the relationships between patient-, care-, and system-level factors and the two primary outcomes; the morphine equivalent dose (MED) at hospital discharge; and the probability of 30-day opioid prescription refill. Sensitivity analyses repeated the generalized linear-mixed model predicting the probability of opioid (re)fill after an appendectomy, but with inclusion of the full sample, including patients who had not received a discharge opioid prescription (e.g., 0 mg MED). RESULTS Discharge MED was twice the recommended guidance and was not associated with opioid refill. Higher discharge MED was associated with opioid/non-opioid combination prescription (+38 mg) relative to opioid-only, lack of non-opioid prescribing at discharge (+6 mg), care received before a Defense Health Agency opioid safety policy was released (+61 mg), documented nicotine dependence (+8 mg), and pre-appendectomy opioid prescription (+5 mg) (all P < .01). Opioid refill was more likely for patients with complicated appendicitis (OR = 1.34; P < .01); patients assigned female (OR = 1.25, P < .01); those with a documented mental health diagnosis (OR = 1.32, P = .03), an antidepressant prescription (OR = 1.84, P < .001), or both (OR = 1.54, P < .001); and patients with documented nicotine dependence (OR = 1.53, P < .001). Opioid refill was less likely for patients who received care after the Defense Health Agency policy was released (OR = 0.71, P < .001), were opioid naive (OR = 0.54, P < .001), or were Asian or Pacific Islander (relative to white patients, OR = 0.68, P = .04). Results from the sensitivity analyses were similar to the main analysis, aside from two exceptions. The probability of refill no longer differed by race and ethnicity or mental health condition only. CONCLUSIONS Individual prescriber practices shifted with new guidelines, but potentially unwarranted variation in opioid prescribing dose remained. Future studies may benefit from evaluating patients' experiences with pain management, satisfaction, and patient-centered education after appendectomy within the context of opioid prescribing practices, amount of medications used, and refill probability. Such could pave a way for standardized patient-centered procedures that both decrease unwarranted prescribing pattern variability and optimize pain management regimens.
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Affiliation(s)
- William A Cronin
- Department of Anesthesiology, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Matthew D Nealeigh
- Department of Surgery, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
- Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Nathaniel M Harry
- Department of Anesthesiology, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
| | - Christopher Kerr
- Department of Anesthesiology, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
| | - Kyle L Cyr
- Department of Anesthesiology, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Alexander G Velosky
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr., #100, Bethesda, MD 20817, USA
- Enterprise Intelligence and Data Solutions (EIDS) Program Office, Program Executive Office, Defense Healthcare Management Systems (PEO DHMS), 3515 S. General McMullen, Building 1, San Antonio, TX 78226, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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Cronin WA, Nealeigh MD, Zeien JL, Goc JM, Amoako MY, Velosky AG, Williman MC, Cyr KL, Highland KB. Opioid Prescribing Variation After Laparoscopic Cholecystectomy in the US Military Health System. J Surg Res 2024; 297:149-158. [PMID: 37604706 DOI: 10.1016/j.jss.2023.06.056] [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: 04/07/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION After laparoscopic cholecystectomy (LC), there is a wide variation in opioid prescription miligram morphine equivalent dose (MED) and refills across US medical institutions. Given wide variation and opioid prescription guidelines, it is essential to conduct thorough health services research across medical, surgical, and patient-level factors that can be implemented to improve system-wide prescribing practices. Therefore, this study describes discharge MED variation and opioid refill probability after emergent and nonemergent LC. MATERIALS AND METHODS This retrospective cohort study included medical record data of adult patients (N = 20,025) undergoing LC from January 2016 to June 2021 in the US Military Health System. Data visualizations and bivariate analyses examined prescription patterns across hospitals and evaluated the relationship between patient-level, care-level, and system-level factors and each outcome: discharge MED and opioid refill probability. Two generalized additive mixed models evaluated the relationship between predictors and each outcome. RESULTS There was a significant variation in opioid and nonopioid pain medication prescribing practices across hospitals. While several factors were associated with discharge MED and opioid refill probability, the strongest effects were related to time period (before versus after a June 2018 Defense Health Agency policy release) and receipt of an opioid/nonopioid combination medication. Despite decreases in MED, the MED remained almost twice the recommended dose per prior research. CONCLUSIONS Variation by hospital suggests the need for system-level changes that target genuine practice change and opioid stewardship. Inclusion of patient-reported outcomes, electronic health record decision support tools, and academic detailing programs may support system-level improvements.
