Langnas E M, Matthay Z A, Lin A, Harbell M W, Croci R, Rodriguez-Monguio R, Chen C L
Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Ave, S455, San Francisco, CA, 94143, USA.
Department of Surgery, University of California, San Francisco, San Francisco, USA.
Perioper Med (Lond). 2021 Nov 15;10(1):38. doi: 10.1186/s13741-021-00209-0.
Enhanced recovery after surgery (ERAS) pathways have emerged as a promising strategy to reduce postoperative opioid use and decrease the risk of developing new persistent opioid use in surgical patients. However, the association between ERAS implementation and discharge opioid prescribing practices is unclear.
We conducted a retrospective observational quasi-experimental study of opioid-naïve patients aged 18+ undergoing cesarean delivery between February 2015 and December 2019 at a large academic center. An interrupted time series analysis (ITSA) was used to model the changes in pain medication prescribing associated with the implementation of ERAS to account for pre-existing temporal trends.
Among the 1473 patients (out of 2249 total) who underwent cesarean delivery after ERAS implementation, 80.72% received a discharge opioid prescription vs. 95.36% at baseline. Pre-ERAS daily oral morphine equivalents (OME) on the discharge prescription decreased by 0.48 OME each month (p<0.01). There was a level shift of 35 more OME prescribed (p<0.01), followed by a monthly decrease of 1.4 OMEs per month after ERAS implementation (p<0.01). Among those who received a prescription, 61.35% received a total daily dose greater than 90 OME compared to 11.35% pre-implementation (p<0.01), while prescriptions with a total daily dose less than 50 OME decreased from 79.86 to 25.85% after ERAS implementation(p<0.01).
Although ERAS implementation reduced the overall proportion of patients receiving a discharge opioid prescription after cesarean delivery, for the subset of patients receiving an opioid prescription, ERAS implementation may have inadvertently increased the prescribing of daily doses greater than 90 OME. This finding highlights the importance of early and continued evaluation after new policies are implemented.
术后加速康复（ERAS）路径已成为一种有前景的策略，可减少手术患者术后阿片类药物的使用，并降低出现新的持续性阿片类药物使用的风险。然而，ERAS实施与出院时阿片类药物处方实践之间的关联尚不清楚。
我们对2015年2月至2019年12月在一家大型学术中心接受剖宫产的18岁及以上未使用过阿片类药物的患者进行了一项回顾性观察性准实验研究。采用中断时间序列分析（ITSA）对与ERAS实施相关的疼痛药物处方变化进行建模，以考虑预先存在的时间趋势。
在ERAS实施后接受剖宫产的1473名患者（总共2249名）中，80.72%的患者出院时收到了阿片类药物处方，而基线时这一比例为95.36%。ERAS实施前出院处方上每日口服吗啡当量（OME）每月减少0.48 OME（p<0.01）。处方的OME水平有35 OME的跃升（p<0.01），随后在ERAS实施后每月减少1.4 OME（p<0.01）。在收到处方的患者中，61.35%的患者每日总剂量大于90 OME，而实施前这一比例为11.35%（p<0.01），而每日总剂量小于50 OME的处方在ERAS实施后从79.86%降至25.85%（p<0.01）。
尽管ERAS的实施降低了剖宫产术后接受出院阿片类药物处方的患者的总体比例，但对于接受阿片类药物处方的患者亚组，ERAS的实施可能无意中增加了每日剂量大于90 OME的处方。这一发现凸显了新政策实施后早期和持续评估的重要性。
