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Chang CY, Jones BL, Hincapie-Castillo JM, Park H, Heldermon CD, Diaby V, Wilson DL, Lo-Ciganic WH. Association between trajectories of prescription opioid use and risk of opioid use disorder and overdose among US nonmetastatic breast cancer survivors. Breast Cancer Res Treat 2024; 204:561-577. [PMID: 38191684 DOI: 10.1007/s10549-023-07205-6] [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: 03/03/2023] [Accepted: 11/29/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE To examine the association between prescription opioid use trajectories and risk of opioid use disorder (OUD) or overdose among nonmetastatic breast cancer survivors by treatment type. METHODS This retrospective cohort study included female nonmetastatic breast cancer survivors with at least 1 opioid prescription fill in 2010-2019 Surveillance, Epidemiology and End Results linked Medicare data. Opioid mean daily morphine milligram equivalents (MME) calculated within 1.5 years after initiating active breast cancer therapy. Group-based trajectory models identified distinct opioid use trajectory patterns. Risk of time to first OUD/overdose event within 1 year after the trajectory period was calculated for distinct trajectory groups using Cox proportional hazards models. Analyses were stratified by treatment type. RESULTS Four opioid use trajectories were identified for each treatment group. For 38,030 survivors with systemic endocrine therapy, 3 trajectories were associated with increased OUD/overdose risk compared with early discontinuation: minimal dose (< 5 MME; adjusted hazard ratio [aHR] = 1.73 [95% CI 1.43-2.09]), very low dose (5-25 MME; 2.67 [2.05-3.48]), and moderate dose (51-90 MME; 6.20 [4.69-8.19]). For 9477 survivors with adjuvant chemotherapy, low-dose opioid use was associated with higher OUD/overdose risk (aHR = 7.33 [95% CI 2.52-21.31]) compared with early discontinuation. For 3513 survivors with neoadjuvant chemotherapy, the differences in OUD/OD risks across the 4 trajectories were not significant. CONCLUSIONS Among Medicare nonmetastatic breast cancer survivors receiving systemic endocrine therapy or adjuvant chemotherapy, compared with early discontinuation, low-dose or moderate-dose opioid use were associated with six- to sevenfold higher OUD/overdose risk. Breast cancer survivors at high-risk of OUD/overdose may benefit from targeted interventions (e.g., pain clinic referral).
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Affiliation(s)
- Ching-Yuan Chang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
| | - Bobby L Jones
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
| | | | - Haesuk Park
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
| | - Coy D Heldermon
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, 32611, USA
| | - Vakaramoko Diaby
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
| | - Debbie L Wilson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, 32611, USA
| | - Wei-Hsuan Lo-Ciganic
- Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, USA.
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, USA.
- Geriatric Research Education and Clinical Center, North Florida/South Georgia Veterans Health System, Gainesville, USA.
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Lussiez A, Zondlak A, Hsu PJ, Delaney L, Vitous CA, Telem D, Rubyan M. Surgeon behaviors related to engaging patients in smoking cessation at the time of elective surgery. Am J Surg 2023; 226:218-226. [PMID: 37105853 DOI: 10.1016/j.amjsurg.2023.04.008] [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: 02/15/2023] [Revised: 04/02/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Despite the abundance of evidence supporting smoking cessation before elective surgery, there is wide variation in surgeon adherence to these best practices. METHODS This qualitative study used convenience sampling to recruit General Surgery trained surgeons. Surgeons participated in semi-structured interviews based on domains from the Theoretical Domains Framework (TDF). Content analysis was guided by the TDF. RESULTS Of the 14 TDF domains, social or professional role/identity, memory, attention and decision processes, environmental context and resources, and beliefs about consequences emerged most frequently. Mapping these domains to the Behavior Change Wheel identified education, enablement, and incentivization as effective intervention functions. CONCLUSIONS Using the TDF, this study identified a widespread sense of responsibility among surgeons to engage patients in perioperative smoking cessation despite workplace barriers and lacking resources. These findings provide valuable insight to facilitate surgeon participation in health promotion through targeted, theory-based interventions informed by surgeon identified barriers to perioperative smoking cessation.
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Affiliation(s)
- Alisha Lussiez
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
| | - Allyse Zondlak
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Phillip J Hsu
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lia Delaney
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - C Ann Vitous
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Dana Telem
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michael Rubyan
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Jogerst K, Coe TM, Gupta N, Pockaj B, Fingeret A. How to teach ERAS protocols: surgical residents' perspectives and perioperative practices for breast surgery patients. GLOBAL SURGICAL EDUCATION : JOURNAL OF THE ASSOCIATION FOR SURGICAL EDUCATION 2023; 2:33. [PMID: 38013861 PMCID: PMC9904524 DOI: 10.1007/s44186-022-00048-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/16/2022] [Accepted: 09/15/2022] [Indexed: 11/29/2023]
Abstract
Purpose Breast enhanced recovery after surgery (ERAS) protocols emphasize multimodal analgesia to expedite home recovery, but variable implementation remains. This study examines how residents learn and use ERAS protocols, how they conceptualize pain management, and what influences breast surgery patients' same-day discharges. Methods Interviews were conducted with surgical residents following their breast surgery rotation using an interview guide adapted from existing pain management literature. Interviews were transcribed, de-identified, and independently inductively coded by two researchers. A codebook was developed and refined using the constant comparative method. Codes were grouped into categories and explored for thematic analysis. Results Twelve interviews were completed with plastic and general surgery residents. Ultimately, 365 primary codes were organized into 26 parent codes, with a Cohen's kappa of 0.93. A total of six themes were identified. Three themes described how participants learn through a mixture of templated care, formal education, and informal experiential learning. Two themes delineated how residents would teach breast surgery ERAS: by emphasizing buy-in and connecting the impetus behind ERAS with daily workflow implementation. One theme illustrated how a patient-centered culture impacts postoperative management and same-day discharges. Conclusions Residents describe learning breast surgery ERAS and postoperative pain management by imitating their seniors, observing patient encounters, completing templated orders, and translating concepts from other ERAS services more so than from formal lectures. When implementing breast ERAS protocols, it is important to consider how informal learning and local culture influence pain management and discharge practices. Ultimately, residents believe in ERAS and often request further educational tools to better connect the daily how-to of breast ERAS pathways with the why behind the enhanced recovery principles.
