Finding the Balance Between Reduced Opioid Prescribing and Patient-reported Pain Management Among General Surgery Patients.

OBJECTIVE: To compare patient-reported outcomes before and after implementation of evidence-based, procedure-specific opioid prescribing guidelines. BACKGROUND: The opioid epidemic remains a significant public health issue. Many institutions have responded by reducing opioid prescribing after surgery. However, the impact of this on patient-reported outcomes remains poorly understood. METHODS: Opioid-naïve adults undergoing 12 elective general surgery procedures at a single institution prospectively completed telephone surveys at median 26 days from discharge. Patients were compared before (March 2017-January 2018) and after (May 2019-November 2019) implementation of evidence-based, procedure-specific opioid prescribing guidelines. RESULTS: A total of 603 preguideline and 138 postguideline patients met inclusion criteria and completed surveys. Overall, 60.5% of preguideline and 92.5% of postguideline prescriptions fell within recommendations ( P <0.001), while refill rates were similar (4.5% vs 5.8%, P =0.50). A statistically significant drop in median morphine milligram equivalent prescribed was observed for 9 of 12 procedures (75%). No opioids were prescribed for 16.7% of patients in both cohorts ( P =0.98). While 93.3% of preguideline and 87.7% of postguideline patients were very/somewhat satisfied with their pain control, the proportion of patients who were very/somewhat dissatisfied increased from 4.2% to 9.4% ( P =0.039). CONCLUSIONS: Prescribing guidelines successfully reduced opioid prescribing without increased refill rates. Despite decreased prescribing overall, there was a continued reluctance to prescribe no opioids after surgery. Although most patients experienced good pain control, there remains a subset of patients whose pain is not optimally managed in the era of reduced opioid prescribing.

Hepatocellular carcinoma as predominant cancer subgroup accounting for sex differences in post-hepatectomy liver failure, morbidity and mortality.

BACKGROUND: Experimental evidence suggests sex dependent differences in liver regeneration. Limited evidence is available examining sex differences in post-hepatectomy liver failure (PHLF) and postoperative outcomes. Our aim was to assess the influence of sex on the outcomes after liver resection. METHODS: The hepatectomy targeted National Surgical Quality Improvement Program (NSQIP) database was assessed for associations between sex and outcomes. RESULTS: A total of 13,401 patients underwent elective hepatic resection between 2014-2017. PHLF was highest among male patients with hepatocellular carcinoma (HCC) (OR = 2.81,95%CI:1.40-5.62). Male sex was independently associated with increased PHLF (OR = 1.47,95%CI:1.15-1.88), major complications (OR = 1.25,95%CI:1.08-1.45), mortality (OR = 1.61,95%CI:1.03-2.50), and if only major resections were assessed (OR = 1.38,95%CI:1.03-1.84). Diagnosis specific subgroup analyses revealed that effects of sex were predominantly HCC associated. CONCLUSIONS: This is the largest series investigating the effects of gender on outcomes after hepatic resection. We documented that women undergoing liver resection have significantly lower risk of PHLF. This difference seemed influenced by the striking increase of PHLF in male HCC patients. These hypothesis suggest that sex might play a role in preoperative risk stratification.

Tiered Guidelines in a Pediatric Orthopaedic Practice Reduce Opioids Prescribed at Discharge.

BACKGROUND: Data regarding opioid prescribing patterns following pediatric orthopaedic procedures is limited. The aim of this work was to evaluate the effects of tiered guidelines for discharge opioid prescriptions following common pediatric orthopaedic procedures. METHODS: Quality improvement project conducted at a single academic institution. Guidelines for discharge opioid prescriptions were implemented January 2018 and established 4 tiers of increasing invasiveness for 28 common pediatric orthopaedic procedures. Patients who underwent these procedures in 2017 comprised the preguideline cohort (N=258), while patients treated in 2019 comprised the postguideline cohort (N=212). Opioid prescriptions were reported as oral morphine equivalents (OMEs). Univariate tests were performed to assess statistically significant differences before and after implementation of the guidelines. RESULTS: There was a significant decrease in OME prescribed between preguideline and postguideline cohorts (median OME 97.5 vs. 37.5). When analyzed according to procedure tiers, tiers 1, 2, and 4 showed significant decreases in OME prescribed between 2017 and 2019. The rate of no opioids prescribed at discharge increased from 13% to 23% between preguideline and postguideline cohorts. The 30-day refill rate did not significantly change. After implementation of guidelines, 91% of all prescriptions were within the guideline parameters, and there was a significant reduction in prescription variability. In tier 4 procedures, median OME prescribed decreased from 375 preguideline to 188 postguideline, but was associated with greater opioid refills within 30 days of discharge (10.2% preguideline vs. 28.8% postguideline). CONCLUSIONS: Tiered guidelines for discharge opioid prescriptions following pediatric orthopaedic procedures can significantly decrease the quantity of opioids prescribed. Furthermore, we noted excellent adherence and no overall increase in the rates of narcotic refills. Such guidelines may improve pediatric orthopaedists' ability to responsibly treat postoperative pain while limiting the distribution of unneeded opioids. LEVEL OF EVIDENCE: Level IV-quality improvement project.

