Predictors of low and high opioid tablet consumption after inguinal hernia repair: an ACHQC opioid reduction task force analysis.

PURPOSE: Prescribing and consumption of opioids remain highly variable. Using a national hernia registry, we aimed to identify patient and surgery specific factors associated with low and high opioid tablet consumption after inguinal hernia repair. METHODS: This was a retrospective cross-sectional study evaluating patients undergoing elective inguinal hernia repair with 30-day follow-up and patient-reported opioid consumption from March 2019 to March 2021 using the Abdominal Core Health Quality Collaborative. Clinically significant patient demographics, comorbidities, operative details, quality-of-life measurements, and surgeon prescribing data were entered into a multivariable logistic regression model to identify statistically significant predictors of patients who took no opioid tablets or >10 tablets. RESULTS: A total of 1937 patients were analyzed. Operations included 59% laparoscopic or robotic, 35% open mesh, and 6% open non-mesh repairs. Of these patients, 50% reported taking zero, 42% took 1-10, and 8% took ≥10 opioid tablets at 30-day follow-up. Patients who were older (OR 1.55, 95% CI 1.34-1.79, p-value <0.001), ASA ≤ 2 (OR 1.56, 95% CI 1.2-2.01, p-value <0.001), had no preoperative opioid use at baseline (OR 2.29, 95% CI 1.31-4.03, p-value = 0.004), had local anesthetic with general anesthesia (OR 1.39, 95% CI 1.0.5-1.85, p-value = 0.022), or prescribed <7 opioid tablets (OR 2.27, 95% CI 1.96-2.62, p-value <0.001) were more likely to take no opioid tablets. CONCLUSION: Older, healthier, opioid naïve patients with local anesthetic administered during elective inguinal hernia repair are most likely to not require opioids. Surgeon prescribing-arguably the most modifiable factor-independently correlates with both low and high opioid consumption.

The opioid reduction task force: using the ACHQC Data Registry to combat an epidemic in hernia patients.

PURPOSE: Post-operative opioid prescriptions contribute to prolonged opioid misuse and abuse. Using a national hernia registry, we aimed to evaluate the effectiveness of a data-driven educational intervention on surgeon prescribing behavior. METHODS: After collecting opioid prescribing and patient consumption data from March 2019-December 2019 in inguinal and umbilical hernia repair, the Abdominal Core Health Quality Collaborative (ACHQC) Opioid Reduction Task Force presented data at a Quality Improvement (QI) Summit to educate surgeons on strategies to minimize opioid prescribing. Surgeons were asked to implement a multimodal pain management approach and were supported with educational tools created by the task force. Prescribing and consumption data after the summit, December 2019-March 2021, were then collected to assess the effectiveness of the QI effort. RESULTS: Registry participation before and after the QI summit increased from 52 to 91 surgeons, with an increase of 353-830 umbilical hernia patients and 976-2447 inguinal hernia patients. After the summit, high (> 10 tablets) surgeon prescribers shifted toward low (≤ 10 tablets) prescribing. Yet, patients consumed less than what was prescribed, with a significant increase in patients consuming ≤ 10 tablets before and after the summit: 79-88% in umbilical hernia (p = 0.01) and 85-94% in inguinal hernia (p < 0.001). CONCLUSIONS: Following an educational QI summit by the ACHQC Opioid Reduction Task Force, high opioid prescribing has shifted toward low. However, patients consume less than prescribed, highlighting the importance of continuing this effort to reduce opioid prescribing.

Utilization of a National Registry to influence opioid prescribing behavior after hernia repair.

