Wyles Cody C, Hevesi Mario, Ubl Daniel S, Habermann Elizabeth B, Gazelka Halena M, Trousdale Robert T, Turner Norman S, Pagnano Mark W, Mabry Tad M
Department of Orthopedic Surgery (C.C.W., M.H., R.T.T, N.S.T., M.W.P., and T.M.M.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program (D.S.U. and E.B.H.), and Division of Pain Medicine, Department of Anesthesiology and Perioperative Pain Medicine (H.M.G.), Mayo Clinic, Rochester, Minnesota.
JB JS Open Access. 2020 Mar 3;5(1):e0050. doi: 10.2106/JBJS.OA.19.00050. eCollection 2020 Jan-Mar.
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.
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.
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.
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.
迫切需要基于证据的、针对特定手术的阿片类药物处方指南，以优化疼痛缓解，同时尽量减少社区中阿片类药物的过度处方和潜在的阿片类药物转移。我们机构的一个多学科小组最近制定了针对常见骨科手术出院阿片类药物处方的特定手术指南。本研究的目的是评估指南实施前后术后阿片类药物的处方量、变异性和30天再填充率。
本回顾性队列研究于2016年12月至2018年3月在一家学术机构进行。指南于2017年8月1日实施，针对14种常见骨科手术推荐了最大阿片类药物处方量。在2016年12月至2017年5月期间接受这14种手术的患者组成了指南前队列（n = 2223），在2017年10月至2018年3月期间接受这些手术的患者组成了指南后队列（n = 2300）。阿片类药物处方量以口服吗啡当量（OME）报告，包括中位数和四分位数间距（IQR）。推荐的处方最大量设定为四个级别，范围从100到400 OME。
在指南前队列中，所有手术的阿片类药物处方中位数为600 OME（IQR，390至863 OME），在指南后期间减少了38%，指南后队列中的中位数为375 OME（IQR，239至400 OME）（p < 0.001）。30天再填充率没有显著变化，从指南前队列中的率24%变为指南后队列中的25%（p = 0.43）。多变量分析表明，指南实施是与超过指南最大量的处方最密切相关的因素（优势比[OR] = 9.9；p < 0.001）。年龄小于80岁的年龄组（OR = 2.0至2.4；p < 0.001）和男性（OR = 1.2；p = 0.025）也显示出超过指南最大量的几率更高。
针对特定手术的指南能够大幅降低阿片类药物的处方量和变异性。此外，再填充率没有变化表明疼痛控制与指南前的处方做法相似。基于证据的指南是一种易于采用的解决方案，可以推动实践中的快速变革，并提高骨科医生提供负责任的疼痛管理的能力。