Variation in opioid prescribing patterns after abdominal transplant surgery.

BACKGROUND: Opioids are associated with negative transplant outcomes. We sought to identify patient and center effects on over-prescribing of opioids (> 200 OME (oral morphine equivalents)). STUDY DESIGN: Clinical and opioid prescription data (2014-2017) were collected from three academic transplant centers for kidney (KT), liver (LT), and simultaneous liver-kidney transplant (SLK) patients. Multivariable models were used to identify predictors of opioid over-prescribing at discharge and the occurrence of refill prescriptions at 90 days. RESULTS: Three-thousand seven-hundred and two patients underwent transplant in the cohort (KT: n = 2358, LT: n = 1221, SLK: n = 123). More than 80% of recipients were over-prescribed opioids at discharge (Median OME (mOME) = 300 (IQR 225-375). LT and SLK had the largest prescription size (LT mOME 338 (IQR 300-450); SLK mOME 338 (IQR 225-450) and refill rate (LT: 64%, SLK 59%) (all, P < .001). Multivariable analysis indicated that transplant center was a significant predictor of opioid over-prescription after KT and LT (all, P < .001); older age (in KT) and length of stay (LOS) (in LT) were protective factors (both, P < .05). Refill occurrence was associated with initial prescription size and was reduced by older age and initial LOS (all, P < .05). CONCLUSIONS: The wide variation in opioid prescribing patterns has implications for transplant practice innovation, guideline development, and further study.

Impact of Opioid Prescribing Guidelines on Postoperative Opioid Prescriptions Following Elective Spine Surgery: Results From an Institutional Quality Improvement Initiative.

BACKGROUND: With a dramatic rise in prescription opioid use, it is imperative to review postsurgical prescribing patterns given their contributions to the opioid epidemic. OBJECTIVE: To evaluate the impact of departmental postoperative prescribing guidelines on opioid prescriptions following elective spine surgery. METHODS: Patients undergoing elective cervical or lumbar spine surgery between 2017 and 2018 were identified. Procedure-specific opioid prescribing guidelines to limit postoperative prescribing following neurosurgical procedures were developed in 2017 and implemented in January 2018. Preguideline data were available from July to December 2017, and postguideline data from July to December 2018. Discharge prescriptions in morphine milliequivalents (MMEs), the proportion of patients (i) discharged with an opioid prescription, (ii) needing refills within 30 d, (iii) with guideline compliant prescriptions were compared in the 2 groups. Multivariable (MV) analyses were performed to assess the impact of guideline implementation on refill prescriptions within 30 d. RESULTS: A total of 1193 patients were identified (cervical: 308; lumbar: 885) with 569 (47.7%) patients from the preguideline period. Following guideline implementation, fewer patients were discharged with a postoperative opioid prescription (92.5% vs 81.7%, P < .001) and median postoperative opioid prescription decreased significantly (300 MMEs vs 225 MMEs, P < .001). The 30-d refill prescription rate was not significantly different between preguideline and postguideline cohorts (pre: 24.4% vs post: 20.2%, P = .079). MV analyses did not demonstrate any impact of guideline implementation on need for 30-d refill prescriptions for both cervical (odds ratio [OR] = 0.68, confidence interval [CI] = 0.37-1.26, P = .22) and lumbar cohorts (OR = 0.95, CI = 0.66-1.36, P = .78). CONCLUSION: Provider-aimed interventions such as implementation of procedure-specific prescribing guidelines can significantly reduce postoperative opioid prescriptions following spine surgery without increasing the need for refill prescriptions for pain control.

Patient Opioid Requirements Are Often Far Less Than Their Discharge Prescription After Orthopaedic Surgery: the Results of a Prospective Multicenter Survey.

INTRODUCTION: Evidence-based, procedure-specific guidelines for opioid prescribing after orthopaedic surgery are urgently needed to standardize care and minimize excess opioids. METHODS: We developed a prospective, multicenter survey study conducted from March 2017 to January 2018 including 7 common elective orthopaedic surgical procedures (total knee arthroplasty, total hip arthroplasty, lumbar fusion, lumbar laminectomy, rotator cuff repair, arthroscopic meniscectomy, and carpal tunnel release). Phone surveys were conducted between 21 and 35 days postoperatively. We aimed to document both the amount and length of time patients consumed opioid medications to inform further improvements in opioid management and prescribing. RESULTS: Among the 919 orthopaedic patients who completed the survey, 94.3% received opioids at discharge with a median of 388 oral morphine equivalents (OMEs) (interquartile range [IQR] 225 to 675). A median of 128 (IQR 23 to 360) OME were consumed with 77% of patients having leftover opioids. Sixty percent of prescribed opioids were unused; 18.2% of patients used no opioids, and 34.7% required <50 OME. In comparison to departmental guidelines, 50.2% of patients consumed <50% of the recommended prescription maximum per procedure. DISCUSSION: Most patients used far fewer opioids after orthopaedic surgery than prescribed. These data have informed further improvement of our opioid prescription guidelines to more precisely align with anticipated procedure- and patient-specific requirements.

