Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan.
Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan.
Ann Thorac Surg. 2021 Oct;112(4):1176-1185. doi: 10.1016/j.athoracsur.2020.11.015. Epub 2020 Dec 4.
Despite the risk of new persistent opioid use after cardiac surgery, postdischarge opioid use has not been quantified and evidence-based prescribing guidelines have not been established.
Opioid-naive patients undergoing primary cardiac surgery via median sternotomy between January and December 2019 at 10 hospitals participating in a statewide collaborative were selected. Clinical data were linked to patient-reported outcomes collected at 30-day follow-up. An opioid prescribing recommendation stratified by inpatient opioid use on the day before discharge (0, 1-3, or ≥4 pills) was implemented in July 2019. Interrupted time-series analyses were performed for prescription size and postdischarge opioid use before (January to June) and after (July to December) guideline implementation.
Among 1495 patients (729 prerecommendation and 766 postrecommendation), median prescription size decreased from 20 pills to 12 pills after recommendation release (P < .001), while opioid use decreased from 3 pills to 0 pills (P < .001). Change in prescription size over time was +0.6 pill/month before and -0.8 pill/month after the recommendation (difference = -1.4 pills/month; P = .036). Change in patient use was +0.6 pill/month before and -0.4 pill/month after the recommendation (difference = -1.0 pills/month; P = .017). Pain levels during the first week after surgery and refills were unchanged. Patients using 0 pills before discharge (n = 710) were prescribed a median of 0 pills and used 0 pills, while those using 1 to 3 pills (n = 536) were prescribed 20 pills and used 7 pills, and those using greater than or equal to 4 pills (n = 249) were prescribed 32 pills and used 24 pills.
An opioid prescribing recommendation was effective, and prescribing after cardiac surgery should be guided by inpatient use.
尽管心脏手术后新的持续性阿片类药物使用的风险存在，但出院后的阿片类药物使用尚未被量化，也没有建立基于证据的处方指南。
选择了 2019 年 1 月至 12 月期间在参与全州合作的 10 家医院通过正中胸骨切开术进行初次心脏手术的阿片类药物初治患者。将临床数据与 30 天随访时收集的患者报告结果相关联。2019 年 7 月，实施了一种根据出院前一天（0、1-3 或≥4 片）的住院内阿片类药物使用情况分层的阿片类药物处方推荐。在指南实施之前（1 月至 6 月）和之后（7 月至 12 月），进行了中断时间序列分析，以分析处方规模和出院后的阿片类药物使用情况。
在 1495 名患者中（推荐前 729 名，推荐后 766 名），推荐发布后，处方规模从 20 片减少到 12 片（P<0.001），而阿片类药物使用从 3 片减少到 0 片（P<0.001）。推荐前后，处方大小随时间的变化分别为+0.6 片/月和-0.8 片/月（差值=-1.4 片/月；P=0.036）。患者使用情况的变化分别为+0.6 片/月和-0.4 片/月（差值=-1.0 片/月；P=0.017）。术后第一周的疼痛水平和续药情况没有变化。出院前使用 0 片（n=710）的患者被开了 0 片的处方，使用了 0 片；出院前使用 1 至 3 片（n=536）的患者被开了 20 片的处方，使用了 7 片；出院前使用大于等于 4 片（n=249）的患者被开了 32 片的处方，使用了 24 片。
阿片类药物处方推荐是有效的，心脏手术后的处方应根据住院内使用情况进行指导。
