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PURPOSE: The diagnosis of carpal tunnel syndrome (CTS) can be made clinically using the Carpal Tunnel Syndrome-6 (CTS-6) criteria. The role of electrodiagnostic studies (EDS) is controversial. We examined differences in the utilization of CTS-6 and EDS based on surgeon experience and practice setting. METHODS: Members of the American Society for Surgery of the Hand were emailed an anonymous web-based link to participate. The survey included an assessment of hypothetical CTS scenarios with varying clinical severity. We collected surgeon demographic attributes, years in practice, practice setting, and frequency of CTS-6 and EDS utilization. A comparison was made of years of experience with surgeon-reported utilization of CTS-6 and EDS as well as treatment recommendation. RESULTS: We received 771 responses (25% response rate). Surgeons recommended carpal tunnel release (CTR) for patients without EDS (16%), normal EDS (33%), and abnormal EDS (90%). Fifty-three percent of surgeons with <15 years in practice reported often/always using CTS-6 criteria in their practice compared to 30% and 29% of surgeons with 16-30 years and > 30 years in practice, respectively. Surgeons with 16-30 and >30 years in practice had significantly lower odds of reporting often/almost always using CTS-6 relative to surgeons with 1-15 years in practice (OR 0.35 and 0.31, respectively). A greater proportion of surgeons with 16-30 years (68%) and >30 years (65.5%) in practice responded often/almost always applying EDS compared to surgeons with <15 years (56%) in practice. In addition, surgeons with 16-30 years and >30 years in practice had a higher odds of often/always using EDS (ORs 1.74 and 1.98, respectively) compared to surgeons with 1-15 years in practice (P < .05). CONCLUSIONS: Utilization of CTS-6 and EDS varied based on years in practice. This difference may reflect changing guidelines, the growing evidence regarding clinical assessment tools, and the emergence of other diagnostic modalities. CLINICAL RELEVANCE: Given the expense and invasiveness of EDS, opportunities to integrate clinical assessment tools readily into the diagnostic algorithm may shift the role of EDS toward selective utilization for complex clinical scenarios rather than for routine use.
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OBJECTIVE: To define recent trends in opioid prescribing after surgery and new persistent opioid use in the United States. SUMMARY BACKGROUND DATA: New persistent opioid use after surgery among opioid-naïve individuals has emerged as an important postoperative complication. In response, initiatives to promote more appropriate post-operative opioid prescribing have been adopted in recent years. However, current estimates of opioid prescribing and new persistent opioid use following surgery remain unknown. METHODS: A retrospective cohort study of opioid-naïve privately insured adult patients undergoing 17 common surgical procedures between 2013 and 2021 was conducted utilizing multi-payer claims data from the Health Care Cost Institute (HCCI). Initial opioid prescription size in oral morphine equivalents and new persistent opioid use were the outcomes of interest. Trends in opioid prescribing and rates of new persistent opioid use were evaluated across the study period. Mixed effects logistic regression was performed to evaluate independent predictors of new persistent opioid use while adjusting for patient-level factors and year. RESULTS: Among 989,354 opioid-naïve individuals, the adjusted initial opioid prescription size decreased from 282 mg OME to 164 mg OME, a reduction of 118 mg OME (95% CI: 116-120). The adjusted incidence of new persistent opioid use decreased from 2.7% in 2013 (95% CI: 2.6%-2.8%) to 1.1% in 2021 (95% CI: 1.0%-1.2%). For every 30 OME increase in initial opioid prescription size, new persistent opioid use increased by 3.1%. Other predictors of new persistent opioid use included preoperative non-opioid controlled substances fills (31-365 days: aOR=1.78, 95% CI: 1.70-1.86; 0-30 days: aOR=2.71, 95% CI: 2.59-2.84) and undergoing orthopedic procedures (total knee arthroplasty (aOR=3.43, 95% CI: 3.15-3.72); shoulder arthroscopy (aOR=2.39, 95% CI: 2.24-2.56)). CONCLUSIONS: Both opioid prescription size after surgery and new persistent opioid use decreased over the last decade, suggesting that opioid stewardship practices had favorable effects on the risk of long-term opioid use.