Emergent pancreatectomy for neoplastic disease: outcomes analysis of 534 ACS-NSQIP patients.

BACKGROUND: While emergent pancreatic resection for trauma has been previously described, no large contemporary investigations into the frequency, indications, and outcomes of emergent pancreatectomy (EP) secondary to complications of neoplastic disease exist. Modern perioperative outcomes data are currently unknown. METHODS: ACS-NSQIP was reviewed for all non-traumatic pancreatic resections (DP - distal pancreatectomy, PD - pancreaticoduodenectomy, or TP- total pancreatectomy) in patients with pancreatico-biliary or duodenal-ampullary neoplasms from 2005 to 2013. Patients treated for complications of pancreatitis were specifically excluded. Emergent operation was defined as NSQIP criteria for emergent case and one of the following: ASA Class 5, preoperative ventilator dependency, preoperative SIRS, sepsis, or septic shock, or requirement of > 4 units RBCs in 72 h prior to resection. Chi-square tests, Fisher's exact tests were performed to compare postoperative outcomes between emergent and elective cases as well as between pancreatectomy types. RESULTS: Of 21,452 patients who underwent pancreatectomy for neoplastic indications, we identified 534 (2.5%) patients who underwent emergent resection. Preoperative systemic sepsis (66.3%) and bleeding (17.9%) were most common indications for emergent operation. PD was performed in 409 (77%) patients, DP in 115 (21%), and TP in 10 (2%) patients. Overall major morbidity was significantly higher (46.1% vs. 25.6%, p < 0.001) for emergent vs. elective operations. Emergent operations resulted in increased transfusion rates (47.6% vs. 23.4%, p < 0.001), return to OR (14.0% vs. 5.6%, p < 0.001), organ-space infection (14.6 vs. 10.5, p = 0.002), unplanned intubation (9.% vs. 4.1%, p < 0.001), pneumonia (9.6% vs. 4.2%, p < 0.001), length of stay (14 days vs. 8 days, p < 0.001), and discharge to skilled facility (31.1% vs. 13.9%). These differences persisted when stratified by pancreatic resection type. The 30-day operative mortality was higher in the emergent group (9.4%vs. 2.7%, p < 0.001) and highest for emergent TP (20%). CONCLUSION: Emergent pancreatic resection is markedly uncommon in the setting of neoplastic disease. Although these operations result in increased morbidity and mortality compared to elective resections, they can be life-saving in specific circumstances. The results of this large series of modern era national data may assist surgeons as well as patients and their families in making critical decisions in select cases of acutely complicated neoplastic disease.

Implementation of Procedure-Specific Opioid Guidelines: A Readily Employable Strategy to Improve Consistency and Decrease Excessive Prescribing Following Orthopaedic Surgery.

BACKGROUND: Evidence-based, procedure-specific guidelines for prescribing opioids are urgently needed to optimize pain relief while minimizing excessive opioid prescribing and potential opioid diversion in our communities. A multidisciplinary panel at our institution recently developed procedure-specific guidelines for discharge opioid prescriptions for common orthopaedic surgical procedures. The purpose of this study was to evaluate postoperative opioid prescription quantities, variability, and 30-day refill rates before and after implementation of the guidelines. METHODS: This retrospective cohort study was conducted at a single academic institution from December 2016 to March 2018. Guidelines were implemented on August 1, 2017, with a recommended maximum opioid prescription quantity for 14 common orthopaedic procedures. Patients who underwent these 14 procedures during the period of December 2016 to May 2017 made up the pre-guideline cohort (n = 2,223), and patients who underwent these procedures from October 2017 to March 2018 made up the post-guideline cohort (n = 2,300). Opioid prescription quantities were reported as oral morphine equivalents (OME), with medians and interquartile ranges (IQRs). Four levels were established for recommended prescription maximums, ranging from 100 to 400 OME. RESULTS: In the pre-guideline cohort, the median amount of prescribed opioids across all procedures was 600 OME (IQR, 390 to 863 OME), which decreased by 38% in the post-guideline period, to a median of 375 OME (IQR, 239 to 400 OME) in the post-guideline cohort (p < 0.001). The 30-day refill rate did not change significantly, from a rate of 24% in the pre-guideline cohort to 25% in the post-guideline cohort (p = 0.43). Multivariable analysis demonstrated that guideline implementation was the factor most strongly associated with prescriptions exceeding guideline maximums (odds ratio [OR] = 9.9; p < 0.001). Age groups of <80 years (OR = 2.0 to 2.4; p < 0.001) and males (OR = 1.2; p = 0.025) were also shown to have higher odds of exceeding guideline maximums. CONCLUSIONS: Procedure-specific guidelines are capable of substantially decreasing opioid prescription amounts and variability. Furthermore, the absence of change in refill rates suggests that pain control remains similar to pre-guideline prescribing practices. Evidence-based guidelines are a readily employable solution that can drive rapid change in practice and enhance the ability of orthopaedic surgeons to provide responsible pain management.