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Affiliation(s)
- Kristen Jogerst
- Department of Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ 85054 USA
- Department of Surgery, Massachusetts General Hospital, Boston, MA USA
| | - Taylor M. Coe
- Department of Surgery, Massachusetts General Hospital, Boston, MA USA
| | - Nikita Gupta
- Alix School of Medicine, Mayo Clinic Arizona, Phoenix, AZ USA
| | - Barbara Pockaj
- Department of Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ 85054 USA
| | - Abbey Fingeret
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE USA
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Howard R, Gunaseelan V, Brummett C, Waljee J, Englesbe M, Telem D. New Persistent Opioid Use After Inguinal Hernia Repair. Ann Surg 2022; 276:e577-e583. [PMID: 33065653 PMCID: PMC8289484 DOI: 10.1097/sla.0000000000004560] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe the incidence of new persistent opioid use after inguinal hernia repair as well as its associated risk factors. SUMMARY OF BACKGROUND DATA The development of new persistent opioid use after surgery is a common complication; however, its incidence following inguinal hernia repair has not been described. Given that roughly 800,000 inguinal hernia repairs are performed annually in the USA, any incidence could have profound implications for patients. METHODS A retrospective cross-sectional study of the incidence of new persistent opioid use after inguinal hernia repair using a national database of de-identified administrative health claims of opioid-naïve patients undergoing surgery from 2008 to 2016. RESULTS During the study period, 59,795 opioid-naïve patients underwent inguinal hernia repair and met inclusion criteria. Mean (SD) age was 57.8 (16.1) years and 55,014 (92%) patients were male. Nine hundred twenty-two (1.5%) patients continued filling opioids prescriptions for at least 3 months after surgery. The most significant risk factor for developing new persistent opioid use after surgery was filling an opioid prescription in the 30 days before surgery (odds ratio 4.34, 95% confidence interval 3.75-5.01). These prescriptions were provided by surgeons in 52% of cases and primary care physicians in 16% of cases. Other risk factors for new persistent opioid use included receiving a larger opioid prescription, having more comorbidities, having a major postoperative complication, and certain mental health disorders and pain disorders. CONCLUSIONS After undergoing inguinal hernia repair, 1.5% of patients developed new persistent opioid use. Filling an opioid prescription in the 30 days before surgery had the strongest association with this complication.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Vidhya Gunaseelan
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Chad Brummett
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Jennifer Waljee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Michael Englesbe
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Dana Telem
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
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Hinds S, Miller J, Maccani M, Patino S, Kaushal S, Rieck H, Walker M, Brummett CM, Bicket MC, Waljee JF. Patient risk screening to improve transitions of care in surgical opioid prescribing: a qualitative study of provider perspectives. Reg Anesth Pain Med 2022; 47:475-483. [PMID: 35697386 PMCID: PMC9240329 DOI: 10.1136/rapm-2021-103304] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 05/12/2022] [Indexed: 11/10/2022]
Abstract
Introduction In patients undergoing surgical procedures, transitions in opioid prescribing occur across multiple providers during the months before and after surgery. These transitions often result in high-risk and uncoordinated prescribing practices, especially for surgical patients with prior opioid exposure. However, perspectives of relevant providers about screening and care coordination to address these risks are unknown. Methods We conducted qualitative interviews with 24 surgery, primary care, and anesthesia providers in Michigan regarding behaviors and attitudes about screening surgical patients to inform perioperative opioid prescribing in relation to transitions of care. We used an interpretive description framework to topically code interview transcripts and synthesize underlying themes in analytical memos. Results Providers believed that coordinated, multidisciplinary approaches to identify patients at risk of poor pain and opioid-related outcomes could improve transitions of care for surgical opioid prescribing. Anesthesia and primary care providers saw value in knowing patients’ preoperative risk related to opioid use, while surgeons’ perceptions varied widely. Across specialties, most providers favored a screening tool if coupled with actionable recommendations, sufficient resources, and facilitated coordination between specialties. Providers identified a lack of pain specialists and a dearth of actionable guidelines to direct interventions for patients at high opioid-related risk as major limitations to the value of patient screening. Discussion These findings provide context to address risk from prescription opioids in surgical transitions of care, which should include identifying high-risk patients, implementing a coordinated plan, and emphasizing actionable recommendations.
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Affiliation(s)
- Shelby Hinds
- Department of Anesthesia, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jacquelyn Miller
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Merissa Maccani
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah Patino
- University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Shivani Kaushal
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Heidi Rieck
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Monica Walker
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Department of Anesthesia, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark C Bicket
- Department of Anesthesia, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer F Waljee
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
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Lockett MA, Ward RC, McCauley JL, Taber DJ, Gebregziabher M, Cina RA, Basco WT, Mauldin PD, Ball SJ. New chronic opioid use in Medicaid patients following cholecystectomy. Surg Open Sci 2022; 9:101-108. [PMID: 35755164 PMCID: PMC9218552 DOI: 10.1016/j.sopen.2022.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/06/2022] [Accepted: 05/14/2022] [Indexed: 11/20/2022] Open
Abstract
Background Commercial insurance data show that chronic opioid use in opioid-naive patients occurs in 1.5% to 8% of patients undergoing surgical procedures, but little is known about patients with Medicaid. Methods Opioid prescription data and medical coding data from 4,788 Medicaid patients who underwent cholecystectomy were analyzed to determine opioid use patterns. Results A total of 54.4% of patients received opioids prior to surgery, and 38.8% continued to fill opioid prescriptions chronically; 27.1% of opioid-naive patients continued to get opioids chronically. Patients who received ≥ 50 MME/d had nearly 8 times the odds of chronic opioid use. Each additional opioid prescription filled within 30 days was associated with increased odds of chronic use (odds ratio: 1.71). Conclusion Opioid prescriptions are common prior to cholecystectomy in Medicaid patients, and 38.8% of patients continue to receive opioid prescriptions well after surgical recovery. Even 27.1% of opioid-naive patients continued to receive opioid prescriptions chronically.
