Division of Urogynecology, Mayo Clinic, Rochester, MN.
Division of Urogynecology, Mayo Clinic, Rochester, MN.
Am J Obstet Gynecol. 2024 Aug;231(2):278.e1-278.e17. doi: 10.1016/j.ajog.2024.05.043. Epub 2024 May 25.
Current evidence supports that many patients do not use prescribed opioids following reconstructive pelvic surgery, yet it remains unclear if it is feasible to eliminate routine opioid prescriptions without a negative impact on patients or providers.
To determine if there is a difference in the proportion of patients discharged without opioids after implementing a bundle of opioid-sparing strategies and tiered prescribing protocol compared to usual care after minimally invasive pelvic reconstructive surgery (transvaginal, laparoscopic, or robotic). Secondary objectives include measures of patient-perceived pain control and provider workload.
The bundle of opioid-sparing strategies and tiered prescribing protocol intervention was implemented as a division-wide evidence-based practice change on August 1, 2022. This retrospective cohort compares a 6-month postintervention (bundle of opioid-sparing strategies and tiered prescribing protocol) cohort to 6-month preintervention (usual care) of patients undergoing minimally invasive pelvic reconstructive surgery. A 3-month washout period was observed after bundle of opioid-sparing strategies and tiered prescribing protocol initiation. We excluded patients <18 years, failure to consent to research, combined surgery with other specialties, urge urinary incontinence or urinary retention procedures alone, and minor procedures not typically requiring opioids. Primary outcome was measured by proportion discharged without opioids and total oral morphine equivalents prescribed. Pain control was measured by pain scores, postdischarge prescriptions and refills, phone calls and visits related to pain, and satisfaction with pain control. Provider workload was demonstrated by phone calls and postdischarge prescription refills. Data were obtained through chart review on all patients who met inclusion criteria. Primary analysis only included patients prescribed opioids according to the bundle of opioid-sparing strategies and tiered prescribing protocol protocol. Two sample t tests compared continuous variables and chi-square tests compared categorical variables.
Four hundred sixteen patients were included in the primary analysis (207 bundle of opioid-sparing strategies and tiered prescribing protocol, 209 usual care). Baseline demographics were similar between groups, except a lower proportion of irritable bowel syndrome (13% vs 23%; P<.01) and pelvic pain (15% vs 24.9%; P=.01), and higher history of prior gynecologic surgery (69.1% vs 58.4%; P=.02) in the bundle of opioid-sparing strategies and tiered prescribing protocol cohort. The bundle of opioid-sparing strategies and tiered prescribing protocol cohort was more likely to be discharged without opioids (68.1% vs 10.0%; P<.01). In those prescribed opioids, total oral morphine equivalents on discharge was significantly lower in the bundle of opioid-sparing strategies and tiered prescribing protocol cohort (48.1 vs 81.8; P<.01). The bundle of opioid-sparing strategies and tiered prescribing protocol cohort had a 20.6 greater odds (confidence interval 11.4, 37.1) of being discharged without opioids after adjusting for surgery type, arthritis/joint pain, IBS, pelvic pain, and contraindication to nonsteroidal anti-inflammatory drugs. The bundle of opioid-sparing strategies and tiered prescribing protocol cohort was also less likely to receive a rescue opioid prescription after discharge (1.4% vs 9.5%; P=.03). There were no differences in opioid prescription refills (19.7% vs 18.1%; P=.77), emergency room visits for pain (3.4% vs 2.9%; P=.76), postoperative pain scores (mean 4.7 vs 4.0; P=.07), or patient satisfaction with pain control (81.5% vs 85.6%; P=.21). After bundle of opioid-sparing strategies and tiered prescribing protocol implementation, the proportion of postoperative phone calls for pain also decreased (12.6% vs 21.5%; P=.02). Similar results were identified when nonadherent prescribing was included in the analysis.
A bundle of evidence-based opioid sparing strategies and tiered prescribing based on inpatient use increases the proportion of patients discharged without opioids after minimally invasive pelvic reconstructive surgery without evidence of uncontrolled pain or increased provider workload.
目前的证据表明，许多接受重建骨盆手术的患者在术后并不使用处方阿片类药物，但仍不清楚是否可以在不影响患者或提供者的情况下消除常规阿片类药物处方。
确定在实施一系列阿片类药物节约策略和分层处方方案后，与微创骨盆重建手术后的常规护理相比，患者出院时不使用阿片类药物的比例是否存在差异（经阴道、腹腔镜或机器人）。次要目标包括患者感知疼痛控制和提供者工作量的措施。
该组阿片类药物节约策略和分层处方方案于 2022 年 8 月 1 日作为一项全部门的循证实践变更实施。这项回顾性队列研究将 6 个月的干预后（组阿片类药物节约策略和分层处方方案）队列与微创骨盆重建手术的 6 个月的干预前（常规护理）进行比较。在启动组阿片类药物节约策略和分层处方方案后观察了 3 个月的洗脱期。我们排除了<18 岁、不同意参与研究、与其他专科联合手术、单纯急迫性尿失禁或尿潴留手术以及通常不需要阿片类药物的小手术的患者。主要结果是通过出院时未使用阿片类药物的比例和开具的口服吗啡等效物总量来衡量。疼痛控制通过疼痛评分、出院后处方和续方、与疼痛相关的电话和就诊以及疼痛控制满意度来衡量。提供者工作量通过电话和出院后处方续方来证明。通过对所有符合纳入标准的患者进行图表审查获得数据。主要分析仅包括根据组阿片类药物节约策略和分层处方方案协议开具阿片类药物的患者。连续变量采用两样本 t 检验比较，分类变量采用卡方检验比较。
共有 416 名患者纳入主要分析（组阿片类药物节约策略和分层处方方案 207 例，常规护理 209 例）。两组的基线人口统计学特征相似，但肠易激综合征（13%比 23%；P<.01）和盆腔疼痛（15%比 24.9%；P=.01）的比例较低，以及既往妇科手术史（69.1%比 58.4%；P=.02）较高。在组阿片类药物节约策略和分层处方方案组中，更有可能在出院时不使用阿片类药物（68.1%比 10.0%；P<.01）。在开具阿片类药物的患者中，组阿片类药物节约策略和分层处方方案组出院时口服吗啡等效物总量显著降低（48.1 比 81.8；P<.01）。调整手术类型、关节炎/关节痛、肠易激综合征、盆腔疼痛和非甾体抗炎药禁忌后，组阿片类药物节约策略和分层处方方案组出院时不使用阿片类药物的可能性高 20.6 倍（置信区间 11.4，37.1）。组阿片类药物节约策略和分层处方方案组出院后接受解救阿片类药物处方的可能性也较低（1.4%比 9.5%；P=.03）。阿片类药物处方续方无差异（19.7%比 18.1%；P=.77）、因疼痛就诊急诊（3.4%比 2.9%；P=.76）、术后疼痛评分（平均 4.7 比 4.0；P=.07）或患者对疼痛控制的满意度（81.5%比 85.6%；P=.21）。实施组阿片类药物节约策略和分层处方方案后，术后因疼痛而致电的比例也下降（12.6%比 21.5%；P=.02）。当非依从性处方纳入分析时，也得到了类似的结果。
一系列基于住院使用的循证阿片类药物节约策略和分层处方方案可增加微创骨盆重建手术后出院时不使用阿片类药物的患者比例，而不会导致疼痛控制不佳或提供者工作量增加。