PURPOSE: Despite progress toward curtailing opioid prescribing, physicians are often slow to adopt new prescribing practices. Using the Abdominal Core Health Quality Collaborative (ACHQC), we aimed to demonstrate the ability of a national, disease-specific, personalized registry to impact opioid prescribing. METHODS: Using a collaborative and iterative process, a module was developed to capture surgeon opioid prescribing, patient-reported consumption, and risk factors for opioid use. Study reported according to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines. RESULTS: Six months after implementation of the ACHQC opioid module, we assessed participation, prescribing and patient consumption patterns. For ventral hernia repair (VHR; n = 398), 23 surgeons reported prescribing > 20 pills (43%), 11-20 (40%), and < 10 (18%). In contrast, patients (n = 217) reported taking < 10 pills in 65% and only 20% reported taking > 15. For inguinal hernia repair (IHR; n = 443) 37 surgeons reported prescribing > 20 tablets (22%), 11-20 (32%), and < 10 (44%). Patients (n = 277) reported taking < 10 pills in 81% of cases, including 50% reporting zero, and only 13% taking > 15. We identified barriers to practice change and developed a strategy for education, provision of individualized data, and encouraging participation. Surgeon participation has since increased significantly (n = 65 for VHR; n = 53 for IHR), and analysis of the impact of this process is ongoing. CONCLUSION: Quality improvement requires physician engagement, which can be facilitated by meaningful and actionable data. The specificity of the ACHQC and the ability to provide surgeons with individualized data is a model method to incite change in physician behavior and improve patient outcomes.

Role of differential neuroaxial blockade in the evaluation and management of pain in chronic pancreatitis.

OBJECTIVES: Chronic pancreatic pain is difficult to treat. Surgical and medical therapies directed at reducing pain have met with little long-term success. In addition, there are no reliable predictors of response including pancreatic duct diameter. A differential neuroaxial blockade allows characterization of chronic abdominal pain into visceral and nonvisceral pain origins and may be useful as a guide to the treatment. Pain from an inflamed, and scarred pancreas should be visceral in origin. The purpose of our study was to determine the frequency with which patients with chronic pancreatitis have visceral pain and whether our modified differential neuroaxial blockade technique using thoracic epidural analgesia can accurately predict which patients will respond to medical or surgical therapy. METHODS: We retrospectively reviewed the medical records of patients with a firmly established diagnosis of chronic pancreatitis (Cambridge classification, calcifications) who had undergone a differential neuroaxial block for their chronic abdominal pain evaluation. Patient demographics and medical or surgical treatment for pancreatic pain was recorded. Response to therapy was defined by a 50% reduction in pain by verbal response score. RESULTS: A total of 23 patients were identified. Alcohol was the most common etiology for chronic pancreatitis (15 of 23, 55%). Surprisingly, the majority of chronic pancreatitis patients had nonvisceral pain (18 of 23, 78%) and only 22% (5 of 23) had visceral pain by differential neuroaxial block. Four of five patients (80%) with visceral pain responded to therapy, whereas only 5 of 17 (29%) of patients with nonvisceral pain responded. CONCLUSIONS: Surprisingly, patients with chronic pancreatitis commonly have nonvisceral pain. Differential neuroaxial blockade can predict which patients will respond to therapy.

Intrathecal morphine for analgesia in children undergoing selective dorsal rhizotomy.

Selective dorsal root rhizotomy is performed for relief of spasticity in children with cerebral palsy. Postoperative pain relief can be provided by intrathecal morphine administered at the time of the procedure. We sought to define an optimal dose of intrathecal morphine in children undergoing selective rhizotomy, through a randomized, double-blinded prospective trial. After institutional approval and parental written informed consent, 27 patients, ages 3-10 years, were randomized to receive 10, 20, or 30 micrograms.kg-1 (Groups A, B, and C, respectively) of preservative-free morphine administered intrathecally by the surgeon after dural closure. Postoperatively, vital signs, pulse oximetry, and pain intensity scores were recorded hourly for 24 hr. Supplemental intravenous morphine was administered postoperatively according to a predetermined schedule based on pain scores. There was considerable individual variability in the time to initial morphine dosing and cumulative supplemental morphine dose. Time to first supplemental morphine dose was not different between groups. When compared to Groups A and B, cumulative 6-hr supplemental morphine dose was significantly lower in Group C (38.6 +/- 47 micrograms versus 79.1 +/- 74 and 189.6 +/- 126 for Groups A and B, respectively). By 12 hr, cumulative supplemental morphine dose was similar in Groups A and C. Group B consistently had a higher supplemental dose requirement than Groups A and C at 6, 12, and 18 hr. By 24 hr, there was no difference in cumulative dose among groups. Postoperative pain scores and the incidence of respiratory events, nausea, vomiting and pruritus were comparable among groups. These data suggest that intrathecal morphine at 30 micrograms.kg-1 provides the most intense analgesia at 6 hr following selective dorsal root rhizotomy, but was otherwise comparable to the 10 micrograms.kg-1 dose.