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Affiliation(s)
- Mark A Lockett
- Department of Surgery, The Medical University of South Carolina, Charleston, SC
| | - Ralph C Ward
- Department of Public Health Sciences, The Medical University of South Carolina, Charleston, SC
| | - Jenna L McCauley
- Department of Psychiatry and Behavioral Science, The Medical University of South Carolina, Charleston, SC
| | - David J Taber
- Department of Surgery, The Medical University of South Carolina, Charleston, SC
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, The Medical University of South Carolina, Charleston, SC
| | - Robert A Cina
- Department of Surgery, The Medical University of South Carolina, Charleston, SC
| | - William T Basco
- Department of Pediatrics, The Medical University of South Carolina, Charleston, SC
| | - Patrick D. Mauldin
- Department of Medicine, The Medical University of South Carolina, Charleston, SC
| | - Sarah J Ball
- Department of Medicine, The Medical University of South Carolina, Charleston, SC
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Harnessing choice architecture in urologic practice: Implementation of an opioid-sparing protocol grounded in cognitive behavioral theory. Urol Oncol 2021; 40:95-102. [PMID: 34876350 DOI: 10.1016/j.urolonc.2021.10.011] [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: 09/13/2021] [Accepted: 10/23/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Opioids are prescribed excessively following surgery. As many urologic oncology procedures are performed minimally invasively, an opportunity exists to push forward initiatives to minimize postoperative opioid use. MATERIALS AND METHODS A quality improvement initiative to reduce inpatient opioid prescribing was launched at a tertiary cancer center. In Phase I (December 2019-July 2020), providers were instructed to start standing acetaminophen. In Phase II (beginning August 2020), education was provided to the entire care team and ordersets were modified to an opioid sparing protocol (OSP). We analyzed the proportion of minimally invasive surgery (MIS) prostatectomy and nephrectomy patients that adhered to an OSP during each phase and compared them to controls from the preceding 2 years. RESULTS A total of 303, 153, and 839 patients underwent MIS during the Phase I, Phase II, and control periods respectively. The proportion of patients adhering to an OSP increased from 16% at the beginning of Phase I to 76% at the end of Phase II (p-trend < 0.001). The median total oral morphine equivalents for oral opioids declined from 20 mg and 40 mg at baseline for prostatectomy and nephrectomy patients respectively to 0 mg for both groups (p-trends < 0.001). Multivariable analysis found that patients received 22% and 81% less oral morphine equivalents during Phase I and II respectively compared to the control period (P < 0.001). CONCLUSIONS Adherence to an OSP is most effective when initiatives incorporate the entire team and are supported by nudge theory-based structural changes. Using these strategies, most patients following urologic MIS can dramatically reduce opioid use postoperatively.
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Baker RC, Brown CS, Montgomery JR, Mouch CA, Kenney BC, Englesbe MJ, Waljee JF, Hemmila MR. Effect of injury location and severity on opioid use after trauma. J Trauma Acute Care Surg 2021; 91:226-233. [PMID: 34144565 PMCID: PMC8243856 DOI: 10.1097/ta.0000000000003138] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Recent data have suggested that persistent opioid use is prevalent following trauma. The effect of type of injury and total injury burden is not known. We sought to characterize the relationship between injury location and severity and risk of persistent opioid use. METHODS We investigated postdischarge opioid utilization among patients who were admitted for trauma between January 2010 and June 2017 using the Optum Clinformatics Database. New persistent opioid use (NPOU) was defined as one of the following scenarios: (1) two separate opioid prescription fills between 0 and 14 days postdischarge and having 1+ fills in the 91 to 180 days following discharge or (2) filling a prescription in the 15 to 90 days following discharge in addition to a filling in the 91 to 180 day postdischarge period. Multivariable logistic regression was used to assess the relationship between injury type and severity with new persistent opioid use development. RESULTS A total of 26,437 opioid-naive patients were included in the analysis. Overall, 2,277 patients (8.6%) met the criteria for NPOU. After adjustment for confounding, NPOU was significantly more common for patients with injury to the extremities (adjusted odds ratio [aOR], 1.75; 95% confidence interval [CI], 1.57-1.94) or abdomen (adjusted odds ratio [aOR], 1.42; 95% CI, 1.22-1.64). Importantly, patients with maximum Abbreviated Injury Scale score of ≥2 for any body region had 1.49-fold odds of NPOU compared with patients with score of 1 (95% CI, 1.28-1.73), while no difference was seen across groupings of total injury burden based on Injury Severity Score. CONCLUSION New persistent opioid use is common among patients suffering from trauma. In addition, patients suffering from extremity and abdominal injuries are at highest risk. Maximum individual region injury severity predicts development of new persistent use, whereas total injury severity does not. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Affiliation(s)
- Rachel C. Baker
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI 48109
| | - Craig S. Brown
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI 48109
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI 48109
| | - John R. Montgomery
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI 48109
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI 48109
| | - Charles A. Mouch
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI 48109
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI 48109
| | - Brooke C. Kenney
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI 48109
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI 48109
| | - Michael J. Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI 48109
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI 48109
| | - Jennifer F. Waljee
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI 48109
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI 48109
| | - Mark R. Hemmila
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI 48109
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Pu T, Erali RA, Share M, Russell GB, Clark CJ, Levine EA, Shen P. Persistent opioid use after curative-intent hepatectomy for neoplastic disease. J Surg Oncol 2021; 124:301-307. [PMID: 34156105 DOI: 10.1002/jso.26472] [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: 02/12/2021] [Accepted: 03/14/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES This study analyzed persistent opioid use in opioid-naïve and nonopioid-naïve patients undergoing hepatectomy for neoplastic disease. METHODS A retrospective review was performed of a prospective database using inclusion criteria of hepatectomy for neoplastic disease from October 2013 to December 2017. Prescription data were collected from the North Carolina Controlled Substance Reporting System. Persistent opioid use was defined as patients who continued filling opioid prescriptions 90 days to 1 year after surgery. Patients who did not receive opioid prescriptions between 12 months and 31 days before surgery were defined as naïve. RESULTS The analysis included 75 surgeries on naïve and 58 surgeries on nonnaïve patients. 56% of naïve patients and 79% of nonnaïve patients developed persistent opioid use, respectively (p = .0056). Naïve patients received 2.24 ± 4.30 MMEs/day, while nonnaïve patients received 5.50 ± 5.98 MMEs/day during Postoperative days 90-360 (95% CI, 1.41-5.10; p < .001). Naïve patients with a lower Preoperative ECOG score were more likely to develop persistent opioid use (OR, 0.45; 95% CI, 0.21-0.99; p = .048). CONCLUSION More than half of naïve patients undergoing hepatectomy developed persistent opioid use within the first year, though significantly less than nonnaïve patients. Improved performance status was associated with an increased risk of persistent opioid use in naïve patients.