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Purpose: Differences in the utilization of carpal tunnel release (CTR) by Blacks and women are well documented, but less is known regarding the impact of patient-provider concordance on treatment recommendations. To investigate this, we surveyed hand surgeons using hypothetical scenarios to evaluate variations in treatment recommendations for carpal tunnel syndrome based on patient-related factors and patient-provider concordance. Methods: Three pairs (six total) of hypothetical scenarios with clinical symptoms of carpal tunnel syndrome were created varying sex, race, and occupation. We used names as a proxy for sex and race. Occupation included manual laborers, secretaries, athletes, and retirees. American Society for Surgery of the Hand members were emailed an anonymous web-based link to participate. We used descriptive statistics to analyze the scenario-based treatment recommendations. Results: We identified 3,067 eligible members for participation; 770 surgeons responded (25%) and provided recommendations for 3,742 scenarios. For scenarios involving symptomatic patients without electrodiagnostic studies (EDS), with normal EDS, and with abnormal EDS, no difference was noted in surgeon treatment recommendations based on patients' race, sex, and occupation. Surgeons recommended EDS for 31% and 32.8% of the scenarios with Black female and White male patients, respectively, who did not have EDS at presentation and CTR for 32.3% and 33% of White females and Black males with normal EDS, respectively. Among retired Black female and White male patients older than 80 years of age with abnormal EDS, surgeons recommended CTR in 89.9% and 89.3% of them, respectively. For patient-provider racially concordant pairs, White surgeons recommended CTR to a similar proportion of Black and White hypothetical patients; however, Black surgeons recommended CTR to a greater proportion of patients with Black-sounding names. Conclusions: We found that surgeon treatment recommendation was not associated with patient race, sex, or occupation; however, differences did emerge based on patient-provider racial concordance, suggesting that alignment of patient and provider identities may influence treatment recommendations. Type of study/level of evidence: Prognostic III.
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Importance: Opioid medications are commonly prescribed for the management of acute postoperative pain. In light of increasing awareness of the potential risks of opioid prescribing, data are needed to define the procedures and populations for which most opioid prescribing occurs. Objective: To identify the surgical procedures accounting for the highest proportion of opioids dispensed to adults after surgery in the United States. Design, Setting, and Participants: This cross-sectional analysis of the 2020-2021 Merative MarketScan Commercial and Multi-State Databases, which capture medical and pharmacy claims for 23 million and 14 million annual privately insured patients and Medicaid beneficiaries, respectively, included surgical procedures for individuals aged 18 to 64 years with a discharge date between December 1, 2020, and November 30, 2021. Procedures were identified using a novel crosswalk between 3664 Current Procedural Terminology codes and 1082 procedure types. Data analysis was conducted from November to December 2023. Main Outcomes and Measures: The total amount of opioids dispensed within 3 days of discharge from surgery across all procedures in the sample, as measured in morphine milligram equivalents (MMEs), was calculated. The primary outcome was the proportion of total MMEs attributable to each procedure type, calculated separately among procedures for individuals aged 18 to 44 years and those aged 45 to 64 years. Results: Among 1â¯040â¯934 surgical procedures performed (mean [SD] age of patients, 45.5 [13.3] years; 663â¯609 [63.7%] female patients), 457â¯016 (43.9%) occurred among individuals aged 18 to 44 years and 583â¯918 (56.1%) among individuals aged 45 to 64 years. Opioid prescriptions were dispensed for 503â¯058 procedures (48.3%). Among individuals aged 18 to 44 years, cesarean delivery accounted for the highest proportion of total MMEs dispensed after surgery (19.4% [11â¯418â¯658 of 58â¯825â¯364 MMEs]). Among individuals aged 45 to 64 years, 4 of the top 5 procedures were common orthopedic procedures (eg, arthroplasty of knee, 9.7% of total MMEs [5â¯885â¯305 of 60â¯591â¯564 MMEs]; arthroscopy of knee, 6.5% [3â¯912â¯616 MMEs]). Conclusions and Relevance: In this cross-sectional study of the distribution of postoperative opioid prescribing in the United States, a small number of common procedures accounted for a large proportion of MMEs dispensed after surgery. These findings suggest that the optimal design and targeting of surgical opioid stewardship initiatives in adults undergoing surgery should focus on the procedures that account for the most opioid dispensed following surgery over the life span, such as childbirth and orthopedic procedures. Going forward, systems that provide periodic surveillance of opioid prescribing and associated harms can direct quality improvement initiatives to reduce opioid-related morbidity and mortality.