Optimizing Opioid-Prescribing Practices After Parathyroidectomy.

BACKGROUND: To help control opioid overprescription, we conducted a large institutional, 3-site initiative to provide discharge prescribing guidelines for different procedures. Our aim is to refine institutional guidelines for parathyroidectomy. METHODS: Patients undergoing parathyroidectomy completed a 28-question survey about opioid consumption. Discharge opioid prescription amounts were converted into morphine milligram equivalents (MMEs) and reported as median and interquartile range (IQR). Consumption was dichotomized into top quartile MME users (Q4) versus standard users (Q1, Q3). Univariate analysis compared opioid consumption. RESULTS: A total of 91 patients were included; 90% were opioid-naive. While the median prescribed was 75 (IQR 75, 150) MME, the median consumed was 0 (IQR 0, 20). Top users reported higher pain scores [median (IQR): 2 (2, 4)] compared to standard users [1 (0, 3), P = 0.01]. However, there was no difference in opioid consumption between unilateral neck exploration, bilateral exploration, or thyroidectomy and parathyroidectomy, P = 0.11. There was no difference in opioid consumption by age, sex, or BMI (all P > 0.05). Of those receiving a prescription, 94.6% had left-over opioids at the time of survey, resulting in 82% of prescribed opioids being unused. CONCLUSIONS: Over half of patients undergoing parathyroidectomy did not consume any opioid, and very few needed more than 2 d of opioid. Moreover, most patients did not dispose the unused opioids, which put these pills at risk of diversion and misuse. Surgical approach did not change consumption, illustrating that these guidelines are applicable to thyroidectomy given the similarity between techniques. We recommend prescribing nonopioid analgesics for patients undergoing parathyroidectomy.

Postoperative Opioid Consumption in Thoracic Surgery Patients: How Much Is Actually Used?

BACKGROUND: The objective of this initiative was to perform a prospective, multicenter survey of patients after lung resection to assess the amount of opioid medication consumed and the disposition of unused opioids to inform the development of evidence-based prescribing guidelines. METHODS: Adults undergoing lung resection with either minimally invasive surgery (MIS; n = 108) or thoracotomy (n = 45) were identified prospectively from 3 academic centers (from March 2017 to January 2018) to complete a 28-question telephone survey 21 to 35 days after discharge. Discharge opioids were converted into morphine milligram equivalents (MME) and were compared across patient and surgical details. RESULTS: Of the 153 patients who completed the survey, 89.5% (137) received opioids at discharge with a median prescription of 320 MME (interquartile range [IQR], 225, 450 MME) after MIS and 450 MME (IQR, 300, 600 MME) after thoracotomy (P = .001). Median opioid consumption varied by surgical approach: 90 MME (IQR, 0, 262.5) after MIS and 300 MME (IQR, 50, 382.5 MME) after thoracotomy (P < .001). The majority of patients (73.7%; 101) had residual opioid medication at the time of the survey, and patients after MIS had a relative increase in amount of remaining opioid medication: 58.3% vs 33.3% (P = .05) of the original prescription. Only 5.9% of patients with opioids remaining had properly disposed of them. CONCLUSIONS: Although patients undergoing MIS lung resection used significantly less opioid medication over a shorter duration of time than did patients after thoracotomy, they had relatively more excess opioid prescription. Evidence-based, procedure-specific guidelines with tailored pain regimens should be developed and implemented to reduce the amount of postoperative opioid medication remaining in the community.

Use of pharmacogenetic data to guide individualized opioid prescribing after surgery.

