Management of pelvic sarcoma.

Pelvic sarcomas are a rare and heterogenous group of tumors divided into two groups: soft tissue sarcomas and bone sarcomas. Soft tissue sarcomas of the pelvis include most commonly liposarcoma, leiomyosarcoma, gastrointestinal stromal tumors, malignant peripheral nerve sheath tumors, and solitary fibrous tumors. Bone sarcomas of the pelvis most commonly include osteosarcoma and chondrosarcoma. Multidisciplinary treatment at a center experienced in the treatment of sarcoma is essential. Management is dictated by histologic type and grade. Surgical resection with wide margins is the cornerstone of treatment for pelvic sarcomas, although this is often challenging due to anatomic constraints of the pelvis. Multimodal treatment is critical due to the high risk of local recurrence in the pelvis.

Association of Postoperative Opioid Prescription Size and Patient Satisfaction.

OBJECTIVE: To evaluate the association between postoperative opioid prescription size and patient-reported satisfaction among surgical patients. SUMMARY BACKGROUND DATA: Opioids are overprescribed after surgery, which negatively impacts patient outcomes. The assumption that larger prescriptions increase patient satisfaction has been suggested as an important driver of excessive prescribing. METHODS: This prospective cohort study evaluated opioid-naive adult patients undergoing laparoscopic cholecystectomy, laparoscopic appendectomy, and minor hernia repair between January 1 and May 31, 2018. The primary outcome was patient satisfaction, collected via a 30-day postoperative survey. Satisfaction was measured on a scale of 0 to 10 and dichotomized into "highly satisfied" (9-10) and "not highly satisfied" (0-8). The explanatory variable of interest was size of opioid prescription at discharge from surgery, converted into milligrams of oral morphine equivalents (OME). Hierarchical logistic regression was performed to evaluate the association between prescription size and satisfaction while adjusting for clinical covariates. RESULTS: One thousand five hundred twenty patients met the inclusion criteria. Mean age was 53 years and 43% of patients were female. One thousand two hundred seventy-nine (84.1%) patients were highly satisfied and 241 (15.9%) were not highly satisfied. After multivariable adjustment, there was no significant association between opioid prescription size and satisfaction (OR 1.00, 95% CI 0.99-1.00). The predicted probability of being highly satisfied ranged from 83% for the smallest prescription (25 mg OME) to 85% for the largest prescription (750 mg OME). CONCLUSIONS: In a large cohort of patients undergoing common surgical procedures, there was no association between opioid prescription size at discharge after surgery and patient satisfaction. This implies that surgeons can provide significantly smaller opioid prescriptions after surgery without negatively affecting patient satisfaction.

Prevalence and Patterns of Opioid Use Before and After Liver Transplantation.

BACKGROUND: Opioid use in liver transplantation is poorly understood and has potential associated morbidity. METHODS: Using a national data set of employer-based insurance claims, we identified 1257 adults who underwent liver transplantation between December 2009 and February 2015. We categorized patients based on their duration of opioid fills over the year before and after transplant admission as opioid-naive/no fills, chronic opioid use (≥120 d supply), and intermittent use (all other use). We calculated risk-adjusted prevalence of peritransplant opioid fills, assessed changes in opioid use after transplant, and identified correlates of persistent or increased opioid use posttransplant. RESULTS: Overall, 45% of patients filled ≥1 opioid prescription in the year before transplant (35% intermittent use, 10% chronic). Posttransplant, 61% of patients filled an opioid prescription 0-2 months after discharge, and 21% filled an opioid between 10-12 months after discharge. Among previously opioid-naive patients, 4% developed chronic use posttransplant. Among patients with pretransplant opioid use, 84% remained intermittent or increased to chronic use, and 73% of chronic users remained chronic users after transplant. Pretransplant opioid use (risk factor) and hepatobiliary malignancy (protective) were the only factors independently associated with risk of persistent or increased posttransplant opioid use. CONCLUSIONS: Prescription opioid use is common before and after liver transplant, with intermittent and chronic use largely persisting, and a small development of new chronic use posttransplant. To minimize the morbidity of long-term opioid use, it is critical to improve pain management and optimize opioid use before and after liver transplant.

Opioid prescribing exceeds consumption following common surgical oncology procedures.