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Affiliation(s)
- Tracey Pu
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Richard A Erali
- Department of Surgery, Wake Forest Baptist Medical Center, Winston, Salem, North Carolina, USA
| | - Michael Share
- Department of Surgery, Wake Forest Baptist Medical Center, Winston, Salem, North Carolina, USA
| | - Gregory B Russell
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston, Salem, North Carolina, USA
| | - Clancy J Clark
- Department of Surgery, Wake Forest Baptist Medical Center, Winston, Salem, North Carolina, USA
| | - Edward A Levine
- Department of Surgery, Wake Forest Baptist Medical Center, Winston, Salem, North Carolina, USA
| | - Perry Shen
- Department of Surgery, Wake Forest Baptist Medical Center, Winston, Salem, North Carolina, USA
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Oluwoye O, Fraser E. Barriers and Facilitators That Influence Providers' Ability to Educate, Monitor, and Treat Substance Use in First-Episode Psychosis Programs Using the Theoretical Domains Framework. QUALITATIVE HEALTH RESEARCH 2021; 31:1144-1154. [PMID: 33593155 PMCID: PMC8149200 DOI: 10.1177/1049732321993443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
In this qualitative study, we explore providers' experiences with addressing substance use among individuals with first-episode psychosis (FEP) enrolled in coordinated specialty care (CSC) programs. Three focus groups were conducted with 24 providers from CSC programs for FEP in Washington. Questions were focused on barriers and facilitators to addressing substance use using the Theoretical Domains Framework (TDF) as a guide. Thematic analysis was used to code all transcripts. Identified TDF domains were then mapped onto the COM-B (Capability, Opportunity, Motivation, Behavior) intervention functions and behavior change techniques. Seven theoretical domains were identified as the most relevant to addressing substance use: "Knowledge," "Skills," "Environmental Context and Resources," "Social Influences," "Social and Professional Role and Identity," "Beliefs about Capabilities," and "Reinforcement." The use of the TDF provides a framework to explore barriers and facilitators for targeting substance use and suggestions for behavior change techniques when considering implementation of evidence-based strategies to enhance CSC models.
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Affiliation(s)
- Oladunni Oluwoye
- Washington State University, Spokane, WA, USA
- Washington State Center for Excellence in Early Psychosis, Spokane, WA, USA
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11
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Dualeh SHA, McMurry K, Herman AE, Maryan S, Pacurar LA, Waits SA, Tischer S. Evaluation of an opioid restrictive pain management initiative in adult kidney transplant recipients. Clin Transplant 2021; 35:e14313. [PMID: 33838060 DOI: 10.1111/ctr.14313] [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: 10/15/2020] [Revised: 03/24/2021] [Accepted: 04/04/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Evidence to guide opioid utilization following kidney transplantation is lacking. The purpose of this study is to evaluate the implementation of an opioid restrictive post-operative pain management protocol in adult kidney transplant recipients. METHODS We analyzed patients who underwent kidney transplant between 1/1/2017 to 8/15/2018. A standardized, opioid restrictive pain management protocol was implemented in February 2018. The primary outcome was quantity of opioid tablets prescribed at discharge. Secondary outcomes included amount of opioid prescribed within first 30 days, number of patient calls for pain, and opioid prescription in electronic medical record (EMR) at 90 days and 1 year. RESULTS After implementation, significantly fewer opioid tablets were prescribed at discharge (4 vs. 60 tablets, p < .001) and less oral morphine milligram equivalence (OME) were prescribed within 30 days of transplant (38 vs. 300, p < .001). In cohort 2, fewer patients received more than one opioid prescription, more patients received truncal block and only 5 patients received patient controlled analgesia compared to all in cohort 1. CONCLUSION A standardized, patient-centered pain management strategy after kidney transplantation reduced opioid prescribing without increasing readmissions or clinic calls. This data may be used to inform guidelines for appropriate OME prescribing at discharge after kidney transplantation.
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Affiliation(s)
| | - Katie McMurry
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | | | - Samantha Maryan
- Heart and Vascular Department, ProHealth Care, Waukesha, WI, USA
| | | | - Seth A Waits
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Sarah Tischer
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
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12
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Dowzicky PM, Shah AA, Barg FK, Eriksen WT, McHugh MD, Kelz RR. An Assessment of Patient, Caregiver, and Clinician Perspectives on the Post-discharge Phase of Care. Ann Surg 2021; 273:719-724. [PMID: 31356271 DOI: 10.1097/sla.0000000000003479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE We sought to elicit patients', caregivers', and health care providers' perceptions of home recovery to inform care personalization in the learning health system. SUMMARY BACKGROUND DATA Postsurgical care has shifted from the hospital into the home. Daily care responsibilities fall to patients and their caregivers, yet stakeholder concerns in these heterogeneous environments, especially as they relate to racial inequities, are poorly understood. METHODS Surgical oncology patients, caregivers, and clinicians participated in freelisting; an open-ended interviewing technique used to identify essential elements of a domain. Within 2 weeks after discharge, participants were queried on 5 domains: home independence, social support, pain control, immediate, and overall surgical impact. Salience indices, measures of the most important words of interest, were calculated using Anthropac by domain and group. RESULTS Forty patients [20 whites and 20 African-Americans (AAs)], 30 caregivers (17 whites and 13 AAs), and 20 providers (8 residents, 4 nurses, 4 nurse practitioners, and 4 attending surgeons) were interviewed. Patients and caregivers attended to the personal recovery experience, whereas providers described activities and individuals associated with recovery. All groups defined surgery as life-changing, with providers and caregivers discussing financial and mortality concerns. Patients shared similar thoughts about social support and self-care ability by race, whereas AA patients described heterogeneous pain management and more hopeful recovery perceptions. AA caregivers expressed more positive responses than white caregivers. CONCLUSIONS Patients live the day-to-day of recovery, whereas caregivers and clinicians also contemplate more expansive concerns. Incorporating relevant perceptions into traditional clinical outcomes and concepts could enhance the surgical experience for all stakeholders.
