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Impact of a tiered discharge opioid algorithm on prescriptions and patient-reported outcomes after open gynecologic surgery
  1. Sarah Huepenbecker1,
  2. Robert Tyler Hillman1,
  3. Maria D Iniesta1,
  4. Tsun Chen2,
  5. Katherine Cain3,
  6. Gabriel Mena4,
  7. Javier Lasala4,
  8. Xin Shelley Wang2,
  9. Loretta Williams2,
  10. Jolyn S Taylor1,
  11. Karen H Lu1,
  12. Pedro T Ramirez1 and
  13. Larissa A Meyer1
  1. 1 Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
  2. 2 Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
  3. 3 Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
  4. 4 Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
  1. Correspondence to Dr Larissa A Meyer, Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; lmeyer{at}mdanderson.org

Abstract

Objective To compare discharge opioid refills, prescribed morphine equivalent dose and quantity, and longitudinal patient-reported outcomes before and after implementation of a tiered opioid prescribing algorithm among women undergoing open gynecologic surgery within an enhanced recovery after surgery program.

Methods We compared opioid prescriptions, clinical outcomes, and patient-reported outcomes among 273 women. Post-discharge symptom burden was collected up to 42 days after discharge using the validated 27-item MD Anderson Symptom Inventory and analyzed using linear mixed effects models and Kaplan–Meier curves for symptom recovery.

Results Among 113 pre-implementation and 160 post-implementation patients there was no difference in opioid refills (9.7% vs 11.3%, p=0.84). The post-implementation cohort had a significant reduction in median morphine equivalent dose (112.5 mg vs 225 mg, p<0.01), with no difference in median hospital length of stay (3 days vs 3 days, p=1.0) or 30-day readmission rate (9.4% vs 7.1%, p=0.66). There was no difference in patient-reported pain between the pre- and post-implementation cohorts on the day of discharge (severity 4.93 vs 5.14, p=0.53) or in any patient-reported symptoms, interference measures, or composite scores by post-discharge day 7. The median recovery time for most symptoms was 7 days, except for pain (14 days), fatigue (18 days), and physical interference (21 days), with no differences between cohorts.

Conclusions After implementation of a tiered opioid prescribing algorithm, the quantity and dose of discharge opioids prescribed decreased with no change in post-operative refills and without negatively impacting patient-reported symptom burden or interference, which can be used to educate and reassure patients and providers.

  • gynecologic surgical procedures
  • opioid-related disorders
  • postoperative care

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Study data were collected and managed using Research Electronic Data Capture tools hosted at MD Anderson as part of an institutionally approved quality improvement study. In accordance with the journal’s guidelines, we will provide our data for the reproducibility of this study in other centers if such is requested.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Study data were collected and managed using Research Electronic Data Capture tools hosted at MD Anderson as part of an institutionally approved quality improvement study. In accordance with the journal’s guidelines, we will provide our data for the reproducibility of this study in other centers if such is requested.

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Footnotes

  • Twitter @sarah_huep, @gabemenaMD, @TaylorJolyn, @pedroramirezMD

  • Contributors SH: Investigation, writing – original draft. RTH: Conceptualization, methodology, investigation, formal analysis. MDI: Software, validation, investigation, project administration. TC: Formal analysis. KC: Validation, writing – review and editing. GM: Writing – review and editing. JL: Writing – review and editing. XSW: Conceptualization. LW: Conceptualization, Writing – review and editing. JST: Conceptualization, methodology, writing – review and editing. KHL: Supervision. PTR: Supervision, writing – review and editing. LAM: Conceptualization, methodology, supervision, writing – review and editing.

  • Funding This work was supported in part by the MD Anderson Cancer Center Support Grant from the National Cancer Institute of the National Institutes of Health (NIH/NCI P30 CA016672, CA217685) and the T32 training grant CA101642 (SPH). LAM is supported by a NIH-NCIK07-CA201013 grant. XSW is supported by NCI/NIH “Improving Recovery After Major Cancer Surgery Using Patient-Reported Outcomes”, R01CA205146.

  • Competing interests LAM reports research funding from AstraZeneca, consulting for GlaxoSmithKline, and stocks in Crispr and Bristol-Myers Squibb. LW reports grants from AstraZeneca, Astellas, Bayer, Bristol Meyers Squibb, Genentech, Merck, and Eli Lily. GM reports a research/academic grant from PACIRA Pharmaceutical.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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