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Analgésicos Opioides , Dolor Postoperatorio , Alta del Paciente , Pautas de la Práctica en Medicina , Humanos , Analgésicos Opioides/uso terapéutico , Adulto , Femenino , Persona de Mediana Edad , Masculino , Estudios Transversales , Dolor Postoperatorio/tratamiento farmacológico , Pautas de la Práctica en Medicina/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Estados Unidos , Adolescente , Adulto Joven , Prescripciones de Medicamentos/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricosRESUMEN
BACKGROUND AND OBJECTIVES: Surgery is one of the most common indications for opioid prescribing to pediatric patients. We identified which procedures account for the most pediatric surgical opioid prescribing. METHODS: We conducted a cross-sectional analysis of commercial and Medicaid claims in the Merative MarketScan Commercial and Multi-State Medicaid Databases. Analyses included surgical procedures for patients aged 0 to 21 years from December 1, 2020, to November 30, 2021. Procedures were identified using a novel crosswalk between 3664 procedure codes and 1082 procedure types. For each procedure type in the crosswalk, we calculated the total amount of opioids in prescriptions dispensed within 3 days of discharge from surgery, as measured in morphine milligram equivalents (MMEs). We then calculated the share of all MMEs accounted for by each procedure type. We conducted analyses separately among patients aged 0 to 11 and 12 to 21 years. RESULTS: Among 107 597 procedures for patients aged 0 to 11 years, the top 3 procedures accounted for 59.1% of MMEs in opioid prescriptions dispensed after surgery: Tonsillectomy and/or adenoidectomy (50.3%), open treatment of upper extremity fracture (5.3%), and removal of deep implants (3.5%). Among 111 406 procedures for patients aged 12 to 21 years, the top 3 procedures accounted for 33.1% of MMEs: Tonsillectomy and/or adenoidectomy (12.7%), knee arthroscopy (12.6%), and cesarean delivery (7.8%). CONCLUSIONS: Pediatric surgical opioid prescribing is concentrated among a small number of procedures. Targeting these procedures in opioid stewardship initiatives could help minimize the risks of opioid prescribing while maintaining effective postoperative pain control.
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Analgésicos Opioides , Dolor Postoperatorio , Pautas de la Práctica en Medicina , Humanos , Niño , Adolescente , Preescolar , Analgésicos Opioides/uso terapéutico , Lactante , Estudios Transversales , Dolor Postoperatorio/tratamiento farmacológico , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/tendencias , Adulto Joven , Femenino , Masculino , Estados Unidos , Recién Nacido , Prescripciones de Medicamentos/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , MedicaidRESUMEN
OBJECTIVE: We sought to compare identification of unhealthy substance use before surgery using The Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS), a standardized 4-item instrument, versus routine clinical documentation in the electronic medical record (EHR). SUMMARY BACKGROUND DATA: Over 20% of individuals exhibit unhealthy substance use before elective surgery. Routine EHR documentation is often based on non-standard questions that may not fully capture the extent of substance use and is subject to bias. In contrast, brief standardized screening could provide a more efficient and systematic approach. METHODS: We conducted a cross-sectional study among adults (≥18 y) at a preoperative clinic from August to September, 2021. Positive screens for unhealthy substances by TAPS were compared to data from the EHR. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were reported. Receiver operating characteristic curves (ROCs) were used to assess diagnostic ability. Multivariable logistic regression was used to estimate the predictors of positive screens by TAPS. RESULTS: The cohort included 240 surgical patients. TAPS screening identified significantly more positive screens than EHR documentation (43.3% vs. 14.2%). Patients with unhealthy substance use were younger (50.8 vs. 56.7 y; P=0.003), and TAPS revealed alcohol misuse in 30.8% of cases, contrasting with 0% in clinician documentation (P<0.001). Of the 104 TAPS-positive patients, 69.2% were missed by EHR documentation. Sensitivity (31%) and accuracy (AUC=0.65) of clinician documentation for any unhealthy substance use were lower compared to TAPS. CONCLUSION: Standardized TAPS screening detected preoperative unhealthy substance use more frequently than routine clinician documentation, emphasizing the need for integrating standardized measures into surgical practice to ensure safer perioperative care and outcomes.