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Affiliation(s)
- Phillip M Dowzicky
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Arnav A Shah
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Frances K Barg
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Whitney T Eriksen
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Rachel R Kelz
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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13
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Kanazaki R, Smith B, Girgis A, Descallar J, Connor S. Survey of barriers to adherence to international inflammatory bowel disease guidelines: Does gastroenterologists' confidence translate to high adherence? Intern Med J 2021; 52:1330-1338. [PMID: 33755298 DOI: 10.1111/imj.15299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/02/2021] [Accepted: 03/11/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND & AIMS Despite the availability of evidence-based inflammatory bowel disease (IBD) guidelines, suboptimal care persists. There is little published research assessing barriers to IBD guideline adherence. This study aimed to identify barriers to IBD guideline adherence including gastroenterologists' knowledge and attitudes towards guidelines. METHODS An online cross-sectional survey of 824 Australian gastroenterologists was conducted from April to August 2018, with 198 (24%) responses. A novel survey was developed which was informed by the theoretical domain's framework. RESULTS Confidence in guideline recommendations was high, however referral to them was low. The European Crohn's and Colitis Organisation (ECCO) guidelines were the most commonly referred to (43.6%). In multivariate analysis, significant predictors of frequent versus infrequent guideline referral were: high confidence in the guideline (OR 7.70, 95% CI: 2.43-24.39, p = 0.001), and low (≤10 years) clinical experience (OR 3.62, 95% CI: 1.11-11.79, p = 0.03). The most common barriers to guideline adherence were not having time (62%) followed by guideline specifics being difficult to remember (61%). Low confidence was reported in managing pregnancy and IBD (34%) and loss of response to therapy (29%). High confidence was reported in managing immunomodulators, however only 43% answered the associated knowledge question correctly. CONCLUSION Although gastroenterologists' have high confidence in guidelines, they use them infrequently, primarily due to specifics being difficult to remember and lack of time. Self-reported confidence in an area of IBD management does not always reflect knowledge. An intervention targeting these barriers, for example computer-based clinical decision support tools, may improve adherence and standardise care. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ria Kanazaki
- South Western Sydney Clinical School, University of New South Wales, Australia
| | - Ben Smith
- South Western Sydney Clinical School, University of New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Afaf Girgis
- South Western Sydney Clinical School, University of New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Joseph Descallar
- South Western Sydney Clinical School, University of New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Susan Connor
- South Western Sydney Clinical School, University of New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia.,Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, Australia
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14
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Eyrich NW, Sloss KR, Howard RA, Klueh MP, Englesbe MJ, Waljee JF, Brummett CM, Sabel MS, Dossett LA, Lee JS. Opioid prescribing exceeds consumption following common surgical oncology procedures. J Surg Oncol 2021; 123:352-356. [PMID: 33125747 PMCID: PMC7770117 DOI: 10.1002/jso.26272] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 09/24/2020] [Accepted: 10/11/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Surgical oncology patients are vulnerable to persistent opioid use. As such, we aim to compare opioid prescribing to opioid consumption for common surgical oncology procedures. METHODS We prospectively identified patients undergoing common surgical oncology procedures at a single academic institution (August 2017-March 2018). Patients were contacted by telephone within 6 months of surgery and asked to report their opioid consumption and describe their discharge instructions and opioid handling practices. RESULTS Of the 439 patients who were approached via telephone, 270 completed at least one survey portion. The median quantity of opioid prescribed was significantly larger than consumed following breast biopsy (5 vs. 2 tablets of 5 mg oxycodone, p < .001), lumpectomy (10 vs. 2 tablets of 5 mg oxycodone, p < .001), and mastectomy or wide local excision (20 tablets vs. 2 tablets of 5 mg oxycodone, p < .001). The majority of patients reported receiving education on taking opioids, but only 27% received instructions on proper disposal; 82% of prescriptions filled resulted in unused opioids, and only 11% of these patients safely disposed of them. CONCLUSIONS This study demonstrates that opioid prescribing exceeds consumption following common surgical oncology procedures, indicating the potential for reductions in prescribing.
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Affiliation(s)
| | | | - Ryan A. Howard
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Michael P. Klueh
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Michael J. Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Jennifer F. Waljee
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Michael S. Sabel
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Division of Surgical Oncology, University of Michigan, Ann Arbor, MI
| | - Lesly A. Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Division of Surgical Oncology, University of Michigan, Ann Arbor, MI
| | - Jay S. Lee
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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15
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Brown CS, Vu JV, Howard RA, Gunaseelan V, Brummett CM, Waljee J, Englesbe M. Assessment of a quality improvement intervention to decrease opioid prescribing in a regional health system. BMJ Qual Saf 2020; 30:251-259. [PMID: 32938775 DOI: 10.1136/bmjqs-2020-011295] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/15/2020] [Accepted: 08/24/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Opioids are prescribed in excess after surgery. We leveraged our continuous quality improvement infrastructure to implement opioid prescribing guidelines and subsequently evaluate changes in postoperative opioid prescribing, consumption and patient satisfaction/pain in a statewide regional health system. METHODS We collected data regarding postoperative prescription size, opioid consumption and patient-reported outcomes from February 2017 to May 2019, from a 70-hospital surgical collaborative. Three iterations of prescribing guidelines were released. An interrupted time series analysis before and after each guideline release was performed. Linear regression was used to identify trends in consumption and patient-reported outcomes over time. RESULTS We included 36 022 patients from 69 hospitals who underwent one of nine procedures in the guidelines, of which 15 174 (37.3%) had complete patient-reported outcomes data following surgery. Before the intervention, prescription size was decreasing over time (slope: -0.7 tablets of 5 mg oxycodone/month, 95% CI -1.0 to -0.5 tablets, p<0.001). After the first guideline release, prescription size declined by -1.4 tablets/month (95% CI -1.8 to -1.0 tablets, p<0.001). The difference between these slopes was significant (p=0.006). The second guideline release resulted in a relative increase in slope (-0.3 tablets/month, 95% CI -0.1 to -0.6, p<0.001). The third guideline release resulted in no change (p=0.563 for the intervention). Overall, mean (SD) prescription size decreased from 25 (17) tablets of 5 mg oxycodone to 12 (8) tablets. Opioid consumption also decreased from 11 (16) to 5 (7) tablets (p<0.001), while satisfaction and postoperative pain remained unchanged. CONCLUSIONS The use of procedure-specific prescribing guidelines reduced statewide postoperative opioid prescribing by 50% while providing satisfactory pain care. These results demonstrate meaningful impact on opioid prescribing using evidence-based best practices and serve as an example of successful utilisation of a regional health collaborative for quality improvement.