BACKGROUND: Despite the current strategies aimed at avoiding opioid overprescription by implementing institutional guidelines, the use of opioids after surgical procedures remains highly variable. It is well known that opioids are activated by the cytochrome p450 CYP2D6 enzyme to exert pharmacologic effect. Individual variation in CYP2D6 activity affects drug metabolism, and genotyping can be performed to predict an individual's ability to metabolize CYP2D6 substrates. We postulate that the pharmacogenomic identification of patients with different opioid metabolism capacity may allow for the individualization of postsurgical opioid prescription. METHODS: This study was generated by the unison of data from 2 prior initiatives taking place at our Institution. In the first study, patients undergoing 1 of 25 elective surgical procedures were prospectively identified as part of a quality initiative and surveyed by phone 21 to 35 days after hospital discharge to complete a 29-question survey regarding opioid utilization and pain experience. Additional chart abstraction was conducted to obtain prescribing data and pain scores during the hospitalization. The second study was the Mayo Clinic Right Drug, Right Dose, Right Time study protocol, in which 5 pharmacogenes, including CYP2D6, were genotyped for 1,000 Mayo Clinic Biobank participants. The goal of this study was to implement preemptive pharmacogenomics in an academic health care setting and to generate data for further pharmacogenomic research. Patients were classified by their predicted CYP2D6 activity based on their CYP2D6 genotype. RESULTS: Of the 2,486 patients with prospective opioid utilization data, 21 had pharmacogenetic data available and were included in the analysis. These patients were classified according to their activity as opioid metabolizers, with 10 patients (48%) classified as intermediate, 4 patients (19%) as intermediate to normal, and 7 patients (33%) as normal or extensive. Compared with the intermediate to normal and intermediate phenotypes, normal or extensive patients had the highest percentages of preoperative opioid naivety and recorded pain scores throughout the surgical experience. The percentage of unused opioids for intermediate, intermediate to normal, and normal or extensive categories was 79%, 63%, and 46%, respectively. Moreover, of the 14 patients declaring the highest level of satisfaction for their pain control after discharge, 60% belonged to intermediate, 100% to intermediate to normal, and 57% to the normal or extensive group. CONCLUSION: This study outlines a possible correlation between genetically controlled metabolism and opioid requirements after surgery. In this setting, an increased CYP2D6 enzymatic activity was associated to a greater opioid consumption, lesser amount of unused opioids, and a lower satisfaction level from opioid prescription.

Pain and opioid prescriptions vary by procedure after breast surgery.

BACKGROUND: With the opioid epidemic in the United States, evaluating opioid prescribing patterns is essential. We evaluated opioids prescribed at discharge following breast surgery and their association with patient factors and pain scores. METHODS: We retrospectively identified adult patients who underwent a mastectomy for cancer at Mayo Clinic sites from January 2010 to December 2016. Pain scores and prescription data were compared across operations and patient factors by univariate and multivariable analyses. RESULTS: Of 4021 patients, 3782 (94.1%) received an opioid prescription. Median oral milligram morphine equivalents (MME) were similar across all site-specific procedure groups (medians ranging from 225 to 375) while pain scores ranged from 1 to 4. Patients undergoing bilateral mastectomy (BM) and immediate breast reconstruction (IBR) reported the greatest pain scores. Pain scores did not vary with age or diagnosis for patients undergoing unilateral mastectomy or BM with lymph node surgery and IBR procedures. On multivariable analysis, variables associated with a MME discharge prescription >Q4 values included age, body mass index, site, year, inpatient status, and pain before discharge >3. CONCLUSION: Patient-reported pain following breast surgery varied by procedure, while MMEs prescribed remained similar. This suggests current opioid prescribing does not reflect intensity of pain and requires further research to optimize discharge opioid prescribing practices.

Opioid utilization in minimally invasive versus open inguinal hernia repair.

BACKGROUND: Open inguinal hernia repair is thought to cause worse postoperative pain than minimally invasive surgery, and thus patients are often prescribed more opioids at discharge. This study evaluates opioid use in inguinal hernia repair patients to optimize discharge prescribing practices for this common procedure. METHODS: Opioid-naive adults undergoing open or minimally invasive surgery inguinal hernia repair were identified prospectively from 3 centers to complete a 29-question telephone interview after discharge as part of a larger initiative. Opioid prescription and consumption data were converted into morphine milligram equivalents and compared between minimally invasive surgery and open inguinal hernia repair. Univariate χ2, Fisher exact test, univariate, and multivariable logistic regression were used. RESULTS: Of 249 contacted patients, 195 (74%) completed the survey (n = 97 open, n = 98 minimally invasive surgery). Patients undergoing open inguinal hernia repair were slightly older (71 vs 65 years, P < .001) and less likely to be female (3% vs 17%, P = .001) than minimally invasive surgery patients. Open patients were more likely to have a unilateral inguinal hernia repair (95% open vs 52% minimally invasive surgery, P < .001). Discharge pain scores using the 10-point, patient-reported Numeric Pain Rating scale were similar (open 2.3 ± 1.7 vs minimally invasive surgery 2.4 ± 1.6; P = .80), and most patients were satisfied with postoperative pain control (open 86% vs minimally invasive surgery 95%; P = .13). Open inguinal hernia repair patients were just as likely to receive opioids at discharge as those undergoing minimally invasive surgery inguinal hernia repair (98% vs 91% minimally invasive surgery; P = .06) and were prescribed similar amounts of opioids (open 155 [IQR 113, 225] morphine milligram equivalents vs 150 [IQR 100, 210] minimally invasive surgery; P = .08). There was no difference in opioid use by approach (open 15 [IQR 0, 60] morphine milligram equivalents vs 9 [IQR 0, 50] minimally invasive surgery; P = .33). More than one-third of patients used no opioids (open 38% vs minimally invasive surgery 44%; P = .42). Bilateral repair was not associated with increased opioid use (univariate odds ratio 1.23, P = .58). On multivariable analysis, low discharge pain and normal body mass index were independently associated with needing no opioids at discharge. Overall, 75% of prescribed opioids remained unused at time of survey, yet only 12% of patients had disposed of unused opioids at the time of survey. CONCLUSION: Postdischarge opioid utilization was clinically similar between patients undergoing open and minimally invasive surgery inguinal hernia repair and those requiring unilateral or bilateral repair. Given that more than one-third of patients required no opioids after discharge, 0 to 8 tablets of 5 mg oxycodone is sufficient for most opioid-naive patients undergoing inguinal hernia repair.

