Enhanced Recovery After Surgery Patients Are Prescribed Fewer Opioids at Discharge: A Propensity-score Matched Analysis.

OBJECTIVE: We aimed to compare discharge opioid prescriptions pre- and post-ERAS implementation. SUMMARY OF BACKGROUND DATA: ERAS programs decrease inpatient opioid use, but their relationship with postdischarge opioids remains unclear. METHODS: All patients undergoing hysterectomy between October 2016 and November 2020 and pancreatectomy or hepatectomy between April 2017 and November 2020 at 1 tertiary care center were included. For each procedure, ERAS was implemented during the study period. PSM was performed to compare pre - versus post-ERAS patients on discharge opioids (number of pills and oral morphine equivalents). Patients were matched on age, sex, race, payor, American Society of Anesthesiologists score, prior opioid use, and procedure. Sensitivity analyses in open versus minimally invasive surgery cohorts were performed. RESULTS: A total of 3983 patients were included (1929 pre-ERAS; 2054 post-ERAS). Post-ERAS patients were younger (56.0 vs 58.4 years; P < 0.001), more often female (95.8% vs 78.1%; P < 0.001), less often white (77.2% vs 82.0%; P < 0.001), less often had prior opioid use (20.1% vs 28.1%; P < 0.001), and more often underwent hysterectomy (91.1% vs 55.7%; P < 0.001). After PSM, there were no significant differences between cohorts in baseline characteristics. Matched post-ERAS patients were prescribed fewer opioid pills (17.4 pills vs 22.0 pills; P < 0.001) and lower oral morphine equivalents (129.4 mg vs 167.6 mg; P < 0.001) than pre-ERAS patients. Sensitivity analyses confirmed these findings [open (18.8 pills vs 25.4 pills; P < 0.001 \ 138.9 mg vs 198.7 mg; P < 0.001); minimally invasive surgery (17.2 pills vs 21.1 pills; P < 0.001 \ 127.1 mg vs 160.1 mg; P < 0.001). CONCLUSIONS: Post-ERAS patients were prescribed significantly fewer opioids at discharge compared to matched pre-ERAS patients.

Cohort study of impact on length of stay of individual enhanced recovery after surgery protocol components.

OBJECTIVE: The goal of this study was to explore which enhanced recovery after surgery (ERAS) bundle items were most associated with decreased length of stay after surgery, most likely associated with decreased length of stay after surgery. DESIGN: A cohort study. SETTING: Large tertiary academic medical centre. PARTICIPANTS: The study included 1318 women undergoing hysterectomy as part of our ERAS pathway between 1 February 2018 and 30 January 2020 and a matched historical cohort of all hysterectomies performed at our institution between 3 October 2016 and 30 January 2018 (n=1063). INTERVENTION: The addition of ERAS to perioperative care.This is a cohort study of all patients undergoing hysterectomy at an academic medical centre after ERAS implementation on 1 February 2018. Compliance and outcomes after ERAS roll out were monitored and managed by a centralised team. Descriptive statistics, multivariate regression, interrupted time series analysis were used as indicated. MAIN OUTCOME MEASURES: Impact of ERAS process measure adherence on length of stay. RESULTS: After initiation of ERAS pathway, 1318 women underwent hysterectomy. There were more open surgeries after ERAS implementation, but cohorts were otherwise balanced. The impact of process measure adherence on length of stay varied based on surgical approach (minimally invasive vs open). For open surgery, compliance with intraoperative antiemetics (-30%, 95% CI -18% to 40%) and decreased postoperative fluid administration (-12%, 95% CI -1% to 21%) were significantly associated with reduced length of stay. For minimally invasive surgery, ambulation within 8 hours of surgery was associated with reduced length of stay (-53%, 95% CI -55% to 52%). CONCLUSIONS: While adherence to overall ERAS protocols decreases length of stay, the specific components of the bundle most significantly impacting this outcome remain elusive. Our data identify early ambulation, use of antiemetics and decreasing postoperative fluid administration to be associated with decreased length of stay.