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Affiliation(s)
- Craig S Brown
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA .,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Ryan A Howard
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Vidhya Gunaseelan
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA.,Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer Waljee
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA.,Department of Plastic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Opioid Prescribing Engagement Network, Ann Arbor, Michigan, USA
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16
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Percy ED, Hirji S, Cote C, Laurin C, Atkinson L, Kiehm S, Malarczyk A, Harloff M, Bozso SJ, Buyting R, Fatehi Hassanabad A, Guo MH, Jaffer I, Lodewyks C, Tam DY, Tremblay P, Légaré JF, Cook R, Kaneko T, Pelletier MP. Variability in opioid prescribing practices among cardiac surgeons and trainees. J Card Surg 2020; 35:2657-2662. [PMID: 32720337 DOI: 10.1111/jocs.14885] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM The opioid epidemic has become a major public health crisis in recent years. Discharge opioid prescription following cardiac surgery has been associated with opioid use disorder; however, ideal practices remain unclear. Our aim was to examine current practices in discharge opioid prescription among cardiac surgeons and trainees. METHODS A survey instrument with open- and closed-ended questions, developed through a 3-round Delphi method, was circulated to cardiac surgeons and trainees via the Canadian Society of Cardiac Surgeons. Survey questions focused on routine prescription practices including type, dosage and duration. Respondents were also asked about their perceptions of current education and guidelines surrounding opioid medication. RESULTS Eighty-one percent of respondents reported prescribing opioids at discharge following routine sternotomy-based procedures, however, there remained significant variability in the type and dose of medication prescribed. The median (interquartile range) number of pills prescribed was 30 (20-30) with a median total dose of 135 (113-200) Morphine Milligram Equivalents. Informal teaching was the most commonly reported primary influence on prescribing habits and a lack of formal education regarding opioid prescription was associated with a higher number of pills prescribed. A majority of respondents (91%) felt that there would be value in establishing practice guidelines for opioid prescription following cardiac surgery. CONCLUSIONS Significant variability exists with respect to routine opioid prescription at discharge following cardiac surgery. Education has come predominantly from informal sources and there is a desire for guidelines. Standardization in this area may have a role in combatting the opioid epidemic.
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Affiliation(s)
- Edward D Percy
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Cardiovascular Surgery, University of British Columbia, Vancouver, Canada
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Claudia Cote
- Division of Cardiac Surgery, Dalhousie Medical School, Halifax, Canada
| | - Charles Laurin
- Division of Cardiac Surgery, Université Laval, Quebec, Canada
| | - Logan Atkinson
- Division of Cardiovascular Surgery, University of British Columbia, Vancouver, Canada
| | - Spencer Kiehm
- Department of Medical Education, Ichan School of Medicine at Mount Sinai, New York, New York
| | - Alexandra Malarczyk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Morgan Harloff
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sabin J Bozso
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Ryan Buyting
- Department of Medicine, Dalhousie Medical School, Dalhousie Medicine New Brunswick, Saint John, New Brunswick, Canada
| | | | - Ming Hao Guo
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada
| | - Iqbal Jaffer
- Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Carly Lodewyks
- Section of Cardiac Sciences, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Philippe Tremblay
- Division of Cardiac Surgery, Dalhousie Medical School, Halifax, Canada
| | - Jean-François Légaré
- Department of Medicine, Dalhousie Medical School, Dalhousie Medicine New Brunswick, Saint John, New Brunswick, Canada
| | - Richard Cook
- Division of Cardiovascular Surgery, University of British Columbia, Vancouver, Canada
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc P Pelletier
- Division of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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17
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Sceats LA, Ayakta N, Merrell SB, Kin C. Drivers, Beliefs, and Barriers Surrounding Surgical Opioid Prescribing: A Qualitative Study of Surgeons’ Opioid Prescribing Habits. J Surg Res 2020; 247:86-94. [DOI: 10.1016/j.jss.2019.10.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 09/30/2019] [Accepted: 10/19/2019] [Indexed: 02/02/2023]
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18
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Howard R, Vu J, Lee J, Brummett C, Englesbe M, Waljee J. A Pathway for Developing Postoperative Opioid Prescribing Best Practices. Ann Surg 2020; 271:86-93. [PMID: 31478976 PMCID: PMC7106149 DOI: 10.1097/sla.0000000000003434] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Opioid prescriptions after surgery are effective for pain management but have been a significant contributor to the current opioid epidemic. Our objective is to review pragmatic approaches to develop and implement evidence-based guidelines based on a learning health system model. SUMMARY BACKGROUND DATA During the last 2 years there has been a preponderance of data demonstrating that opioids are overprescribed after surgery. This contributes to a number of adverse outcomes, including diversion of leftover pills in the community and rising rates of opioid use disorder. METHODS We conducted a MEDLINE/PubMed review of published examples and reviewed our institutional experience in developing and implementing evidence-based postoperative prescribing recommendations. RESULTS Thirty studies have described collecting data regarding opioid prescribing and patient-reported use in a cohort of 13,591 patients. Three studies describe successful implementation of opioid prescribing recommendations based on patient-reported opioid use. These settings utilized learning health system principles to establish a cycle of quality improvement based on data generated from routine practice. Key components of this pathway were collecting patient-reported outcomes, identifying key stakeholders, and continual assessment. These pathways were rapidly adopted and resulted in a 37% to 63% reduction in prescribing without increasing requests for refills or patient-reported pain scores. CONCLUSION A pathway for creating evidence-based opioid-prescribing recommendations can be utilized in diverse practice environments and can lead to significantly decreased opioid prescribing without adversely affecting patient outcomes.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Joceline Vu
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Jay Lee
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Chad Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Surgical Quality Collaborative, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Jennifer Waljee
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
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19
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Sisk BA, Schulz GL, Mack JW, Yaeger L, DuBois J. Communication interventions in adult and pediatric oncology: A scoping review and analysis of behavioral targets. PLoS One 2019; 14:e0221536. [PMID: 31437262 PMCID: PMC6705762 DOI: 10.1371/journal.pone.0221536] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/08/2019] [Indexed: 12/22/2022] Open
Abstract
Background Improving communication requires that clinicians and patients change their behaviors. Interventions might be more successful if they incorporate principles from behavioral change theories. We aimed to determine which behavioral domains are targeted by communication interventions in oncology. Methods Systematic search of literature indexed in Ovid Medline, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov (2000–October 2018) for intervention studies targeting communication behaviors of clinicians and/or patients in oncology. Two authors extracted the following information: population, number of participants, country, number of sites, intervention target, type and context, study design. All included studies were coded based on which behavioral domains were targeted, as defined by Theoretical Domains Framework. Findings Eighty-eight studies met inclusion criteria. Interventions varied widely in which behavioral domains were engaged. Knowledge and skills were engaged most frequently (85%, 75/88 and 73%, 64/88, respectively). Fewer than 5% of studies engaged social influences (3%, 3/88) or environmental context/resources (5%, 4/88). No studies engaged reinforcement. Overall, 7/12 behavioral domains were engaged by fewer than 30% of included studies. We identified methodological concerns in many studies. These 88 studies reported 188 different outcome measures, of which 156 measures were reported by individual studies. Conclusions Most communication interventions target few behavioral domains. Increased engagement of behavioral domains in future studies could support communication needs in feasible, specific, and sustainable ways. This study is limited by only including interventions that directly facilitated communication interactions, which excluded stand-alone educational interventions and decision-aids. Also, we applied stringent coding criteria to allow for reproducible, consistent coding, potentially leading to underrepresentation of behavioral domains.