BACKGROUND AND OBJECTIVES: Surgical oncology patients are vulnerable to persistent opioid use. As such, we aim to compare opioid prescribing to opioid consumption for common surgical oncology procedures. METHODS: We prospectively identified patients undergoing common surgical oncology procedures at a single academic institution (August 2017-March 2018). Patients were contacted by telephone within 6 months of surgery and asked to report their opioid consumption and describe their discharge instructions and opioid handling practices. RESULTS: Of the 439 patients who were approached via telephone, 270 completed at least one survey portion. The median quantity of opioid prescribed was significantly larger than consumed following breast biopsy (5 vs. 2 tablets of 5 mg oxycodone, p < .001), lumpectomy (10 vs. 2 tablets of 5 mg oxycodone, p < .001), and mastectomy or wide local excision (20 tablets vs. 2 tablets of 5 mg oxycodone, p < .001). The majority of patients reported receiving education on taking opioids, but only 27% received instructions on proper disposal; 82% of prescriptions filled resulted in unused opioids, and only 11% of these patients safely disposed of them. CONCLUSIONS: This study demonstrates that opioid prescribing exceeds consumption following common surgical oncology procedures, indicating the potential for reductions in prescribing.

Classifying Preoperative Opioid Use for Surgical Care.

OBJECTIVE: We characterized patterns of preoperative opioid use in patients undergoing elective surgery to identify the relationship between preoperative use and subsequent opioid fill after surgery. BACKGROUND: Preoperative opioid use is common, and varies by dose, recency, duration, and continuity of fills. To date, there is little evidence to guide postoperative prescribing need based on prior opioid use. METHODS: We analyzed claims data from Clinformatics DataMart Database for patients aged 18 to 64 years undergoing major and minor surgery between 2008 and 2015. Preoperative use was defined as any opioid prescription filled in the year before surgery. We used cluster analysis to group patients by the dose, recency, duration, and continuity of use. Our primary outcome was second postoperative fill within 30 postoperative days. Our primary explanatory variable was opioid use group. We used logistic regression to examine likelihood of second fill by opioid use group. RESULTS: Out of 267,252 patients, 102,748 (38%) filled an opioid prescription in the 12 months before surgery. Cluster analysis yielded 6 groups of preoperative opioid use, ranging from minimal (27.6%) to intermittent (7.7%) to chronic use (2.7%). Preoperative opioid use was the most influential predictor of second fill, with larger effect sizes than other factors even for patients with minimal or intermittent opioid use. Increasing preoperative use was associated with risk-adjusted likelihood of requiring a second opioid fill compared with naive patients [minimal use: odds ratio (OR) 1.49, 95% confidence interval (95% CI) 1.45-1.53; recent intermittent use: OR 6.51, 95% CI 6.16-6.88; high chronic use: OR 60.79, 95% CI 27.81-132.92, all P values <0.001). CONCLUSION: Preoperative opioid use is common among patients who undergo elective surgery. Although the majority of patients infrequently fill opioids before surgery, even minimal use increases the probability of needing additional postoperative prescriptions in the 30 days after surgery when compared with opioid-naive patients. Going forward, identifying preoperative opioid use can inform surgeon prescribing and care coordination for pain management after surgery.

Provider Characteristics Associated With Outpatient Opioid Prescribing After Surgery.

OBJECTIVE: To characterize differences in postoperative opioid prescribing across surgical, nonsurgical, and advanced practice providers. BACKGROUND: There is a critical need to identify best practices around perioperative opioid prescribing. To date, differences in postoperative prescribing among providers are poorly understood. METHODS: This is a retrospective multicenter analysis of commercial insurance claims from a statewide quality collaborative. We identified 15,657 opioid-naïve patients who underwent a range of surgical procedures between January 2012 and October 2015 and filled an opioid prescription within 30 days postoperatively. Our primary outcome was total amount of opioid filled per prescription within 30 days postoperatively [in oral morphine equivalents (OME)]. Hierarchical linear regression was used to determine the association between provider characteristics [specialty, advanced practice providers (nurse practitioners and physician assistants) vs. physician, and gender] and outcome while adjusting for patient factors. RESULTS: Average postoperative opioid prescription amount was 326 ± 285 OME (equivalent: 65 tablets of 5 mg hydrocodone). Advanced practice providers accounted for 19% of all prescriptions, and amount per prescription was 18% larger in this group compared with physicians (315 vs. 268, P < 0.001). Primary care providers accounted for 13% of all prescriptions and prescribed on average 279 OME per prescription. The amount of opioid prescribed varied by surgical specialty and ranged from 178 OME (urology) to 454 OME (neurosurgery). CONCLUSIONS: Advanced practice providers account for 1-in-5 postoperative opioid prescriptions and prescribe larger amounts per prescription relative to surgeons. Engaging all providers involved in postoperative care is necessary to understand prescribing practices, identify barriers to reducing prescribing, and tailor interventions accordingly.