The 2018 Chitranjan S. Ranawat, MD Award: Developing and Implementing a Novel Institutional Guideline Strategy Reduced Postoperative Opioid Prescribing After TKA and THA.

BACKGROUND: Opioid prescription management is challenging for orthopaedic surgeons, and we lack evidence-based guidelines for responsible opioid prescribing. Our institution recently developed opioid prescription guidelines for patients undergoing several common orthopaedic procedures including TKA and THA in an effort to reduce and standardize prescribing patterns. QUESTIONS/PURPOSES: (1) How do opioid prescriptions at discharge and 30-day refill rates change in opioid-naïve patients undergoing primary TKA and THA before and after implementation of a novel prescribing guideline strategy? (2) What patient, surgical, and in-hospital factors influence opioid prescription quantity and refill rate? METHODS: New institutional guidelines for patients undergoing TKA and THA recommend a maximum postoperative prescription of 400 oral morphine equivalents (OME), comparable to 50 tablets of 5 mg oxycodone or 80 tablets of 50 mg tramadol. All opioid-naïve patients, defined as those who did not take any opioids within 90 days preceding surgery, undergoing primary TKA and THA at a single tertiary care institution were evaluated from program initiation on August 1, 2017, through December 31, 2017, as the postguideline era cohort. This group (n = 751 patients) was compared with all opioid-naïve patients undergoing TKA and THA from 2016 at the same institution (n = 1822 patients). Some providers were early adopters of the guidelines as they were being developed, which is why January to July 2017 was not evaluated. Patients in the preguideline and postguideline eras were not different in terms of age, sex, race, body mass index, education level, employment status, psychiatric illness, marital status, smoking history, outpatient use of benzodiazepines or gabapentinoids, or diagnoses of diabetes mellitus, peripheral neuropathy, or cancer. The primary outcome assessed was adherence to the new guidelines with a secondary outcome of opioid medication refills ordered within 30 days from any provider. Multivariable logistic regression analyses were performed with outcomes of guideline compliance and refills and adjusted for demographic, surgical, and patient care factors. Patients were followed for 30 days after surgery and no patients were lost to followup. RESULTS: Median opioid prescription and range of prescriptions decreased in the postguideline era compared with the preguideline era (750 OME, interquartile range [IQR] 575-900 OME versus 388 OME, IQR 350-389; difference of medians = 362 OME; p < 0.001). There was no difference among patients undergoing TKA before and after guideline implementation in terms of the 30-day refill rate (35% [349 of 1011] versus 35% [141 of 399]; p = 0.77); this relationship was similar among patient undergoing THA (16% [129 of 811] versus 17% [61 of 352]; p = 0.55). After controlling for relevant patient-level factors, we found that implementation of an institutional guideline was the strongest factor associated with a prescription of ≤ 400 OME (adjusted odds ratio, 36; 95% confidence interval, 25-52; p < 0.001); although a number of patient-level factors also were associated with prescription quantity, the effect sizes were much smaller. CONCLUSIONS: This study provides a proof of concept that institutional guidelines to reduce postoperative opioid prescribing can improve aftercare in patients undergoing arthroplasty in a short period of time. The current report evaluates our experience with the first 5 months of this program; therefore, longer term data will be mandatory to determine longitudinal guideline adherence and whether the cutoffs established by this pilot initiative require further refinement for individual procedures. LEVEL OF EVIDENCE: Level II, therapeutic study.

Death and Postoperative Complications After Hip Fracture Repair: Dialysis Effect.

INTRODUCTION: It is unknown whether patients receiving dialysis have a higher morbidity and mortality risk after hip fracture repair conferred by their kidney failure or by the high comorbidity burden often present. METHODS: We examined associations of dialysis dependency with postoperative complications, death, and readmission in a matched cohort study of U.S. patients undergoing hip fracture repair, from January 2010 to December 2013, in the American College of Surgeons National Surgical Quality Improvement Program. Matching included sex, age, race, diabetes mellitus, operation year, primary surgery type, and anesthesia technique. RESULTS: Among 22,621 patients, 377 dialysis-dependent patients were matched to 1508 nondialysis patients. Median age was 78 years (interquartile range = 68-85) years, 56% were men, 70% were white, 43% had diabetes, and 47% underwent fracture fixation under mostly (80%) general anesthesia. Dialysis-dependent patients had higher physical status classification, had more heart failure and hypoalbuminemia, and were less often smokers. After adjustment, a greater risk of prolonged postoperative stays beyond 7 days (odds ratio [OR] = 1.43, 95% confidence interval [CI] = 1.09-1.89), higher in-hospital mortality (OR = 3.13, CI = 1.72-5.7), and 30-day death (OR = 2.29, CI = 1.51-3.48) but not 30-day readmission (P = 0.09) was observed with dialysis dependency. Adjusted analyses in the original cohort (n = 22,621) were similar: the dialysis group had greater risk of prolonged postoperative stay (OR = 1.77, CI = 1.42-2.21), in-hospital mortality (OR = 2.65, CI = 1.74-4.05), and 30-day death (OR = 2.03, CI = 1.48-2.80) and 30-day readmission (OR = 1.62, CI = 1.66-2.26). CONCLUSION: Dialysis dependency is associated with an increased risk of death and postoperative complications after hip fracture repair. These findings have implications for case-mix adjustment and quality metrics.