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Affiliation(s)
- Bryan A. Sisk
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri, United States of America
- * E-mail:
| | - Ginny L. Schulz
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Jennifer W. Mack
- Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts; and Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Lauren Yaeger
- Becker Library, Washington University School of Medicine, St. Louis, MO, United States of America
| | - James DuBois
- Department of Medicine, Division of General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri, United States of Ameica
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20
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Klueh MP, Sloss KR, Dossett LA, Englesbe MJ, Waljee JF, Brummett CM, Lagisetty PA, Lee JS. Postoperative opioid prescribing is not my job: A qualitative analysis of care transitions. Surgery 2019; 166:744-751. [PMID: 31303324 DOI: 10.1016/j.surg.2019.05.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 05/08/2019] [Accepted: 05/29/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Persistent opioid use is common after surgical procedures, and postoperative opioid prescribing often transitions from surgeons to primary care physicians in the months after surgery. It is unknown how surgeons currently transition these patients or the preferred approach to successful coordination of care. This qualitative study aimed to describe transitions of care for postoperative opioid prescribing and identify barriers and facilitators of ideal transitions for potential intervention targets. METHODS We conducted a qualitative study of surgeons and primary care physicians at a large academic healthcare system using a semi-structured interview guide. Transcripts were independently coded using the Theoretical Domains Framework to identify underlying determinants of physician behaviors. We mapped dominant themes to the Behavior Change Wheel to propose potential interventions targeting these behaiors. RESULTS Physicians were interviewed between July 2017 and December 2017 beyond thematic saturation (n = 20). Surgeons report passive transitions to primary care physicians after ruling out surgical complications, and these patients often bounce back to the surgeon when primary care physicians are uncertain of the cause of ongoing pain. Ideal practices were identified as setting preoperative expectations and engaging in active transition for postoperative opioid prescribing. We identified 3 behavioral targets for multidisciplinary intervention: knowledge (guidelines for coordination of care), barriers (utilizing support staff for active transition), and professional role (incentive for multidisciplinary collaboration). CONCLUSION This qualitative study identifies potential interventions aimed at changing physician behaviors regarding transitions of care for postoperative opioid prescribing. Implementation of these interventions could improve coordination of care for patients with persistent postoperative opioid use.
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Affiliation(s)
- Michael P Klueh
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; University of Michigan Medical School, Ann Arbor, MI
| | - Kenneth R Sloss
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
| | | | - Michael J Englesbe
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI.
| | - Jennifer F Waljee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI; Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Pooja A Lagisetty
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jay S Lee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
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21
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Kourouche S, Buckley T, Van C, Munroe B, Curtis K. Designing strategies to implement a blunt chest injury care bundle using the behaviour change wheel: a multi-site mixed methods study. BMC Health Serv Res 2019; 19:461. [PMID: 31286954 PMCID: PMC6615309 DOI: 10.1186/s12913-019-4177-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/20/2019] [Indexed: 12/16/2022] Open
Abstract
Background Blunt chest injury can lead to significant morbidity and mortality if not treated appropriately. A blunt chest injury care bundle was to be implemented at two sites to guide care. Aim To identify facilitators and barriers to the implementation of a blunt chest injury care bundle and design strategies tailored to promote future implementation. Methods 1) A mixed-method survey based on the theoretical domains framework (TDF) was used to identify barriers and facilitators to the implementation of a blunt chest injury care bundle. This survey was distributed to 441 staff from 12 departments across two hospitals. Quantitative data were analysed using SPSS and qualitative using inductive content analysis. 2) The quantitative and qualitative results from the survey were integrated and mapped to each of the TDF domains. 3) The facilitators and barriers were evaluated using the Behaviour Change Wheel to extract specific intervention functions, policies, behaviour change techniques and implementation strategies. Each phase was assessed against the Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects or safety and Equity (APEASE) criteria. Results One hundred ninety eight staff completed the survey. All departments surveyed were represented. Nine facilitators and six barriers were identified from eight domains of the TDF. Facilitators (TDF domains) were: understanding evidence-informed patient care and understanding risk factors (Knowledge); patient assessment skills and blunt chest injury management skills (Physical skills); identification with professional role (Professional role and identity); belief of consequences of care bundle (Belief about consequences); provision of training and protocol design (Environmental context and resources); and social supports (Social influences). Barriers were: not understanding the term ‘care bundle’ (Knowledge); lacking regional analgesia skills (Physical skills); not remembering to follow protocol (Memory, attention, and decision processes); negative emotions relating to new protocols (Emotions); equipment and protocol access (Environmental context and resources). Implementation strategies were videos, education sessions, visual prompt for electronic medical records and change champions. Conclusions Multiple facilitators and barriers were identified that may affect the implementation of a blunt chest injury care bundle. Implementation strategies developed through this process have been included in a plan for implementation in the emergency departments of two hospitals. Evaluation of the implementation is underway. Electronic supplementary material The online version of this article (10.1186/s12913-019-4177-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah Kourouche
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia.