Patterns of Initial Opioid Prescribing to Opioid-Naive Patients.

OBJECTIVE: To determine the proportion of initial opioid prescriptions for opioid-naive patients prescribed by surgeons, dentists, and emergency physicians. We hypothesized that the percentage of such prescriptions grew as scrutiny of primary care and pain medicine opioid prescribing increased and guidelines were developed. SUMMARY OF BACKGROUND DATA: Data regarding the types of care for which opioid-naive patients are provided initial opioid prescriptions are limited. METHODS: A retrospective cross-sectional study using a nationwide insurance claims dataset to study US adults aged 18 to 64 years. Our primary outcome was a change in opioid prescription share for opioid-naive patients undergoing surgical, emergency, and dental care from 2010 to 2016; we also examined the type and amounts of opioid filled. RESULTS: From 87,941,718 analyzed lives, we identified 16,292,018 opioid prescriptions filled by opioid-naive patients. The proportion of prescriptions for patients receiving surgery, emergency, and dental care increased by 15.8% from 2010 to 2016 (P < 0.001), with the greatest increases related to surgical (18.1%) and dental (67.8%) prescribing. In 2016, surgery patients filled 22.0% of initial prescriptions, emergency medicine patients 13.0%, and dental patients 4.2%. Surgical patients' mean total oral morphine equivalents per prescription increased from 240 mg (SD 509) in 2010 to 403 mg (SD 1369) in 2016 (P < 0.001). Over the study period, surgical patients received the highest proportion of potent opioids (90.2% received hydrocodone or oxycodone). CONCLUSIONS: Initial opioid prescribing attributable to surgical and dental care is increasing relative to primary and chronic pain care. Evidence-based guideline development for surgical and dental prescribing is warranted in order to curb iatrogenic opioid morbidity and mortality.

Health Care Spending and New Persistent Opioid Use After Surgery.

OBJECTIVE: We sought to describe the differences in health care spending and utilization among patients who develop persistent postoperative opioid use. SUMMARY OF BACKGROUND DATA: Although persistent opioid use following surgery has garnered concern, its impact on health care costs and utilization remains unknown. METHODS: We examined insurance claims among 133,439 opioid-naive adults undergoing surgery. Outcomes included 6-month postoperative health care spending; proportion of spending attributable to admission, readmission, ambulatory or emergency care; monthly spending 6 months before and following surgery. We defined persistent opioid use as continued opioid fills beyond 3 months postoperatively. We used linear regression to estimate outcomes adjusting for clinical covariates. RESULTS: In this cohort, 8103 patients developed persistent opioid use. For patients who underwent inpatient procedures, new persistent opioid use was associated with health care spending (+$2700 per patient, P < 0.001) compared with patients who did not develop new persistent use. For patients who underwent outpatient procedures, new persistent opioid use was similarly correlated with higher health care spending (+$1500 per patient, P < 0.001) compared with patients who did not develop new persistent use. Patients without persistent opioid use returned to baseline health care spending within 6 months, regardless of other complications. However, patients with persistent opioid use had sustained increases in spending by approximately $200 per month. CONCLUSION: Unlike other postoperative complications, persistent opioid use is associated with sustained increases in spending due to greater readmissions and ambulatory care visits. Early identification of patients vulnerable to persistent use may enhance the value of surgical care.

Association of State Opioid Duration Limits With Postoperative Opioid Prescribing.

