Buyback Program of Unused Prescription Opioids in US Rural Communities, 2017-2018.

Objective. To implement an opioid buyback program after ambulatory surgery.Methods. We performed a prospective cohort study of 578 opioid-naïve patients prescribed opioids after ambulatory surgery at a rural US Veterans Affairs (VA) hospital from 2017 to 2018. We reimbursed $5 per unused opioid pill ($50 limit) returned to our VA for proper disposal. We tracked the number of participants, number of unused opioid pills returned, surgeon prescribing, and refill requests.Results. Out of 578 eligible patients, 171 (29.6%) returned 2136.5 unused opioid pills. Information shared with surgeons after 6 months led to a 27% decrease in opioid prescribing without an increase in refills.Conclusions. With this opioid buyback program, rural patients had a safe and convenient place to dispose of unused opioids. Surgeons used information about returns to adjust opioid prescribing after common ambulatory surgeries without an increase in refill requests.Public Health Implications. Although providers prescribe within state opioid guidelines, there will be variations in patient use after ambulatory surgery. An opioid buyback program helped our patients and surgeons decrease unused prescription opioids available for diversion in our rural communities.

Nudging patients and surgeons to change ambulatory surgery pain management: Results from an opioid buyback program.

BACKGROUND: Optimal postoperative opioid stewardship combines adequate pain medication to control expected discomfort while avoiding abuse and community diversion of unused prescribed opioids. We hypothesized that an opioid buyback program would motivate patients to return unused opioids, and surgeons will use that data to calibrate prescribing. METHODS: Prospective cohort study of postambulatory surgery pain management at a level II Veterans Affairs rural hospital (2017-2019). Eligible patients were offered $5/unused opioid pill ($50 limit) returned to our Veterans Affairs hospital for proper disposal. After 6 months, buyback data was shared with each surgical specialty. RESULTS: Overall, 934 of 1,880 (49.7%) eligible ambulatory surgery patients were prescribed opioids and invited to participate in the opioid buyback. We had 281 patients (30%) return 3,165 unused opioid pills; this return rate remained constant over the study period. In 2017, 62.4% of patients were prescribed an opioid; after data was shared with providers, prescriptions for opioids were reduced to 50.7% and 38.3% of eligible patients in 2018 and 2019, respectively (P < .0001). The median morphine milligram equivalents prescribed also decreased from 108.8 morphine milligram equivalents in 2017 to 75.0 morphine milligram equivalents in 2018 and sustained at 75.0 morphine milligram equivalents in 2019 (P < .001). Surgical providers, surgeries performed, patient characteristics, and 30-day refill rates were similar throughout the study period. CONCLUSION: A small financial incentive resulted in patients returning unused opioids after ambulatory surgery. Feedback to surgeons regarding opioids returned reduced the proportion of patients prescribed an opioid and the amount of opioid after ambulatory surgery without an increase in refills.

Symptoms and treatment burden of gastroesophageal reflux disease: validating the GERD assessment scales.

BACKGROUND: A comprehensive assessment instrument that measures the burden of both symptoms and treatment is needed to determine the optimal management of gastroesophageal reflux disease (GERD), and we developed such an instrument. METHODS: This validation study included 3 groups: patients with active GERD (n = 193), surgical patients with prior GERD (n = 197), and general medical outpatients (n = 63). All completed an initial survey. General medical patients and patients with active GERD were resurveyed after 2 to 6 weeks. The main outcome measures were test-retest reliability, internal consistency, discriminant validity, and responsiveness to change for 3 scales graduated from 0 to 100: a GERD burden (or overall impact on quality of life scale), a symptoms scale, and a treatment scale. Higher scores indicated greater disease burden. RESULTS: The GERD burden, symptoms, and treatment scales all demonstrated good discriminant validity, as patients in the active-GERD group had the highest scores. Scores on each scale effectively classified the patients who belonged to the active-GERD group. Moreover, scores improved substantially 8 weeks after surgery, thereby demonstrating the scales' responsiveness to change. As hypothesized, the burden of treatment was distinct from that of symptoms, as 23% of patients not bothered by GERD symptoms described their GERD treatment to be a moderate or serious problem. Indeed, the impact of treatment problems approached that of symptoms problems. All pairwise comparisons were significant (P<.02). CONCLUSIONS: The GERD burden, symptoms, and treatment scales were valid, reliable, and responsive instruments for use in patients with GERD. Our analyses highlight the importance of assessing both symptoms and treatment burden in patients with GERD.

Determining an appropriate threshold for referral to surgery for gastroesophageal reflux disease.