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OBJECTIVE: To evaluate changes in opioid prescribing and patient-reported outcomes after surgery following implementation of Michigan's prescription drug monitoring program (PDMP) use mandate in June 2018. BACKGROUND: Most states mandate clinicians to query prescription drug monitoring program (PDMP) databases before prescribing controlled substances. Whether these PDMP use mandates affect opioid prescribing and patient-reported outcomes after surgery is unclear, especially among patients with elevated "Narx" scores, a risk score for overdose death used in most PDMPs. METHODS: We conducted an interrupted time series analysis of a statewide surgical registry linked to Michigan's PDMP database. Analyses included adults undergoing general surgical procedures during January 2017-October 2019. Outcomes included monthly mean days supplied in dispensed opioid prescriptions (those filled within 3 days of discharge) and monthly mean scores for 3 patient-reported outcomes (pain in the week after surgery, care satisfaction, regret undergoing surgery). Segmented regression models were used to assess for level and slope changes in outcomes in June 2018. Analyses were repeated among patients with Narx scores ≥200, a threshold that defines the top quartile. RESULTS: Analyses included 21,897 patients. The mandate was associated with a -0.5 (95% CI: -0.8, -0.2) level decrease in mean days supplied in dispensed opioid prescriptions, but not with worsened patient-reported outcomes. Findings were similar among patients with Narx scores ≥200. CONCLUSIONS: Following implementation of Michigan's PDMP use mandate, the duration of opioid prescriptions decreased, but patient-reported outcomes did not worsen. Findings suggest PDMP use mandates may not be associated with worsened experience among general surgical patients.
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OBJECTIVE: To investigate the relationships between opioid prescribing, consumption, and patient reported outcomes (PROs) in emergency surgery patients. SUMMARY BACKGROUND DATA: Overprescribing of opioids for pain management after surgery has become a public health concern and major contributor to opioid misuse and dependency. Current guidelines do not address opioid prescribing following emergency surgical procedures, highlighting the importance of understanding the relationship between opioid prescribing and consumption in this setting. METHODS: Retrospective analysis of the quantity of opioids prescribed and patient-reported outcomes (PROs) in a population-based setting. The sample included adults 18 years and older undergoing emergency surgery across 69 hospitals in Michigan. Patients were included if they received a discharge opioid prescription and had valid data for opioid consumption and PROs. Surgical procedures took place between January 1, 2018 and December 31, 2020. RESULTS: During the study period, a total of 3,742 patients underwent an emergency operation. The mean number of opioid pills prescribed was 9.6 and the mean number of opioid pills consumed was 4.6. In a two-model with logit in the first part and a linear regression in the second, prescription size was significantly associated with both the probability of consumption (aOR 1.02, 95% CI 1.01-1.04) and the amount of consumption conditional on any consumption (coefficient 0.70 95% CI 0.54-0.86). CONCLUSIONS AND RELEVANCE: Patients only consumed half of the opioids they were prescribed after undergoing emergency surgery. Additionally, patients who were given larger prescriptions consumed more opioids, but did not experience less pain, higher satisfaction, better quality of life, or less regret to undergo surgery. Overall, this suggests that opioids may be excessively prescribed to patients undergoing emergency surgical procedures, and that larger prescriptions do not improve the patient experience after surgery.
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Importance: Excess opioid prescribing after surgery can result in prolonged use and diversion. Email feedback based on social norms may reduce the number of pills prescribed. Objective: To assess the effectiveness of 2 social norm-based interventions on reducing guideline-discordant opioid prescribing after surgery. Design, Setting, and Participants: This cluster randomized clinical trial conducted at a large health care delivery system in northern California between October 2021 and October 2022 included general, obstetric/gynecologic, and orthopedic surgeons with patients aged 18 years or older discharged to home with an oral opioid prescription. Interventions: In 19 hospitals, 3 surgical specialties (general, orthopedic, and obstetric/gynecologic) were randomly assigned to a control group or 1 of 2 interventions. The guidelines intervention provided email feedback to surgeons on opioid prescribing relative to institutionally endorsed guidelines; the peer comparison intervention provided email feedback on opioid prescribing relative to that of peer surgeons. Emails were sent to surgeons with at least 2 guideline-discordant prescriptions in the previous month. The control group had no intervention. Main Outcome and Measures: The probability that a discharged patient was prescribed a quantity of opioids above the guideline for the respective procedure during the 12 intervention months. Results: There were 38â¯235 patients discharged from 640 surgeons during the 12-month intervention period. Control-group surgeons prescribed above guidelines 36.8% of the time during the intervention period compared with 27.5% and 25.4% among surgeons in the peer comparison and guidelines arms, respectively. In adjusted models, the peer comparison intervention reduced guideline-discordant prescribing by 5.8 percentage points (95% CI, -10.5 to -1.1; P = .03) and the guidelines intervention reduced it by 4.7 percentage points (95% CI, -9.4 to -0.1; P = .05). Effects were driven by surgeons who performed more surgeries and had more guideline-discordant prescribing at baseline. There was no significant difference between interventions. Conclusions and Relevance: In this cluster randomized clinical trial, email feedback based on either guidelines or peer comparison reduced opioid prescribing after surgery. Guideline-based feedback was as effective as peer comparison-based feedback. These interventions are simple, low-cost, and scalable, and may reduce downstream opioid misuse. Trial Registration: ClinicalTrials.gov NCT05070338.