Importance: Since the Centers for Disease Control and Prevention published opioid prescribing guidelines in March 2016, 31 states have implemented legislation to restrict the duration of opioid prescriptions for acute pain. However, the association of these policies with the amount of opioid prescribed following surgery remains unknown. Objective: To examine the association of opioid prescribing duration limits with postoperative opioid prescribing in Massachusetts and Connecticut, the first 2 states to implement limits after March 2016. Design, Setting, and Participants: This interrupted time series analysis and cross-sectional study examined immediate level and slope changes in monthly outcomes after prescribing limit implementation in Massachusetts and Connecticut. These states implemented 7-day limits on initial opioid prescriptions on March 14, 2016, and July 1, 2016, respectively. Using the 2014 to 2017 IBM MarketScan Research Database, 16 281 opioid-naive adults in these states who filled a prescription within 3 days of surgery between July 1, 2014, and November 30, 2017, were identified. Data were analyzed from December 2018 to June 2019. Main Outcomes and Measures: The primary outcome was the prescription size in oral morphine equivalents (OMEs) for the initial postoperative opioid prescription (one 5/325 mg hydrocodone-acetaminophen pill = 5 OMEs). Secondary outcomes included days supplied in the initial prescription and the proportion of initial prescriptions exceeding a 7-day supply. Results: In total, 16 281 opioid-naive patients (9708 [59.6%] female; median [interquartile range] age range, 45-54 [35-44 to 55-64] years) undergoing surgical procedures were included. In Massachusetts, there were 5340 and 5435 patients in the preimplementation and postimplementation periods, respectively. In Connecticut, there were 2869 and 2637 patients in the preimplementation and postimplementation periods, respectively. Limit implementation in Massachusetts was associated with an immediate mean level decrease in prescription size (-38 OMEs [95% CI, -44 to -32 OMEs]) and with a mean decrease in slope (-1.5 OMEs/mo [95% CI, -2.1 to -0.9 OMEs/mo]). Implementation was also associated with an immediate mean level decrease in days supplied (-0.4 days [95% CI, -0.6 to -0.2 days]) and the proportion of prescriptions exceeding a 7-day supply (-5.9 percentage points [95% CI, -7.9 to -3.9 percentage points]). In contrast, limit implementation in Connecticut was not associated with level or slope changes in any outcome. Conclusions and Relevance: Opioid prescribing duration limits had a variable association with postoperative opioid prescribing in Massachusetts and Connecticut. The mean opioid prescription size filled, days supplied, and prescribing exceeding a 7-day supply decreased after limit implementation in Massachusetts only. Given the potential differences in policy dissemination and uptake, efforts to reduce opioid prescribing should also include surgeon education and evidence-based prescribing recommendations.

Postoperative opioid prescribing is not my job: A qualitative analysis of care transitions.

BACKGROUND: Persistent opioid use is common after surgical procedures, and postoperative opioid prescribing often transitions from surgeons to primary care physicians in the months after surgery. It is unknown how surgeons currently transition these patients or the preferred approach to successful coordination of care. This qualitative study aimed to describe transitions of care for postoperative opioid prescribing and identify barriers and facilitators of ideal transitions for potential intervention targets. METHODS: We conducted a qualitative study of surgeons and primary care physicians at a large academic healthcare system using a semi-structured interview guide. Transcripts were independently coded using the Theoretical Domains Framework to identify underlying determinants of physician behaviors. We mapped dominant themes to the Behavior Change Wheel to propose potential interventions targeting these behaiors. RESULTS: Physicians were interviewed between July 2017 and December 2017 beyond thematic saturation (n = 20). Surgeons report passive transitions to primary care physicians after ruling out surgical complications, and these patients often bounce back to the surgeon when primary care physicians are uncertain of the cause of ongoing pain. Ideal practices were identified as setting preoperative expectations and engaging in active transition for postoperative opioid prescribing. We identified 3 behavioral targets for multidisciplinary intervention: knowledge (guidelines for coordination of care), barriers (utilizing support staff for active transition), and professional role (incentive for multidisciplinary collaboration). CONCLUSION: This qualitative study identifies potential interventions aimed at changing physician behaviors regarding transitions of care for postoperative opioid prescribing. Implementation of these interventions could improve coordination of care for patients with persistent postoperative opioid use.

Association Between Long-term Opioid Use in Family Members and Persistent Opioid Use After Surgery Among Adolescents and Young Adults.

