By Mitchell Linder, MD
Assistant Professor, Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Strong Memorial Hospital, Rochester, NY
SYNOPSIS: In this quality improvement initiative study, patients undergoing scheduled gynecologic abdominal surgery via both minimally invasive and open routes were able to be discharged safely without a prescription of opioids without significant increases in postoperative calls about pain or the need for filling opioid prescriptions after discharge.
SOURCE: Margolis B, Andriani L, Baumann K, et al. Safety and feasibility of discharge without an opioid prescription for patients undergoing gynecologic surgery. Obstet Gynecol 2020;136:1126-1134.
The authors of this retrospective cohort study sought to evaluate a quality improvement (QI) initiative aimed at decreasing the amount of opioids a patient was given after minimally invasive or open gynecology surgery in the gynecologic oncology department of a single institution. Their QI project employed a three-tiered approach, including preoperative counseling, standardization of perioperative analgesia, and a postoperative prescription algorithm. Exclusion criteria for the project included patients who underwent procedures in conjunction with other departments; those who had vulvar, vaginal, or hysteroscopic procedures; and those with a documented allergy to both ibuprofen and acetaminophen. A six-month historical control cohort was used to compare to the six-month window after the initiative was put in place.
After the six-month intervention was completed, a retrospective chart review was undertaken for analysis. Data collection included patient demographics, baseline characteristics, and procedure details as well as perioperative deaths. Post-discharge phone calls to the office and any need for new opioid prescriptions or refills also were included in data collection. The primary outcome measure was a reduction in the percentage of patients discharged without an opioid prescription. Various thresholds were put in place in case the initiative was found to worsen patient care. Patients were surveyed with questions including opioid usage, pain control strategies, and pain scores at the two-week postoperative mark.
The preoperative counseling tier of the project consisted of standardized education sessions with a trained nurse, including targeted pamphlets and a specific script with postoperative expectations detailing the goal to give limited or no opioids upon discharge. Patients also were screened for any preexisting opioid use disorders using a standardized tool. The perioperative analgesia platform included enhanced recovery items, such as preoperative acetaminophen and pregabalin, early feeding and ambulation, and postoperative multimodal opioid-sparing analgesia. Regarding the postoperative prescription intervention, patients were given gabapentin as well as ibuprofen and acetaminophen. A four-tablet prescription for 5 mg of oxycodone was given on discharge only if the patient had stayed overnight in the hospital and required more than five opioid administrations during their hospitalization.
There were 398 patients in the preintervention window and 375 patients in the postintervention window. Of those, 122 patients in the preintervention group and 119 patients in the postintervention group were removed because of exclusion criteria. This left 256 patients in the preintervention group and 276 patients in the post-intervention group. The samples were not statistically different regarding age, body mass index, smoking status, prior abdominal surgeries, or preoperative benign vs. malignant diagnoses. There were more white patients in the preintervention group (71% vs. 63%) and more patients with chronic opioid use (six vs. one). Perioperative characteristics, such as perioperative pain scores, length of stay, median duration of procedure, surgery route, and proportion of staging/debulking surgeries, were similar among the two time periods. Provider compliance with the established protocol was found to be 85% or greater.
When evaluating for the primary outcome, the number of patients discharged with an opioid prescription was decreased significantly from 82.7% preintervention to 23.1% postintervention; 82.9% of patients who underwent a minimally invasive hysterectomy and were discharged on day 0 or day 1 went home without any opioids. The mean number of opioid tablets prescribed was significantly reduced across all surgeries from 7.2 tablets to 1.8 tablets (P < 0.001).
From a postoperative perspective, the percentage of patients contacting the office after discharge was consistent across the two groups (6.5% vs. 5.9% postintervention). Postoperative complications (8.3% vs. 12.9%, P = 0.09) and patient calls for pain (8.3% vs. 10.9%, P = 0.31) were not significantly increased postintervention. Patient reported data from the two-week postoperative surveys showed 91% either “agreed” or “strongly agreed” that their pain was well controlled after surgery.
It is more than obvious that there is an opioid crisis in the United States. Prescription drugs play a large role in this epidemic. According to the Centers for Disease Control and Prevention, 450,000 people died from an overdose involving opioids between 1999 and 2018, with prescription opioids being a contributor in almost six deaths per 100,000 population in 2017.1 A large contributor to this is excess narcotics given on discharge from the hospital, potentially giving access to both the patient as well as family members or friends. Numerous interventions have begun to take place at various levels of government and at the institutional level to help curb opioid prescriptions. In addition, many medical societies have published advanced recovery from surgery guidelines to help avoid the need for narcotics.
Thanks to these efforts, we are now starting to see a decrease in the prescription opioid-involved death rate, which decreased by 13.5% from 2017 to 2018.2 This study looks to further efforts to help reassure providers that it is both safe and reasonable to discharge patients with minimal to no opioids, even after major gynecologic surgeries. The authors pointed out their intervention adds to the existing evidence in support of minimizing discharge opioids, as they focused on ambulatory hysterectomies and the postoperative use of gabapentin. They attributed a large degree of the success of the program to institutional buy-in and commitment to compliance with the protocols. The authors found positives in the fact that their data collection at each step of the process was thorough, including the two-week patient postoperative surveys. They acknowledged the study’s shortcomings, including the absence of randomization and the likely lack of generalizability of their results to other institutions given that their cohort was largely insured, urban, and relatively homogenous. They also pointed to the limitations that are inherent with retrospective chart reviews, since, although this was a prospective intervention, any chart review may miss important clinical information that occurred but was not documented or happened at an outside facility.
I find this study interesting in that our institution has only just begun the process of outpatient hysterectomies. Some of our providers are hesitant to send patients home without medication because of concern for postoperative pain control issues in the first number of hours after surgery. This study helps provide reassurance that, with the properly selected patient who has been adequately counseled about postoperative expectations and given a standardized non-opioid pain control regimen of prescriptions, same-day discharge — even from what once were considered major abdominal procedures — can be completed safely with limited to no opioids and without affecting patient pain control.
- Centers for Disease Control and Prevention. Wide-ranging online data for epidemiologic research (WONDER). https://wonder.cdc.gov/
- Wilson N, Kariisa M, Seth P, et al. Drug and opioid-involved overdose deaths—United States, 2017-2018. MMWR Morb Mortal Wkly Rep 2020;69:290-297.