Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.
Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr., #100, Bethesda, MD, 20817, USA.
BMC Anesthesiol. 2022 Jul 12;22(1):218. doi: 10.1186/s12871-022-01765-8.
BACKGROUND: To examine factors associated with post-Cesarean section analgesic prescription variation at hospital discharge in patients who are opioid naïve; and examine relationships between pre-Cesarean section patient and care-level factors and discharge morphine equivalent dose (MED) on outcomes (e.g., probability of opioid refill within 30 days) across a large healthcare system. METHODS: The Walter Reed Institutional Review Board provided an exempt determination, waiver of consent, and waiver of HIPAA authorization for research use in the present retrospective longitudinal cohort study. Patient records were included in analyses if: sex assigned in the medical record was "female," age was 18 years of age or older, the Cesarean section occurred between January 2016 to December 2019 in the Military Health System, the listed TRICARE sponsor was an active duty service member, hospitalization began no more than three days prior to the Cesarean section, and the patient was discharged to home < 4 days after the Cesarean section. RESULTS: Across 57 facilities, 32,757 adult patients had a single documented Cesarean section procedure in the study period; 24,538 met inclusion criteria and were used in analyses. Post-Cesarean section discharge MED varied by facility, with a median MED of 225 mg and median 5-day supply. Age, active duty status, hospitalization duration, mental health diagnosis, pain diagnosis, substance use disorder, alcohol use disorder, gestational diabetes, discharge opioid type (combined vs. opioid-only medication), concurrent tubal ligation procedure, single (vs. multiple) births, and discharge morphine equivalent dose were associated with the probability of an opioid prescription refill in bivariate analyses, and therefore were included as covariates in a generalized additive mixed model (GAMM). Generalized additive mixed model results indicated that non-active duty beneficiaries, those with mental health and pain conditions, those who received an opioid/non-opioid combination medication, those with multiple births, and older patients were more likely to obtain an opioid refill, relative to their counterparts. CONCLUSION: Significant variation in discharge pain medication prescriptions, as well as the lack of association between discharge opioid MED and probability of refill, indicates that efforts are needed to optimize opioid prescribing and reduce unnecessary healthcare variation.
背景：在初次使用阿片类药物的剖宫产患者中，研究出院时与阿片类药物处方差异相关的因素；并研究剖宫产前患者和护理水平因素与出院时吗啡当量剂量（MED）与结局之间的关系（例如，30 天内阿片类药物再开处方的概率）在一个大型医疗保健系统中。 方法：沃尔特·里德机构审查委员会提供了豁免决定、同意豁免和医疗保健信息隐私授权豁免，以用于本回顾性纵向队列研究的研究用途。如果患者记录符合以下条件，则将其纳入分析：病历中记录的性别为“女性”，年龄为 18 岁或以上，剖宫产发生在 2016 年 1 月至 2019 年 12 月期间的军人健康系统，列出的 TRICARE 赞助商是现役军人，住院时间不超过剖宫产前三天，且患者在剖宫产后 4 天内出院回家。 结果：在 57 家医疗机构中，有 32757 名成年患者在研究期间进行了单次剖宫产手术；有 24538 名患者符合纳入标准并用于分析。剖宫产出院 MED 因机构而异，中位数 MED 为 225mg，中位数 5 天供应量。年龄、现役状态、住院时间、心理健康诊断、疼痛诊断、物质使用障碍、酒精使用障碍、妊娠期糖尿病、出院时阿片类药物类型（联合用药与单独使用阿片类药物）、同期输卵管结扎术、单胎（与多胎）分娩以及出院时吗啡当量剂量与双变量分析中阿片类药物再开处方的概率相关，因此被纳入广义加性混合模型（GAMM）的协变量。广义加性混合模型结果表明，非现役受益人的、有心理健康和疼痛状况的、接受阿片类药物/非阿片类药物联合药物治疗的、多胎分娩的和年龄较大的患者比他们的同龄人更有可能获得阿片类药物再开处方。 结论：出院时疼痛药物处方的显著差异，以及出院时阿片类 MED 与再开处方概率之间缺乏关联，表明需要努力优化阿片类药物处方并减少不必要的医疗保健差异。
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