Importance: Prior studies have found a substantial risk of persistent opioid use among adolescents and young adults undergoing surgical and dental procedures. It is unknown whether family-level factors, such as long-term opioid use in family members, is associated with persistent opioid use. Objective: To determine whether long-term opioid use in family members is associated with persistent opioid use among opioid-naive adolescents and young adults undergoing surgical and dental procedures. Design, Setting, and Participants: This retrospective cohort study used data from a commercial insurance claims database for January 1, 2010, to June 30, 2016, to study 346 251 opioid-naive patients aged 13 to 21 years who underwent 1 of 11 surgical and dental procedures and who were dependents on a family insurance plan. Exposures: Long-term opioid use in family members, defined as having 1 or more family members who (1) filled opioid prescriptions totaling a 120 days' supply or more during the 12 months before the procedure date or (2) filled 3 or more opioid prescriptions in the 90 days before the procedure date. Main Outcomes and Measures: The main outcome measure was persistent opioid use, defined as 1 or more postoperative prescription opioid fills between 91 and 180 days among patients with an initial opioid prescription fill. Generalized estimating equations with robust SEs clustered at the family level were used to model persistent opioid use as a function of long-term opioid use among family members, controlling for procedure, total morphine milligram equivalents of the initial fill, and patient and family characteristics. Results: A total of 346 251 patients (mean [SD] age, 17.0 [2.3] years; 175 541 [50.7%] female) were studied. Among these patients, 257 085 (74.3%) had an initial opioid fill. Among patients with an initial opioid fill, 11 016 (4.3%) had long-term opioid use in a family member. Persistent opioid use occurred in 453 patients (4.1%) with long-term opioid use in a family member compared with 5940 patients (2.4%) without long-term opioid use in a family member (adjusted odds ratio, 1.54; 95% CI, 1.39-1.71). Conclusion and Relevance: The findings suggest that long-term opioid use among family members is associated with persistent opioid use among opioid-naive adolescents and young adults undergoing surgical and dental procedures. Physicians should screen young patients for long-term opioid use in their families and implement heightened efforts to prevent opioid dependence among patients with this important risk factor.

Effect of new persistent opioid use on physiologic and psychologic outcomes following bariatric surgery.

INTRODUCTION: New persistent opioid use following surgery is a common iatrogenic complication, developing in roughly 6% of patients after elective surgery. Despite increased awareness of misuse and associated morbidity, opioids remain the cornerstone of pain management in bariatric surgery. The potential impact of new persistent opioid use on long-term postoperative outcomes is unknown. We sought to determine the relationship between new persistent opioid use and 1-year postoperative outcomes for patients undergoing bariatric surgery. METHODS: Using data from the MBSC registry, we identified patients undergoing primary bariatric surgery between 2006 and 2016. Using previously validated patient-reported survey methodology, we evaluated patient opioid use preoperatively and at 1 year following surgery. New persistent use was defined as a previously opioid-naïve patient who self-reported opioid use 1 year after surgery. We used multivariable logistic regression models to evaluate the association between new persistent opioid use, risk-adjusted weight loss, and psychologic outcomes (psychological wellbeing, body image, and depression). RESULTS: 27,799 patients underwent primary bariatric surgery between 2006 and 2016. Among opioid-naïve patients, the rate of new persistent opioid use was 6.3%. At 1-year after surgery, patients with new persistent opioid user lost significantly less excess body weight compared to those without new persistent use (57.6% vs. 60.3%; p < 0.0001). Patients with new persistent opioid use had significantly worse psychological wellbeing (35.0 vs. 33.1; p < 0.0001), body image (19.9 vs. 18.0; p < 0.0001), and depression scores (2.4 vs. 5.0; p < 0.0001). New persistent opioid users also reported less overall satisfaction with their bariatric surgery (75.1% vs. 85.7%; p < 0.0001). CONCLUSIONS: New persistent opioid use is common following bariatric surgery and associated with significantly worse physiologic and psychologic outcomes. More effective screening and postoperative surveillance tools are needed to identify these patients, who likely require more aggressive counseling and treatment to maximize the benefits of bariatric surgery.

Factors Associated With New Persistent Opioid Usage After Lung Resection.

