The Impact of Multidisciplinary Conferences on Treatment Plans for Patients With Inflammatory Bowel Disease in a Tertiary Canadian Centre.

BACKGROUND: Multidisciplinary conference presentation may provide recommendations for diagnosis, monitoring and treatment for patients with inflammatory bowel disease. METHODS: A prospective observational study was completed evaluating if case presentation resulted in a direct change in management for patients presented over a 2-year period in a tertiary Canadian centre. Change in management was defined as hospital admission, surgery or surgical referral, start/change in biologic therapy or other medication or initiation of parenteral nutrition. Secondary outcomes included the involvement of specialists and other referrals. Data were analyzed using frequencies and means with standard deviations. RESULTS: In 63 multidisciplinary conferences, 181 patients were presented, of whom 136 patients met the inclusion criteria of inflammatory bowel disease (Crohn's n = 45, ulcerative colitis n = 88, undifferentiated n = 3). The majority were outpatient cases 110 (81%). Indications included 71 (52%) patients presented for IBD management with diagnosis > 1 year, 37 (27%) with an acute IBD flare in a chronic patient (>1 year since diagnosis) and 24 (18%) with new diagnosis of IBD. Change in management was recommended in 35 (26%) patients. The most common change was referral to surgery in 17 (13%), surgery in 12 (9%) or change in biologic therapy 11 (8%). Compliance with the recommendations was 85%. There was frequent specialist involvement in case discussions (gastroenterologist 100%, surgeon 60%, radiologist 68% and pathologist 32%). CONCLUSIONS: Presentation of complex inflammatory bowel disease cases at multidisciplinary conference leads to a direct change in treatment in one quarter of cases, with surgical referral as the most frequent outcome.

The Standardization of Outpatient Procedure (STOP) Narcotics: A Prospective Health Systems Intervention to Reduce Opioid Use in Ambulatory Breast Surgery.

BACKGROUND: During the past 15 years, opioid-related overdose death rates for women have increased 471%. Many surgeons provide opioid prescriptions well in excess of what patients actually use. This study assessed a health systems intervention to control pain adequately while reducing opioid prescriptions in ambulatory breast surgery. METHODS: This prospective non-inferiority study included women 18-75 years of age undergoing elective ambulatory general surgical breast procedures. Pre- and postintervention groups were compared, separated by implementation of a multi-pronged, opioid-sparing strategy consisting of patient education, health care provider education and perioperative multimodal analgesic strategies. The primary outcome was average pain during the first 7 postoperative days on a numeric rating scale of 0-10. The secondary outcomes included medication use and prescription renewals. RESULTS: The average pain during the first 7 postoperative days was non-inferior in the postintervention group despite a significant decrease in median oral morphine equivalents (OMEs) prescribed (2.0/10 [100 OMEs] pre-intervention vs 2.1/10 [50 OMEs] post-intervention; p = 0.40 [p < 0.001]). Only 39 (44%) of the 88 patients in the post-intervention group filled their rescue opioid prescription, and 8 (9%) of the 88 patients reported needing an opioid for additional pain not controlled with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) postoperatively. Prescription renewals did not change. CONCLUSION: A standardized pain care bundle was effective in minimizing and even eliminating opioid use after elective ambulatory breast surgery while adequately controlling postoperative pain. The Standardization of Outpatient Procedure Narcotics (STOP Narcotics) initiative decreases unnecessary and unused opioid medication and may decrease risk of persistent opioid use. This initiative provides a framework for future analgesia guidelines in ambulatory breast surgery.

Standardization of Outpatient Procedure (STOP) Narcotics: A Prospective Non-Inferiority Study to Reduce Opioid Use in Outpatient General Surgical Procedures.

BACKGROUND: There has been a dramatic rise in opioid abuse, and diversion of excess, unused prescriptions is a major contributor. We assess the impact of implementing a new standardized pain care bundle to reduce postoperative opioids in outpatient general surgical procedures. STUDY DESIGN: This study was designed to demonstrate non-inferiority for the primary end point: patient-reported average pain in the first 7 postoperative days. We prospectively evaluated 224 patients who underwent laparoscopic cholecystectomy or open hernia repair (inguinal, umbilical) pre-intervention to 192 patients post-intervention. We implemented a multimodal intra- and postoperative analgesic bundle, including promoting co-analgesia, opioid-reduced prescriptions, and patient education designed to clarify patient expectations. Patients completed a brief pain inventory at their first postoperative visit. Groups were compared using chi-square test, Mann-Whitney U test, and independent samples t-test, where appropriate. RESULTS: No difference was seen in average postoperative pain scores in the pre- vs post-intervention groups (2.3 vs 2.1 of 10; p = 0.12). The reported quality of pain control improved post-intervention (good/very good pain control in 69% vs 85%; p < 0.001). The median total morphine equivalents for prescriptions filled in the post-intervention group were significantly less (100; interquartile range 75 to 116 pre-intervention vs 50; interquartile range 50 to 50 post-intervention; p < 0.001). Only 78 of 172 (45%) patients filled their opioid prescription in the post-intervention group (p < 0.001), with no significant difference in prescription renewals (3.5% pre-intervention vs 2.6% post-intervention; p = 0.62). CONCLUSIONS: For outpatient open hernia repair and cholecystectomy, a standardized pain care bundle decreased opioid prescribing significantly and frequently eliminated opioid use, and adequately treating postoperative pain and improving patient satisfaction.