| | - Tom Buckley
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia
| | - Connie Van
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia
| | - Belinda Munroe
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia.,Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong, NSW, Australia
| | - Kate Curtis
- Faculty of Medicine and Health, The University of Sydney Susan Wakil School of Nursing and Midwifery, Mallet St, Camperdown, NSW, Australia.,Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong, NSW, Australia
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22
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Lee JS, Howard RA, Klueh MP, Englesbe MJ, Waljee JF, Brummett CM, Sabel MS, Dossett LA. The Impact of Education and Prescribing Guidelines on Opioid Prescribing for Breast and Melanoma Procedures. Ann Surg Oncol 2018; 26:17-24. [PMID: 30238243 DOI: 10.1245/s10434-018-6772-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Excessive opioid prescribing is common in surgical oncology, with 72% of prescribed opioids going unused after curative-intent surgery. In this study, we sought to reduce opioid prescribing after breast and melanoma procedures by designing and implementing an intervention focused on education and prescribing guidelines, and then evaluating the impact of this intervention. METHODS In this single-institution study, we designed and implemented an intervention targeting key factors identified in qualitative interviews. This included mandatory education for prescribers, evidence-based prescribing guidelines, and standardized patient instructions. After the intervention, interrupted time-series analysis was used to compare the mean quantity of opioid prescribed before and after the intervention (July 2016-September 2017). We also evaluated the frequency of opioid prescription refills. RESULTS During the study, 847 patients underwent breast or melanoma procedures and received an opioid prescription. For mastectomy or wide local excision for melanoma, the mean quantity of opioid prescribed immediately decreased by 37% after the intervention (p = 0.03), equivalent to 13 tablets of oxycodone 5 mg. For lumpectomy or breast biopsy, the mean quantity of opioid prescribed decreased by 42%, or 12 tablets of oxycodone 5 mg (p = 0.07). Furthermore, opioid prescription refills did not significantly change for mastectomy/wide local excision (13% vs. 14%, p = 0.8), or lumpectomy/breast biopsy (4% vs. 5%, p = 0.7). CONCLUSION Education and prescribing guidelines reduced opioid prescribing for breast and melanoma procedures without increasing the need for refills. This suggests further reductions in opioid prescribing may be possible, and provides rationale for implementing similar interventions for other procedures and practice settings.
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Affiliation(s)
- Jay S Lee
- Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Ryan A Howard
- Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
| | - Michael P Klueh
- Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
| | - Michael J Englesbe
- Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer F Waljee
- Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Michael S Sabel
- Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
| | - Lesly A Dossett
- Department of Surgery, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA. .,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA. .,Division of Surgical Oncology, Michigan Medicine, Ann Arbor, MI, USA.
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Howard R, Alameddine M, Klueh M, Englesbe M, Brummett C, Waljee J, Lee J. Spillover Effect of Evidence-Based Postoperative Opioid Prescribing. J Am Coll Surg 2018; 227:374-381. [PMID: 30056059 PMCID: PMC7092645 DOI: 10.1016/j.jamcollsurg.2018.06.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/10/2018] [Accepted: 06/11/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Opioid prescribing after operations is often excessive, resulting in leftover pills in the community available for diversion. Procedure-specific postoperative prescribing guidelines can reduce excessive prescribing, however, it is unclear whether such guidelines are associated with reductions in opioid prescribing for other procedures. STUDY DESIGN A retrospective chart review was conducted for patients undergoing laparoscopic appendectomy, laparoscopic inguinal hernia repair, laparoscopic sleeve gastrectomy, and thyroidectomy/parathyroidectomy between January 1, 2016 and August 31, 2017. Postoperative opioid prescription size (in oral morphine equivalents [OME]) was compared before and after November 1, 2016, when prescribing guidelines were introduced for laparoscopic cholecystectomy. An interrupted time series analysis was conducted to evaluate changes in opioid prescribing after this intervention. RESULTS A total of 1,158 patients were included in the cohort (558 pre-intervention, 600 post-intervention). Opioid prescription size was significantly reduced for laparoscopic sleeve gastrectomy (447.6 ± 74.3 OME vs 291.9 ± 104.3 OME; p < 0.001), laparoscopic appendectomy (173.7 ± 101.6 OME vs 85.8 ± 52.7 OME; p < 0.001), laparoscopic inguinal hernia repair (185.0 ± 101.8 OME vs 107.9 ± 57.9 OME; p < 0.001), and thyroidectomy/parathyroidectomy (81.5 ± 52.8 OME vs 42.6 ± 22.5 OME; p < 0.001). Interrupted time series analysis revealed that this reduction was attributable to intervention for laparoscopic sleeve gastrectomy (-24.5 ± 5.3 OME; p = 0.001), laparoscopic appendectomy (-50.2 ± 28.7 OME; p = 0.04), and thyroidectomy/parathyroidectomy (-28.8 ± 9.4 OME; p = 0.001). For laparoscopic inguinal hernia repair, the immediate decrease in prescription size was not statistically significant (-38.8 ± 33.1 OME; p = 0.24). There was a significant increase in requests for refills after laparoscopic appendectomy (0.8% vs 6.6%; p = 0.01) but not for other procedures. CONCLUSIONS After implementing evidence-based opioid prescribing recommendations for a single surgical procedure, opioid prescribing decreased for 4 other surgical procedures. Requests for refills did not increase substantially. This spillover effect demonstrates the potential impact of raising awareness about safe and appropriate opioid prescribing after operations.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | | | - Michael Klueh
- University of Michigan Medical School, Ann Arbor, MI
| | - Michael Englesbe
- Section of Transplant Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI.
| | - Chad Brummett
- Department of Anesthesia, University of Michigan Health System, Ann Arbor, MI
| | - Jennifer Waljee
- Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Jay Lee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
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