BACKGROUND: Opioid dependence, misuse, and abuse in the United States continue to rise. Prior studies indicate an important risk factor for persistent opioid use includes elective surgical procedures, though the probability following thoracic procedures remains unknown. We analyzed the incidence and factors associated with new persistent opioid use after lung resection. METHODS: We evaluated data from opioid-naïve cancer patients undergoing lung resection between 2010 and 2014 using insurance claims from the Truven Health MarketScan Databases. New persistent opioid usage was defined as continued opioid prescription fills between 90 and 180 days following surgery. Variables with a p value less than 0.10 by univariate analysis were included in a multivariable logistic regression performed for risk adjustment. Multivariable results were each reported with odds ratio (OR) and confidence interval (CI). RESULTS: A total of 3,026 patients (44.8% men, 55.2% women) were identified as opioid-naïve undergoing lung resection. Mean age was 64 ± 11 years and mean postoperative length of stay was 5.2 ± 3.3 days. A total of 6.5% underwent neoadjuvant therapy, while 21.7% underwent adjuvant therapy. Among opioid-naïve patients, 14% continued to fill opioid prescriptions following lung resection. Multivariable analysis showed that age less than or equal to 64 years (OR, 1.28; 95% CI, 1.03 to 1.59; p = 0.028), male sex (OR, 1.40; 95% CI, 1.13 to 1.73; p = 0.002), postoperative length of stay (OR, 1.32; 95% CI, 1.05 to 1.65; p = 0.016), thoracotomy (OR, 1.58; 95% CI, 1.24 to 2.02; p < 0.001), and adjuvant therapy (OR, 2.19; 95% CI, 1.75 to 2.75; p < 0.001) were independent risk factors for persistent opioid usage. CONCLUSIONS: The greatest risk factors for persistent opioid use (14%) following lung resection were adjuvant therapy and thoracotomy. Future studies should focus on reducing excess prescribing, perioperative patient education, and safe opioid disposal.

A statewide comparison of opioid prescribing in teaching versus nonteaching hospitals.

BACKGROUND: Postoperative opioid prescribing is often excessive, but the differences in opioid prescribing between teaching hospitals and nonteaching hospitals is not well understood. Given the workload of surgical training and frequent turnover of prescribers on surgical services, we hypothesized that postoperative opioid prescribing would be higher among teaching compared with nonteaching hospitals. STUDY DESIGN: We used insurance claims from a statewide quality collaborative in Michigan to identify 17,075 opioid-naïve patients who underwent 22 surgical procedures across 76 hospitals from 2012 to 2016. Our outcomes included the following: (1) the amount of opioid prescribed for the initial postoperative prescription in oral morphine equivalents and (2) high-risk prescribing in the 30 days after surgery (high daily dose [≥ 100 oral morphine equivalents], new long-acting/extended-release opioid, overlapping prescriptions, or concurrent benzodiazepine prescription). Teaching hospital status was obtained from the 2014 American Hospital Association survey. Multilevel regression was used to adjust for patient and procedural factors and to perform reliability adjustment. RESULTS: The amount of opioid prescribed per initial opioid prescription varied 4.7-fold across all hospitals from 130 oral morphine equivalents to 616 oral morphine equivalents. Patients discharged from teaching hospitals filled larger initial opioid prescriptions overall compared with nonteaching hospitals (251 oral morphine equivalents versus 232 oral morphine equivalents; P = .026). Teaching hospitals had higher risk-adjusted rates of high-risk prescribing compared with nonteaching hospitals (13.7% vs 10.3%; P = .034). CONCLUSION: In Michigan, surgical patients discharged from teaching hospitals received significantly larger postoperative opioid prescriptions and had higher rates of high-risk prescribing compared with nonteaching hospitals. All hospitals, and particularly teaching institutions, should ensure that adequate resources are devoted to facilitating safe postoperative opioid prescribing.

The Impact of Education and Prescribing Guidelines on Opioid Prescribing for Breast and Melanoma Procedures.

BACKGROUND: Excessive opioid prescribing is common in surgical oncology, with 72% of prescribed opioids going unused after curative-intent surgery. In this study, we sought to reduce opioid prescribing after breast and melanoma procedures by designing and implementing an intervention focused on education and prescribing guidelines, and then evaluating the impact of this intervention. METHODS: In this single-institution study, we designed and implemented an intervention targeting key factors identified in qualitative interviews. This included mandatory education for prescribers, evidence-based prescribing guidelines, and standardized patient instructions. After the intervention, interrupted time-series analysis was used to compare the mean quantity of opioid prescribed before and after the intervention (July 2016-September 2017). We also evaluated the frequency of opioid prescription refills. RESULTS: During the study, 847 patients underwent breast or melanoma procedures and received an opioid prescription. For mastectomy or wide local excision for melanoma, the mean quantity of opioid prescribed immediately decreased by 37% after the intervention (p = 0.03), equivalent to 13 tablets of oxycodone 5 mg. For lumpectomy or breast biopsy, the mean quantity of opioid prescribed decreased by 42%, or 12 tablets of oxycodone 5 mg (p = 0.07). Furthermore, opioid prescription refills did not significantly change for mastectomy/wide local excision (13% vs. 14%, p = 0.8), or lumpectomy/breast biopsy (4% vs. 5%, p = 0.7). CONCLUSION: Education and prescribing guidelines reduced opioid prescribing for breast and melanoma procedures without increasing the need for refills. This suggests further reductions in opioid prescribing may be possible, and provides rationale for implementing similar interventions for other procedures and practice settings.

