阿片类药物安全倡议对全膝关节置换术患者的影响：时间序列分析。
Impact of an Opioid Safety Initiative on Patients Undergoing Total Knee Arthroplasty: A Time Series Analysis.
机构信息
From the Patient Safety Center of Inquiry, Veterans Affairs Boston Healthcare System, Boston, Massachusetts (Q.C.) the Patient Safety Center of Inquiry, Durham Veterans Affairs Healthcare System (H.-L.H., W.B., M.P., T.B., K.R.) the Department of Anesthesiology, Duke University Health System (H.-L.H., T.B., V.K., K.R.) NoviSci, LLC. (R.O., M.A.B.), Durham, North Carolina Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Healthcare System and the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California (E.R.M., S.C.M.) Veterans Affairs Pharmacy Benefits Management Services, Hines, Illinois (C.B.G.) the Center for Value Based Pharmacy Initiatives, University of Pittsburgh Medical Center Health Plan, Pittsburgh, Pennsylvania (C.B.G.).
出版信息
Anesthesiology. 2019 Aug;131(2):369-380. doi: 10.1097/ALN.0000000000002771.
BACKGROUND
The Opioid Safety Initiative decreased high-dose prescriptions across the Veterans Health Administration. This study sought to examine the impact of this intervention (i.e., the Opioid Safety Initiative) on pain scores and opioid prescriptions in patients undergoing total knee arthroplasty.
METHODS
This was an ecological study of group-level data among 700 to 850 patients per month over 72 consecutive months (January 2010 to December 2015). The authors examined characteristics of cohorts treated before versus after rollout of the Opioid Safety Initiative (October 2013). Each month, the authors aggregated at the group-level the differences between mean postoperative and preoperative pain scores for each patient (averaged over 6-month periods), and measured proportions of patients (per 1,000) with opioid (and nonopioid) prescriptions for more than 3 months in 6-month periods, preoperatively and postoperatively. The authors compared postintervention trends versus trends forecasted based on preintervention measures.
RESULTS
After the Opioid Safety Initiative, patients were slightly older and sicker, but had lower mortality rates (postintervention n = 28,509 vs. preintervention n = 31,547). Postoperative pain scores were slightly higher and the decrease in opioid use was statistically significant, i.e., 871 (95% CI, 474 to 1,268) fewer patients with chronic postoperative prescriptions. In time series analyses, mean postoperative minus preoperative pain scores had increased from 0.65 to 0.81, by 0.16 points (95% CI, 0.05 to 0.27). Proportions of patients with chronic postoperative and chronic preoperative opioid prescriptions had declined by 20% (n = 3,355 vs. expected n = 4,226) and by 13% (n = 5,861 vs. expected n = 6,724), respectively. Nonopioid analgesia had increased. Sensitivity analyses confirmed all findings.
CONCLUSIONS
A system-wide initiative combining guideline dissemination with audit and feedback was effective in significantly decreasing opioid prescriptions in populations undergoing total knee arthroplasty, while minimally impacting pain scores.
背景
阿片类药物安全倡议减少了退伍军人事务部的高剂量处方。本研究旨在探讨这一干预措施（即阿片类药物安全倡议）对接受全膝关节置换术患者的疼痛评分和阿片类药物处方的影响。
方法
这是一项 72 个月（2010 年 1 月至 2015 年 12 月）内每月 700 至 850 名患者的组水平数据的生态学研究。作者研究了在阿片类药物安全倡议（2013 年 10 月）推出前后接受治疗的队列的特征。每个月，作者在组水平上汇总每位患者（6 个月期间平均）术后和术前疼痛评分的差异，并测量每个 1000 名患者中（6 个月期间）术后和术前使用阿片类药物（和非阿片类药物）处方超过 3 个月的比例。作者比较了干预后的趋势与基于干预前措施预测的趋势。
结果
阿片类药物安全倡议后，患者年龄稍大，病情稍重，但死亡率较低（干预后 n = 28509 例，干预前 n = 31547 例）。术后疼痛评分略高，阿片类药物使用减少具有统计学意义，即慢性术后处方减少 871 例（95%CI，474 至 1268）。时间序列分析显示，术后平均减去术前疼痛评分从 0.65 增加到 0.81，增加了 0.16 分（95%CI，0.05 至 0.27）。慢性术后和慢性术前阿片类药物处方患者的比例分别下降了 20%（n = 3355 例，预期 n = 4226 例）和 13%（n = 5861 例，预期 n = 6724 例）。非阿片类镇痛药的使用增加。敏感性分析证实了所有发现。
结论
一项结合指南传播、审计和反馈的系统范围倡议，有效地显著减少了接受全膝关节置换术患者的阿片类药物处方，同时对疼痛评分的影响最小。
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