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Analgésicos Opioides , Trastornos Relacionados con Opioides , Humanos , Femenino , Analgésicos Opioides/uso terapéutico , Retroalimentación , Pautas de la Práctica en Medicina , Trastornos Relacionados con Opioides/tratamiento farmacológico , PrescripcionesRESUMEN
OBJECTIVE: This study examined the association between insurance type and postoperative unplanned care encounters among patients on long-term opioid therapy prior to surgery. SUMMARY BACKGROUND DATA: Preoperative long-term opioid therapy is associated with unique risks and poorer outcomes following surgery. To date, the extent to which insurance coverage influences postoperative outcomes in this population remains unclear. METHODS: Among individuals receiving a supply of greater than 120 total days or at least 10 opioid prescriptions in the year prior to surgery, we examined patients with Medicaid or private insurance who underwent abdominopelvic surgery from 2017 to 2021 across 70 hospitals in the state of Michigan. The primary outcome was unplanned care encounters, defined as an emergency department visit or unplanned readmission within 30 days of discharge from surgery. Multivariable logistic regression was used to assess the likelihood of acute care events with insurance type as the primary covariate of interest. RESULTS: Among 1212 patients on long-term opioid therapy prior to surgery, 45.6% (n = 553) had Medicaid insurance. Overall, one in eight (n=151) patients met criteria for a postoperative unplanned care encounter within 30 days. The probability of an unplanned encounter was 4.5 percentage points higher among patients with Medicaid insurance compared to private insurance (95% CI: 0.5%, 8.4%). CONCLUSIONS: Among patients on preoperative long-term opioid therapy, unplanned care encounters were higher among patients with Medicaid when compared to private insurance. While this is likely multifactorial, differences by insurance status may point to disparities in underlying social determinants of health and suggest the need for postoperative care pathways that address these gaps.
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Although substantial attention has been given to opioid prescribing in the United States, opioid-related mortality continues to climb due to the rising incidence and prevalence of opioid use disorder. Perioperative care has an important role in the consideration of opioid prescribing and the care of individuals at risk for poor postoperative pain- and opioid-related outcomes. Opioids are effective for acute pain management and commonly prescribed for postoperative pain. However, failure to align prescribing with patient need can result in overprescribing and exacerbate the flow of unused opioids into communities. Conversely, underprescribing can result in the undertreatment of pain, complicating recovery and impairing well-being after surgery. Optimizing pain management can be particularly challenging for individuals who are previously exposed to opioids or have critical risk factors, including opioid use disorder. In this review, we will explore the role of perioperative care in the broader context of the opioid epidemic in the United States, and provide considerations for a multidisciplinary, comprehensive approach to perioperative pain management and optimal opioid stewardship.
