Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm.

Autor:	Boyev A; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas., Jain AJ; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas., Newhook TE; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas., Prakash LR; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas., Chiang YJ; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas., Bruno ML; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas., Arvide EM; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas., Dewhurst WL; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas., Kim MP; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas., Maxwell JE; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas., Ikoma N; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas., Snyder RA; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas., Lee JE; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas., Katz MHG; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas., Tzeng CD; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
Jazyk:	angličtina
Zdroj:	JAMA surgery [JAMA Surg] 2023 Nov 01; Vol. 158 (11), pp. e234154. Date of Electronic Publication: 2023 Nov 08.
DOI:	10.1001/jamasurg.2023.4154
Abstrakt:	Importance: Postoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume. Objective: To analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes. Design, Setting, and Participants: This cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]). Exposures: After V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1. Main Outcomes and Measures: Inpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses. Results: A total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P < .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P < .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P < .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P < .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups. Conclusions and Relevance: In this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.
Databáze:	MEDLINE
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