BACKGROUND: Persistent symptomatic gastroesophageal reflux disease (GERD) can be treated with medication or surgery. The purposes of this study were (1) to determine how poor the quality of life on medication would need to be to justify assuming the risks of surgery, and (2) to estimate the proportion of patients currently on medication whose quality of life is below this value. METHODS: We developed a Markov decision analysis model to simulate health outcomes (measured in quality adjusted life years [QALY]) over 10 years for medication and surgery in patients with typical GERD symptoms. We included probabilities of events obtained from a systematic literature review. Quality of life adjustments, expressed as utilities, were drawn from a survey of 131 patients 1 to 5 years after antireflux surgery. By using this model, we calculated what quality of life on medications would change the optimal strategy from medication to surgery (threshold). To determine the proportion of patients below this value, we prospectively surveyed 40 medically treated GERD patients at our hospital. RESULTS: Surgery resulted in more QALYs than medical therapy when the utility with medication use was below 0.90. Sensitivity analysis showed this value to be relatively insensitive to reasonable variations in surgical risks (mortality, failures, reoperation) and quality of life after surgery. Among those surveyed on medications, 48% fell below this threshold and would be predicted to benefit from surgery. CONCLUSION: Our model suggests that surgery would likely benefit a high proportion of medically treated GERD patients. Individual assessment of quality of life with GERD should be considered to aid clinical decision making.

Late outcomes after laparoscopic surgery for gastroesophageal reflux.

HYPOTHESIS: Patients still have symptoms following laparoscopic antireflux surgery and require ongoing treatment. DESIGN: Mailed survey. SETTING: Academic tertiary care center. PATIENTS: Of 247 consecutive adults, 197 (80% response) who underwent laparoscopic fundoplication for gastroesophageal reflux disease in the prior 1 to 5 years. MAIN OUTCOME MEASURES: Gastrointestinal symptoms (frequency and bother), actions taken to treat these symptoms (medications and dietary and lifestyle changes), and assessment of surgery. RESULTS: The mean age of the respondents was 51.1 years, and 52% were men. The median time since surgery was 2.6 years. Overall, 28% reported typical reflux symptoms (heartburn or regurgitation), but only 5% were bothered "a lot" or "terribly" by them. While 65% reported other gastrointestinal symptoms (bloating or dysphagia) that may be related to gastroesophageal reflux disease or to surgery, only 19% were bothered a lot or terribly by them. About half of the respondents reported taking at least 1 of the following actions for their symptoms: 6% take frequent over-the-counter medications, 13% take daily prescription acid-reducing medications, 41% make lifestyle changes (eg, eating smaller meals), and 44% avoid certain foods (eg, carbonated beverages). Nevertheless, 90% believed their surgery was working well. CONCLUSIONS: In 1 to 5 years after laparoscopic antireflux surgery, many patients report gastrointestinal symptoms and take action to control these symptoms. Most, however, believe their surgical treatment is working well.

Long-term survival of dialysis patients after coronary bypass grafting.

BACKGROUND: Dialysis patients are undergoing coronary artery bypass grafting (CABG) with increasing frequency. The long-term effect of preoperative dialysis-dependent renal failure on mortality after CABG has not been well studied. METHODS: We conducted a prospective regional cohort study of 15,574 consecutive patients undergoing isolated CABG in northern New England from 1992 to 1997. Patient records were linked to the National Death Index to assess mortality. Five-year survival and adjusted hazard ratios were calculated. RESULTS: During 32,589 person-years of follow-up 1298 deaths were recorded. Renal failure was present in 283 patients (1.8%), and 67.8% of patients with renal failure also had diabetes or peripheral vascular disease (PVD). The annual death rate was 3.8% for nonrenal failure patients, 16.9% for all renal failure patients, 7.7% for renal failure patients without diabetes or PVD, and 23.0% for renal failure patients with diabetes or PVD. Five-year survival was 83.5% for nonrenal failure patients, 55.8% for all renal failure patients, 78.5% for renal failure patients without diabetes or PVD, and 42.2% for renal failure patients with diabetes or PVD. After adjustment for differences in base line patient and disease characteristics, renal failure patients without diabetes or PVD had a statistically nonsignificant 57% increase rate of death compared with those without renal failure; renal failure patients with diabetes or PVD had more than a fourfold increased risk of death. CONCLUSIONS: After adjustment for other risk factors, renal failure remains a highly significant predictor of decreased long-term survival in CABG patients. Patients with renal failure plus diabetes or PVD are at especially high risk of death.