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OBJECTIVE: To examine the association of prescription opioid fills over the year prior to surgery with postoperative outcomes. BACKGROUND: Nearly one third of patients report opioid use in the year preceding surgery, yet an understanding of how opioid exposure influences patient-reported outcomes after surgery remains incomplete. Therefore, this study was designed to test the hypothesis that preoperative opioid exposure may impede recovery in the postoperative period. METHODS: This retrospective cohort study used a statewide clinical registry from 70 hospitals linked to opioid fulfillment data from the state's prescription drug monitoring program to categorize patients' preoperative opioid exposure as none (naïve), minimal, intermittent, or chronic. Outcomes were patient-reported pain intensity (primary), as well as 30-day clinical and patient-reported outcomes (secondary). RESULTS: Compared to opioid-naïve patients, opioid exposure was associated with higher reported pain scores at 30 days after surgery. Predicted probabilities was higher among the opioid exposed versus naive group for reporting moderate pain (43.5% [95% CI 42.6 - 44.4%] vs 39.3% [95% CI 38.5 - 40.1%]) and severe pain (13.% [95% CI 12.5 - 14.0%] vs 10.0% [95% CI 9.5 - 10.5%]), and increasing probability was associated increased opioid exposure for both outcomes. Clinical outcomes (incidence of ED visits, readmissions, and reoperation within 30-days) and patient-reported outcomes (reported satisfaction, regret, and quality of life) were also worse with increasing preoperative opioid exposure for most outcomes. CONCLUSIONS: This study is the first to examine the effect of presurgical opioid exposure on both clinical and non-clinical outcomes in a broad cohort of patients, and shows that exposure is associated with worse postsurgical outcomes. A key question to be addressed is whether and to what extent opioid tapering before surgery mitigates these risks after surgery.
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INTRODUCTION: While identifying opioid prescriptions in claims data has been instrumental in informing best practises, studies have not evaluated whether certain methods of identifying opioid prescriptions yield better results. We compared three common approaches to identify opioid prescriptions in large, nationally representative databases. METHODS: We performed a retrospective cohort study, analyzing MarketScan, Optum, and Medicare claims to compare three methods of opioid classification: claims database-specific classifications, National Drug Codes (NDC) from the Centers for Disease Control and Prevention (CDC), or NDC from Overdose Prevention Engagement Network (OPEN). The primary outcome was discrimination by area under the curve (AUC), with secondary outcomes including the number of opioid prescriptions identified by experts but not identified by each method. RESULTS: All methods had high discrimination (AUC>0.99). For MarketScan (n=70,162,157), prescriptions that were not identified totalled 42,068 (0.06%) for the CDC list, 2,067,613 (2.9%) for database-specific categories, and 0 (0%) for the OPEN list. For Optum (n=61,554,852), opioid prescriptions not identified totalled 9,774 (0.02%) for the CDC list, 83,700 (0.14%) for database-specific categories, and 0 (0%) for the OPEN list. In Medicare claims (n=92,781,299), the number of opioid prescriptions not identified totalled 8,694 (0.01%) for the CDC file and 0 (0%) for the OPEN list. DISCUSSION: This analysis found that identifying opioid prescriptions using methods from CDC and OPEN were similar and superior to prespecified database-specific categories. Overall, this study shows the importance of carefully selecting the approach to identify opioid prescriptions when investigating claims data.
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OBJECTIVE: To compare outcomes of patients using versus not using cannabis as a treatment for pain after discharge from surgery. BACKGROUND: Cannabis is increasingly available and is often taken by patients to relieve pain. However, it is unclear whether cannabis use for pain after surgery impacts opioid consumption and postoperative outcomes. METHODS: Using Michigan Surgical Quality Collaborative registry data at 69 hospitals, we analyzed a cohort of patients undergoing 16 procedure types between January 1, 2021, and October 31, 2021. The key exposure was cannabis use for pain after surgery. Outcomes included postdischarge opioid consumption (primary) and patient-reported outcomes of pain, satisfaction, quality of life, and regret to undergo surgery (secondary). RESULTS: Of 11,314 included patients (58% females, mean age: 55.1 years), 581 (5.1%) reported using cannabis to treat pain after surgery. In adjusted models, patients who used cannabis consumed an additional 1.0 (95% CI: 0.4-1.5) opioid pills after surgery. Patients who used cannabis were more likely to report moderate-to-severe surgical site pain at 1 week (adjusted odds ratio: 1.7, 95% CIL 1.4-2.1) and 1 month (adjusted odds ratio: 2.1, 95% CI: 1.7-2.7) after surgery. Patients who used cannabis were less likely to endorse high satisfaction (72.1% vs 82.6%), best quality of life (46.7% vs 63.0%), and no regret (87.6% vs 92.7%) (all P < 0.001). CONCLUSIONS: Patient-reported cannabis use, to treat postoperative pain, was associated with increased opioid consumption after discharge from surgery that was of clinically insignificant amounts, but worse pain and other postoperative patient-reported outcomes.