Predictors of early mortality and readmissions among dialysis patients undergoing lower extremity amputation.

OBJECTIVE: Patients receiving dialysis are at increased risk for lower extremity amputations (LEAs) and postoperative morbidity. Limited studies have examined differences in 30-day outcomes of mortality and health care use after amputation or the preoperative factors that relate to worsened outcomes in dialysis patients. Our objective was to examine dialysis dependency and other preoperative factors associated with readmission or death after LEA. METHODS: A retrospective cohort study was conducted of dialysis-dependent and nondialysis patients undergoing major LEA in the 2012 to 2013 American College of Surgeons National Surgical Quality Improvement Program. Primary outcomes included death and hospital readmission within 30 days of amputation. RESULTS: Of 6468 patients, 1166 (18%) were dialysis dependent. The dialysis cohort had more blacks (39% vs 23%), diabetes (76% vs 58%), below-knee amputations (62% vs 55%), and in-hospital deaths (8% vs 3%; all P < .001). The 30-day postoperative death rates (15% vs 7%) and readmission rates (35% vs 20% per 30 person-days; both P < .001) were higher in dialysis patients. Among the live discharges, the rate of any readmission or death within 30 days from amputation was highest in those aged ≥50 years (40% per 30 person-days). Multivariable analyses in the dialysis cohort revealed increased age, above-knee amputation, decreased physical status, heart failure, high preoperative white blood cell count, and low platelet count to be associated with death (P < .05; C statistic, 0.75). The only preoperative factor associated with readmission in dialysis patients was race (P = .04; C statistic, 0.58). CONCLUSIONS: Readmission or death after amputation is increased among dialysis patients. Predicting which dialysis patients are at highest risk for death is feasible, whereas predicting which will require readmission is less so. Risk factor identification may improve risk stratification, inform reimbursement policies, and allow targeted interventions to improve outcomes.

Results of a Prospective, Multicenter Initiative Aimed at Developing Opioid-prescribing Guidelines After Surgery.

OBJECTIVE: The aim of this study was to conduct a prospective, multicenter survey of patients regarding postoperative opioid use to inform development of standardized, evidence-based, procedure-specific opioid prescribing guidelines. SUMMARY OF BACKGROUND DATA: Previous work has shown significant variation in the amount of opioids prescribed after elective procedures, calling for optimization of prescribing. METHODS: Adults (n = 3412) undergoing 25 elective procedures were identified prospectively from 3 academic centers (March 2017 to January 2018) to complete a 29-question telephone interview survey 21 to 35 days post-discharge (n = 688 not contacted, n = 107 refused). Discharge opioids were converted into Morphine Milligram Equivalents (MMEs). RESULTS: Of the 2486 patients who completed the survey, 91.2% received opioids at discharge [median 225 (interquartile range, IQR 125 to 381) MME]. A median of 43 (0 to 184) MMEs were consumed after discharge with 77.3% of patients having leftover opioids at the time of the survey. In total, 61.5% of prescribed opioids were unused; 31.4% of patients used no opioids, and 52.6% required <50 MME. Overall, 90.6% of patients were satisfied with their postdischarge pain control. While 28.3% reported being prescribed too many opioids, 9.0% felt they were not prescribed enough. Only 9.6% of patients disposed of remaining opioids. Of the 2068 opioid-naive respondents (83.2%), 33.6% consumed no opioids (range 5.2% to 80.0% by procedure) and 57.0% (65.7% nonorthopedic) consumed <50 MME. Utilization data and predictors of low/high opioid consumption informed development of postoperative prescribing guidelines. CONCLUSION: A large proportion of postoperative patients reported using no or few opioids following discharge. Guidelines were developed to minimize opioid prescribing and identify patients requiring low doses or additional multimodal pain control.

The impact of spine disease, relative to cranial disease, on perception of health and care experience: an analysis of 1484 patients in a tertiary center.