The next step to reducing emergency department (ED) crowding: Engaging specialist physicians.

BACKGROUND: Much work on reducing ED utilization has focused on primary care practices, but few studies have examined ED visits from patients followed by specialists, especially when the ED visit is related to the specialist's clinical practice. OBJECTIVE: To determine the proportion and characteristics of patients that utilized the ED for specialty-related diagnosis. METHODS: Retrospective, population-based, cohort study was conducted using information from electronic health records and billing database between January 2016 and December 2016. Patients who had seen a specialist during the last five years from the index ED visit date were included. The identification of ED visits attributable to specialists was based on the primary diagnosis of ED visits and the frequency of visit with specialists within a given timeframe. RESULTS: Approximately 28% of ED visits analyzed were attributable to specialists. ED visits attributed specialists were represented by older patients and occurred more during working hours and early days of week. The most common diagnoses related to ED visits attributed to specialists were Circulatory, Musculoskeletal, Skin, Breast and Mental. Multiple departments, subdivisions and specialists were involved with each ED visit. The number of specialists following the patients who visited the ED ranged from one to six and the number of departments/subdivisions ranged from one to four. Patients that used the ED often were more likely to belong to departments (OR = 1.53) and specialists (OR = 1.18) associated with high ED utilization patterns. CONCLUSION: Patients coming to the ED with specialty-related complaints are unique and require full engagement of the specialist and the specialty group. This study offers a new view of connections patients have with their specialists and engaging specialists both at department level and individual specialist level may be an important factor to reduce ED overcrowding.

Using Physician-Level Emergency Department Utilization Reports to Address Avoidable Visits by Patients Managed by Pediatric Specialists.

OBJECTIVES: Emergency department (ED) utilization is a major driver of cost. Specialist physicians have an important role in addressing ED utilization, especially at tertiary medical centers that treat highly specialized patients. We analyzed if reporting of ED utilization to pediatric specialist physicians can decrease ED visits. METHODS: Physicians within pediatric neurology, hematology and oncology, infectious diseases, and pulmonary divisions received their ED use reports. By using control charts, we examined if this intervention decreased the rate of ED utilization. RESULTS: Overall, for the 4 divisions, specialty-related ED utilization decreased significantly during all hours, weekdays, and office hours. This was in the setting of ED utilization increasing for all diagnoses ED visits. Pediatric ED volume did not change during the study period. CONCLUSIONS: Physician-level reporting of ED utilization was associated with a reduction in ED use by patients managed by our pediatric specialists.

Emergency Department Utilization Report to Decrease Visits by Pediatric Gastroenterology Patients.

BACKGROUND AND OBJECTIVES: Emergency department (ED) utilization is a major driver of health care costs. Specialist physicians have an important role in addressing ED utilization, especially at highly specialized, academic medical centers. We sought to investigate whether reporting of ED utilization to specialist physicians can decrease ED visits. METHODS: This study analyzed an intervention to reduce ED utilization among ED patients who were followed by pediatric gastroenterologists. In May 2013, each pediatric gastroenterologist began receiving reports with rates of ED use by their patients. The reports generated discussion that resulted in a cultural and process change in which patients with urgent gastrointestinal (GI)-related complaints were preferentially seen in the office. Using control charts, we examined GI-related and all-diagnoses ED use over a 2-year period. RESULTS: The rate of GI-related ED visits decreased by 60% after the intervention, from 4.89 to 1.95 per 1000 office visits (P < .001). Similarly, rates of GI-related ED visits during office hours decreased by 59% from 2.19 to 0.89 per 1000 (P < .001). Rates of all-diagnoses ED visits did not change. CONCLUSIONS: Physician-level reporting of ED utilization to pediatric gastroenterologists was associated with physician engagement and a cultural and process change to preferentially treat patients with urgent issues in the office.