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Analgésicos Opioides , Cannabis , Femenino , Humanos , Persona de Mediana Edad , Masculino , Analgésicos Opioides/uso terapéutico , Alta del Paciente , Cuidados Posteriores , Calidad de Vida , Dolor Postoperatorio/tratamiento farmacológico , Medición de Resultados Informados por el PacienteRESUMEN
This qualitative study examines how incentive-based and salary-only compensation models affect academic surgeons.
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Centros Médicos Académicos , Organizaciones , Humanos , Estados Unidos , Investigación Cualitativa , Salarios y BeneficiosRESUMEN
Importance: Many early-career surgeons struggle to develop their clinical practices, leading to high rates of burnout and attrition. Furthermore, women in surgery receive fewer, less complex, and less remunerative referrals compared with men. An enhanced understanding of the social and structural barriers to optimal growth and equity in clinical practice development is fundamental to guiding interventions to support academic surgeons. Objective: To identify the barriers and facilitators to clinical practice development with attention to differences related to surgeon gender. Design, Setting, and Participants: A multi-institutional qualitative descriptive study was performed using semistructured interviews analyzed with a grounded theory approach. Interviews were conducted at 5 academic medical centers in the US between July 12, 2022, and January 31, 2023. Surgeons with at least 1 year of independent practice experience were selected using purposeful sampling to obtain a representative sample by gender, specialty, academic rank, and years of experience. Main Outcomes and Measures: Surgeon perspectives on external barriers and facilitators of clinical practice development and strategies to support practice development for new academic surgeons. Results: A total of 45 surgeons were interviewed (23 women [51%], 18 with ≤5 years of experience [40%], and 20 with ≥10 years of experience [44%]). Surgeons reported barriers and facilitators related to their colleagues, department, institution, and environment. Dominant themes for both genders were related to competition, case distribution among partners, resource allocation, and geographic market saturation. Women surgeons reported additional challenges related to gender-based discrimination (exclusion, questioning of expertise, role misidentification, salary disparities, and unequal resource allocation) and additional demands (related to appearance, self-advocacy, and nonoperative patient care). Gender concordance with patients and referring physicians was a facilitator of practice development for women. Surgeons suggested several strategies for their colleagues, department, and institution to improve practice development by amplifying facilitators and promoting objectivity and transparency in resource allocation and referrals. Conclusions and Relevance: The findings of this qualitative study suggest that a surgeon's external context has a substantial influence on their practice development. Academic institutions and departments of surgery may consider the influence of their structures and policies on early career surgeons to accelerate practice development and workplace equity.
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Agotamiento Profesional , Cirujanos , Humanos , Femenino , Masculino , Investigación Cualitativa , Centros Médicos Académicos , Atención a la SaludRESUMEN
INTRODUCTION: To balance adequate pain management while minimizing opioid-related harms after surgery, opioid prescribing guidelines rely on patient-reported use after surgery. However, it is unclear how many patients are required to develop precise guidelines. We aimed to compare patterns of use, required sample size, and the precision for patient-reported opioid consumption after common surgical procedures. METHODS: We analyzed procedure-specific 30-day opioid consumption data reported after discharge from 15 common surgical procedures between January 2018 and May 2019 across 65 hospitals in the Michigan Surgical Quality Collaborative. We calculated proportions of patients using no pills and the estimated number of pills meeting most patients' needs, defined as the 75th percentile of consumption. We compared several methods to model consumption patterns. Using the best method (Tweedie), we calculated sample sizes required to identify opioid consumption within a 5-pill interval and estimates of pills to meet most patients' needs by calculating the width of 95% CIs. RESULTS: In a cohort of 10,688 patients, many patients did not consume any opioids after all types of procedures (range 20%-40%). Most patients' needs were met with 4 pills (thyroidectomy) to 13 pills (abdominal hysterectomy). Sample sizes required to estimate opioid consumption within a 5-pill wide 95% CI ranged from 48 for laparoscopic appendectomy to 188 for open colectomy. The 95% CI width for estimates ranged from 0.7 pills for laparoscopic cholecystectomy to 7.0 pills for ileostomy/colostomy. CONCLUSIONS: This study demonstrates that profiles of opioid consumption share more similarities than differences for certain surgical procedures. Future investigations on patient-reported consumption are required for procedures not currently included in prescribing guidelines to ensure surgeons and perioperative providers can appropriately tailor recommendations to the postoperative needs of patients.