Improving pain management and safe opioid use after surgery: A DMAIC-based quality intervention.

Background: Multimodal perioperative patient education and expectation-setting can reduce post-operative opioid use while maintaining pain control and satisfaction. As part of a quality-improvement project, we developed a standardized model for perioperative education built upon the American College of Surgeons (ACS) Safe and Effective Pain Control After Surgery (SEPCAS) brochure to improve perioperative education regarding opioid use and pain control. Material and methods: Our study was designed within the Define, Measure, Analyze, Improve, Control (DMAIC) quality-improvement framework. Patients were surveyed about the adequacy of their perioperative education regarding pain control and use of prescription opioid medication. After gathering baseline data, a multimodal educational intervention based on the SEPCAS brochure was implemented. Survey responses were then compared between groups. Results: Twenty-seven subjects were included from the pre-intervention period, and thirty-nine were included from the post-intervention period (n = 66). Those in the post-intervention period were more likely to report receiving the appropriate amount of education regarding recognizing the signs of opioid overdose and how to safely store and dispose of opioid medications. The majority of patients who received the SEPCAS brochure reported that it was useful in their post-operative recovery and that it should be given to every patient undergoing surgery. Conclusions: The ACS SEPCAS brochure is an effective tool for improving patient preparation to safely store and dispose of their opioid medication and recognize the signs of opioid overdose. The brochure was also well received by patients and perceived as an effective educational material.

Use of post-discharge opioid consumption patterns as a tool for evaluating opioid prescribing guidelines.

BACKGROUND: Leftover pills from postoperative opioid prescriptions place patients and members of their communities at risk for opioid misuse. We aimed to better understand patients' post-discharge opioid consumption patterns to inform new methods of postoperative opioid prescribing. METHODS: We assessed post-discharge opioid consumption of general surgery patients and assessed the adequacy of discharge opioid prescriptions. We then compared patient opioid consumption to a number of theoretical discharge prescriptions based on different opioid prescribing guidelines and a proposed discharge prescription based on the metric 24-h pre-discharge opioid consumption (PDOC). RESULTS: 62/99 patients (62.6%) returned an opioid log book. Median 24-h PDOC was 22.5 MME (IQR 5.0-45.0) and median discharge prescription size was 15 pills (IQR:10-20). Prescriptions were adequate for 83.7% of patients. The median number of pills used was 3 (IQR:0-11) and median time to opioid cessation was 3 days (IQR:0-5). Actual prescriptions were consistent with national opioid prescribing guidelines. Prescriptions based on the formula 2 × 24-h PDOC would have decreased the number of leftover pills by 7.5 per patient. CONCLUSIONS: Despite prescribing opioids consistent with national opioid prescribing guidelines, patients still receive too many pills. Improved opioid prescribing could be accomplished by use of the formula 2 × 24-h PDOC.

Decreased continuity in a residency clinic: a consequence of open access scheduling.

BACKGROUND AND OBJECTIVES: Open access scheduling decreases waiting time to see physicians by using same-day appointment scheduling. In primary care residency training, continuity of care may be difficult to preserve with this method of scheduling because requirements for rotations often results in residents being unavailable in their primary clinic practice. Our objective was to examine continuity of care in a family medicine residency clinic during a 1-year period prior to implementation of open-access scheduling and during a 1-year period after open access scheduling started. METHODS: Two indices to measure continuity were used: the Usual Provider Continuity Index (UPC) and the Modified Modified Continuity Index (MMCI). The Mann-Whitney test was used to determine differences in the UPC and MMCI between groups. RESULTS: The mean UPC and MMCI scores decreased with open access scheduling. Mean UPC was 0.59 with traditional scheduling versus 0.55 with open access scheduling. Mean MMCI was 0.51 for traditional scheduling and 0.44 with open access. CONCLUSIONS: Continuity of care decreased in our clinic after implementation of open access scheduling. Our results have implications for all primary care residency training programs since one of the hallmarks of primary care is maintaining continuity in the physician-patient relationship.

Trends in off-label beta-blocker use: a secondary data analysis.

BACKGROUND: The off-label use of beta-blockers might be prevalent, but no studies have provided empiric data on the off-label use based on utilization data. OBJECTIVE: This secondary data analysis was conducted to describe the trends of off-label use of beta-blockers among ambulatory visits made to office-based physicians in the United States. METHODS: Data from the National Ambulatory Medical Care Surveys from 1999 to 2002 were used in this study. Physician visits at which beta-blockers were prescribed (beta-blocker visits) were included and classified as within-label or off-label visits according to whether an approved indication for the beta-blocker was coded for the visits. Variables of patient demographic characteristics, diagnosis, prescriber's specialty, and concomitant medication use were also analyzed. Logistic regression analysis was employed to investigate the potential determinants for the off-label use of beta-blockers. RESULTS: A total of 3349 million visits were made to office-based physicians during the study period. About 65% (2167 million) of all visits were prescribed with > or =1 medication (medication visits). Beta-blockers were prescribed in 5.9% (127.3 million) of all medication visits in the years 1999 to 2002. The 3 most frequently prescribed beta-blockers in this study were atenolol, metoprolol, and propranolol. The proportions of off-label use among beta-blocker visits were 44.3% (1999), 56.3% (2000), 62.3% (2001), and 46.9% (2002); overall, 52.0% (66.2 million). About 11% (75.7 million) of these off-label uses were prescribed to patients with concomitant conditions that required judicious use of beta-blockers. Specialists, such as cardiologists, were more likely to prescribe beta-blockers for off-label use than primary care physicians (odds ratio, 2.147; 95% CI, 2.1464-2.1473). CONCLUSIONS: Our study found that the off-label use rate of beta-blockers was higher than what has been previously reported for other diseases and medications. Compared with visits made to general practitioners, visits made to specialists were more likely to be prescribed off-label use of beta-blockers. Future studies are needed to understand the legal, economic, and clinical impact of off-label use.

Childhood pesticide exposures on the Texas-Mexico border: clinical manifestations and poison center use.

OBJECTIVES: The purpose of this study was to describe differences in childhood pesticide exposures between counties on the Texas-Mexico border and nonborder counties. METHOD: The authors reviewed all pesticide exposures among children younger than 6 years reported to the South Texas Poison Center during 1997 through 2000. RESULTS: Nonborder counties had twice the reported exposure rate of border counties. Parents of border children were significantly less likely to contact the poison center after an exposure and more likely to have their children evaluated in a health care facility. CONCLUSIONS: Increasing residents' awareness of the poison center and identifying potential barriers to its use among residents of Texas-Mexico border communities may prevent unnecessary visits to health care facilities.