Persistent Opioid Use and High-Risk Prescribing in Body Contouring Patients.

BACKGROUND: Opioid misuse occurs commonly among obese patients and after bariatric surgery. However, the risk of new persistent use following postbariatric body contouring procedures remains unknown. METHODS: The authors examined insurance claims from Clinformatics Data Mart (OptumInsight, Eden Prairie, Minn.) between 2001 and 2015 for opioid-naive patients undergoing five body contouring procedures: abdominoplasty/panniculectomy, breast reduction, mastopexy, brachioplasty, and thighplasty (n = 11,257). Their primary outcomes included both new persistent opioid use, defined as continued prescription fills between 90 and 180 days after surgery, and the prevalence of high-risk prescribing. They used multilevel logistic regression to assess the risk of new persistent use, adjusting for relevant covariates. RESULTS: In this cohort, 6.1 percent of previously opioid-naive patients developed new persistent use, and 12.9 percent were exposed to high-risk prescribing. New persistent use was higher in patients with high-risk prescribing (9.2 percent). New persistent use was highest after thighplasty (17.7 percent; 95 percent CI, 0.03 to 0.33). Increasing Charlson comorbidity indices (OR, 1.11; 95 percent CI, 1.05 to 1.17), mood disorders (OR, 1.27; 95 percent CI, 1.05 to 1.54), anxiety (OR, 1.41; 95 percent CI, 1.16 to 1.73), tobacco use (OR, 1.22; 95 percent CI, 1.00 to 1.49), neck pain (OR, 1.23; 95 percent CI, 1.04 to 1.46), arthritis (OR, 1.30; 95 percent CI, 1.08 to 1.58), and other pain disorders (OR, 1.36; 95 percent CI, 1.16 to 1.60) were independently associated with persistent use. CONCLUSIONS: Similar to other elective procedures, 6 percent of opioid-naive patients developed persistent use, and 12 percent were exposed to high-risk prescribing practices. Plastic surgeons should remain aware of risk factors and offer opioid alternatives. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Completion Lymph Node Dissection or Radiation Therapy for Sentinel Node Metastasis in Merkel Cell Carcinoma.

BACKGROUND: For sentinel lymph node (SLN) metastasis from Merkel cell carcinoma (MCC), the benefit of completion lymph node dissection (CLND) versus radiation therapy (RT) is unclear. This study compares outcomes for patients with SLN metastasis undergoing CLND or RT. We also evaluated positive non-SLNs as a prognostic factor. METHODS: Using a prospective database, we identified MCC patients with SLN metastasis who underwent CLND or RT. At our institution, CLND was recommended for patients with acceptable perioperative risk, while therapeutic RT was offered to those with high perioperative risk. Primary outcomes were MCC-specific survival (MCCSS), disease-free survival (DFS), nodal recurrence-free survival (NRFS), and distant recurrence-free survival (DRFS). RESULTS: From 2006 to 2017, 163 patients underwent CLND (n = 137) or RT (n = 26). Median follow-up was 1.9 years. CLND had no significant differences for MCCSS (5-year survival 71% vs. 64%, p = 1.0), DFS (52% vs. 61%, p = 0.8), NRFS (76% vs. 91%, p = 0.3), or DRFS (65% vs. 75%, p = 0.3) compared with RT. Patients with positive non-SLNs (n = 44) had significantly worse MCCSS (5-year survival 39% vs. 87%, p < 0.001), DFS (35% vs. 60%, p = 0.005), and DRFS (54% vs. 71%, p = 0.03) compared with negative non-SLNs (n = 93). Multivariate analysis showed positive non-SLNs were independently associated with MCCSS, DFS, and DRFS. CONCLUSIONS: CLND and RT may have similar outcomes for MCC patients with SLN metastasis when treatment aligns with our institutional practices. For patients undergoing CLND, positive non-SLNs is an important prognostic factor associated with poor survival and distant recurrence. This high-risk group should be considered for adjuvant systemic therapy trials.