OBJECTIVEPatient-reported outcomes have been increasingly mandated by regulators and payers to evaluate hospital and physician performance. The purpose of this study is to delineate the differences in patient-reported experience of hospital care for cranial and spinal operations.METHODSThe authors selected all patients who underwent inpatient, elective cranial or spinal procedures and completed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey at a single, high-volume, tertiary care institution between October 2012 and September 2015. The association of the surgical procedure and diagnosis with various HCAHPS composite measures, calculated across 9 domains using standard top-box methodology, was investigated. Multivariable logistic regression models were fitted for outcomes that were significant with procedure type and diagnosis group on univariate analysis, adjusting for age, sex, case complexity, overall health rating, and education level.RESULTSA total of 1484 patients met criteria and returned an HCAHPS survey. Overall, patients undergoing a cranial procedure gave top-box (most favorable) scores more often in pain management measure (66.3% vs 59.6%, p = 0.01) compared with those undergoing spine surgery. Furthermore, despite better discharge scores (93.1% vs 87.1%, p < 0.001), spinal patients were less likely to report excellent health (7.4% vs 12.7%). Lastly, patients with a primary diagnosis of brain or spinal tumor compared with those with degenerative spinal disease and those with other neurosurgical diagnoses provided top-box scores more often regarding communication with doctors (82.7% vs 76.4% vs 75.2%, p = 0.04), pain management (71.8% vs 60.9% vs 59.1%, p = 0.002), and global rating (90.4% vs 84.0% vs 87.3%, p = 0.02). On multivariable analysis, spinal patients had significantly lower odds of reporting top-box scores in pain management (OR 0.67, 95% CI 0.52-0.85; p = 0.001), staff responsiveness (OR 0.68, 95% CI 0.53-0.87; p = 0.002), and global rating (OR 0.59, 95% CI 0.42-0.82; p = 0.002), and significantly higher odds of top-box scoring in discharge information (OR 2.15, 95% CI 1.45-3.18; p < 0.001) than cranial patients. Similarly, brain tumor cases were associated with significantly higher odds of top-box scoring in communication with doctors (OR 1.46, 95% CI 1.01-2.12; p = 0.04), pain management (OR 1.81, 95% CI 1.29-2.55; p < 0.001), staff responsiveness (OR 1.88, 95% CI 1.33-2.66; p < 0.001), and global rating (OR 2.00, 95% CI 1.26-3.17; p = 0.003) compared with degenerative spine cases.CONCLUSIONSSignificant differences in patient-reported experience with hospital care exist across different cranial and spine surgery patient populations. Overall, spinal patients, particularly those with degenerative spine disease, rated their health and their hospital experience lower relative to cranial patients. Identifying weaker areas of hospital performance in target populations can stimulate quality initiatives that aim to increase the overall hospital score.

Adoption of Minimally Invasive Surgery and Decrease in Surgical Morbidity for Endometrial Cancer Treatment in the United States.

OBJECTIVE: To assess how the widespread adoption of minimally invasive surgery in the United States is associated with changes in 30-day morbidity and mortality in endometrial cancer treatment. METHODS: In this retrospective cohort study, the American College of Surgeons' National Surgical Quality Improvement Project database for 2008-2014 was reviewed for patients who had undergone surgery for endometrial cancer according to their primary Current Procedural Terminology (CPT) codes. Women with CPT codes for advanced cancer or with disseminated disease were excluded. A trend analysis across the time period by surgical approach (open surgery through laparotomy, vaginal surgery, and minimally invasive surgery) was performed using a Cochran-Armitage test for trend. Thirty-day surgical outcomes were compared between patients who had minimally invasive surgery and open surgery. Inverse probability of treatment weighting models were used to investigate the independent effect of minimally invasive surgery on 30-day outcomes. RESULTS: Overall, 12,283 patients met the inclusion criteria. A significant implementation of minimally invasive surgery (24.2-71.4%) and a concomitant decrease in open surgery through laparotomy (71.1-26.4%) were observed from 2008 to 2014 (both P<.001). Rate of vaginal surgery did not change over time (1.5-2.2%, P=.06). After adjusting for possible confounders, open surgery (compared with minimally invasive surgery) was independently associated with increased odds of major complications (n=347 versus n=274, adjusted odds ratio [OR] 2.4, 95% CI 2.0-2.8), readmission (n=269 versus n=238, adjusted OR 2.2, 95% CI 1.8-2.6), reoperation (n=80 versus n=93, adjusted OR 1.5, 95% CI 1.2-2.1), superficial surgical site infection (n=190 versus n=55, adjusted OR 6.8, 95% CI 5.0-9.2), perioperative transfusion (n=430 versus n=149, adjusted OR 5.9, 95% CI 4.8-7.1), and death (n=41 vs, n=20, adjusted OR 3.8, 95% CI 2.2-6.6). A comprehensive decrease in 30-day morbidity for the treatment of endometrial cancer overall was observed from 2008 to 2014 (P<.001), whereas 30-day mortality remained stable (P=.24). CONCLUSION: The widespread adoption of minimally invasive surgery is associated with substantial decreases in 30-day morbidity, readmission, and reoperation for women treated for endometrial cancer in the United States.