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Affiliation(s)
- William A Cronin
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland; Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland
| | - Matthew D Nealeigh
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland; Department of Surgery, Uniformed Services University, Bethesda, Maryland
| | - Justin L Zeien
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Jonathan M Goc
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Maxwell Y Amoako
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Rockville, Maryland; Enterprise Intelligence and Data Solutions (EIDS) Program Office, Program Executive Office, Defense Healthcare Management Systems (PEO DHMS), San Antonio, Texas
| | - Alexander G Velosky
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Rockville, Maryland; Enterprise Intelligence and Data Solutions (EIDS) Program Office, Program Executive Office, Defense Healthcare Management Systems (PEO DHMS), San Antonio, Texas
| | - Melina C Williman
- School of Medicine, Uniformed Services University, Bethesda, Maryland; Department of Anesthesiology, Brooke Army Medical Center, San Antonio, Texas
| | - Kyle L Cyr
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland; Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland.
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Melucci AD, Dave YA, Lynch OF, Hsu S, Erlick MR, Linehan DC, Moalem J. Predictors of opioid-free discharge after laparoscopic cholecystectomy. Am J Surg 2023; 225:206-211. [PMID: 35948514 DOI: 10.1016/j.amjsurg.2022.07.027] [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: 07/05/2022] [Revised: 07/25/2022] [Accepted: 07/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Post-discharge opioid requirement after laparoscopic cholecystectomy (LC) is minimal, yet postoperative opioid prescriptions vary and opioid-free discharges are rare. STUDY DESIGN Adult patients who underwent LC from 01/2019-12/2019 were reviewed. Univariate and multivariable logistic regression analyses were performed to identify predictors of opioid-free discharge. RESULTS Of 393 included patients, 330 were discharged with opioids (median 12 oxycodone 5 mg pills) and 63 were discharged without opioids. One opioid-free discharge patient called for a prescription. Older age (OR = 1.02, 95% CI = 1.002-1.041) and non-elective procedure (OR = 0.35, 95% CI = 0.2291-0.8521) were independent predictors of opioid-free discharge. CONCLUSION Significant opportunities for opioid reduction or elimination after discharge from LC exist. Non-elective procedure and older age are predictors of opioid-free discharge, and should be considered when individualizing prescription quantities as surgeons strive to reduce or eliminate opioid overprescription.
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Affiliation(s)
- Alexa D Melucci
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA. https://twitter.com/AlexaMelucci
| | - Yatee A Dave
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Olivia F Lynch
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, 14642, USA
| | - Shawn Hsu
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Mariah R Erlick
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, 14642, USA
| | - David C Linehan
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Jacob Moalem
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
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Schwartz HEM, Matthay ZA, Menza R, Fernández A, Mackersie R, Stein DM, Bongiovanni T. Inequity in discharge pain management for trauma patients with limited English proficiency. J Trauma Acute Care Surg 2021; 91:898-902. [PMID: 34039923 DOI: 10.1097/ta.0000000000003294] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pain management is critical for optimal recovery after trauma. Previous work at our institution revealed differences in pain assessment by patient language, which may impact management. This study aimed to understand differences in discharge opioid prescribing for trauma patients with limited English proficiency (LEP). METHODS We conducted a cross-sectional study of adult trauma patients discharged to the community from a diverse, urban level 1 trauma center in 2018. Opioid prescriptions were obtained from discharge pharmacy records and converted to standard oral morphine equivalents (OMEs). Multivariable logistic and quantile regression was used to examine the relationship between LEP, opioid prescriptions, and OMEs at discharge, controlling for demographic and clinical characteristics. RESULTS Of 1,419 patients included in this study, 83% were English proficient (EP) and 17% were LEP. At discharge, 56% of EP patients received an opioid prescription, compared with 41% of LEP patients. In multivariable models, EP patients were 1.63 times more likely to receive any opioid prescription (95% CI, 1.17-2.25; p = 0.003). Mean OME was 147 for EP and 94 for LEP patients. In multivariable models, the difference between EP and LEP patients was 40 OMEs (95% CI, 21.10-84.22; p = 0.004). In adjusted quantile regression models, differences in total OMEs increased with the amount of OMEs prescribed. There was no difference in OMEs at the 20th and 40th percentile of total OMEs, but LEP patients received 26 fewer OMEs on average at the 60th percentile (95% CI, -3.23 to 54.90; p = 0.081) and 45 fewer OMEs at the 80th percentile (95% CI, 5.48-84.48; p = 0.026). CONCLUSION Limited English proficiency patients with traumatic injuries were less likely to receive any opioid prescription and were prescribed lower quantities of opiates, which could contribute to suboptimal pain management and recovery. Addressing these disparities is an important focus for future quality improvement efforts. LEVEL OF EVIDENCE Care Management, level IV.
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Affiliation(s)
- Hope E M Schwartz
- From the Department of Surgery, School of Medicine (H.E.M.S.), Department of Surgery (Z.A.M., R. Menza, R. Mackersie, D.M.S., T.B.), Department of Physiological Nursing (R. Menza), and Department of Medicine (A.F.), University of California, San Francisco, San Francisco, California
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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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