Quality Measurement and Pay for Performance.

Recent debate has focused on which quality measures are appropriate for surgical oncology and how they should be implemented and incentivized. Current quality measures focus primarily on process measures (use of adjuvant therapy, pathology reporting) and patient-centered outcomes (health-related quality of life). Pay for performance programs impacting surgical oncology patients focus primarily on preventing postoperative complications, but are not specific to cancer surgery. Future pay for performance programs in surgical oncology will likely focus on incentivizing high-quality, low-cost cancer care by evaluating process measures, patient-centered measures, and costs of care specific to cancer surgery.

Transitions of Care for Postoperative Opioid Prescribing in Previously Opioid-Naïve Patients in the USA: a Retrospective Review.

BACKGROUND: New persistent opioid use is a common postoperative complication, with 6% of previously opioid-naïve patients continuing to fill opioid prescriptions 3-6 months after surgery. Despite these risks, it is unknown which specialties prescribe opioids to these vulnerable patients. OBJECTIVE: To identify specialties prescribing opioids to surgical patients who develop new persistent opioid use. DESIGN, SETTING, AND PARTICIPANTS: Using a national dataset of insurance claims, we identified opioid-naïve patients aged 18-64 years undergoing surgical procedures (2008-2014) who continued filling opioid prescriptions 3 to 6 months after surgery. We then examined opioid prescriptions claims during the 12 months after surgery, and identified prescribing physician specialty using National Provider Identifier codes. MAIN MEASURES: Percentage of opioid prescriptions provided by each specialty evaluated at 90-day intervals during the 12 months after surgery. KEY RESULTS: We identified 5276 opioid-naïve patients who developed new persistent opioid use. During the first 3 months after surgery, surgeons accounted for 69% of opioid prescriptions, primary care physicians accounted for 13%, Emergency Medicine accounted for 2%, Physical Medicine & Rehabilitation (PM&R)/Pain Medicine accounted for 1%, and all other specialties accounted for 15%. In contrast, 9 to 12 months after surgery, surgeons accounted for only 11% of opioid prescriptions, primary care physicians accounted for 53%, Emergency Medicine accounted for 5%, PM&R/Pain Medicine accounted for 6%, and all other specialties provided 25%. CONCLUSIONS: Among surgical patients who developed new persistent opioid use, surgeons provide the majority of opioid prescriptions during the first 3 months after surgery. By 9 to 12 months after surgery, however, the majority of opioid prescriptions were provided by primary care physicians. Enhanced care coordination between surgeons and primary care physicians could allow earlier identification of patients at risk for new persistent opioid use to prevent misuse and dependence.

Opioid Prescribing After Curative-Intent Surgery: A Qualitative Study Using the Theoretical Domains Framework.

BACKGROUND: Excessive opioid prescribing is common after curative-intent surgery, but little is known about what factors influence prescribing behaviors among surgeons. To identify targets for intervention, we performed a qualitative study of opioid prescribing after curative-intent surgery using the Theoretical Domains Framework, a well-established implementation science method for identifying factors influencing healthcare provider behavior. METHODS: Prior to data collection, we constructed a semi-structured interview guide to explore decision making for opioid prescribing. We then conducted interviews with surgical oncology providers at a single comprehensive cancer center. Interviews were recorded, transcribed verbatim, then independently coded by two investigators using the Theoretical Domains Framework to identify theoretical domains relevant to opioid prescribing. Relevant domains were then linked to behavior models to select targeted interventions likely to improve opioid prescribing. RESULTS: Twenty-one subjects were interviewed from November 2016 to May 2017, including attending surgeons, resident surgeons, physician assistants, and nurses. Five theoretical domains emerged as relevant to opioid prescribing: environmental context and resources; social influences; beliefs about consequences; social/professional role and identity; and goals. Using these domains, three interventions were identified as likely to change opioid prescribing behavior: (1) enablement (deploy nurses during preoperative visits to counsel patients on opioid use); (2) environmental restructuring (provide on-screen prompts with normative data on the quantity of opioid prescribed); and (3) education (provide prescribing guidelines). CONCLUSIONS: Key determinants of opioid prescribing behavior after curative-intent surgery include environmental and social factors. Interventions targeting these factors are likely to improve opioid prescribing in surgical oncology.