IMPORTANCE Real-world surgical practice often lags behind the best scientific evidence. For example, although optimizing comorbidities such as smoking and morbid obesity before ventral and incisional hernia repair improves outcomes, as many as 25% of these patients have a high-risk characteristic at the time of surgery. Implementation strategies may effectively increase use of evidence-based practice.OBJECTIVE To describe current trends in preoperative optimization among patients undergoing ventral hernia repair, identify barriers to optimization, develop interventions to address these barriers, and then pilot these interventions. DESIGN, SETTING, AND PARTICIPANTSThis quality improvement study used a retrospective medical record review to identify hospital-level trends in preoperative optimization among patients undergoing ventral and incisional hernia repair. Semistructured interviews with 21 practicing surgeons were conducted to elicit barriers to optimizing high-risk patients before surgery. Next, a task force of experts was convened to develop pragmatic interventions to increase surgeon use of preoperative optimization. Finally, these interventions were piloted at 2 sites to assess acceptability and feasibility. This study was performed from January 1, 2014, to December 31, 2019. MAIN OUTCOMES AND MEASURESThe main outcome was rate of referrals for preoperative patient optimization at the 2 pilot sites. RESULTS Among 23 000 patients undergoing ventral hernia repair, the mean (SD) age was 53.9 (14.3) years, and 12 315 (53.5%) were men. Of these, 8786 patients (38.2%) had at least 1 high-risk characteristic at the time of surgery, including 7683 with 1, 1079 with 2, and 24 with 3. At the hospital level, the mean proportion of patients with at least 1 of 3 high-risk characteristics at the time of surgery was 38.2% (95% CI, 38.1%-38.3%). This proportion varied widely from 21.5% (95% CI, 17.6%-25.5%) to 52.8% (95% CI, 43.9%-61.8%) across hospitals. Interviews with surgeons identified 3 major barriers to improving this practice: lost financial opportunity by not offering a patient an operation, lack of surgeon awareness of available resources for optimization, and organizational barriers. A task force therefore developed 3 interventions: a financial incentive to optimize high-risk patients, an educational intervention to make surgeons aware of available optimization resources, and on-site facilitation. These strategies were piloted at 2 sites where preoperative risk optimization referrals increased 860%. CONCLUSIONS AND RELEVANCEThis study demonstrates a stepwise process of identifying a practice gap, eliciting barriers that contribute to this gap, using expert consensus and local resources to develop strategies to address these barriers, and piloting these strategies. This implementation (continued) Key Points Question Is a stepwise implementation intervention associated with increased use of preoperative optimization by surgeons for patients with abdominal wall hernia? Findings In this quality improvement study in...
Opioid and benzodiazepine prescribing after COVID‐19 hospitalization is not well understood. We aimed to characterize opioid and benzodiazepine prescribing among naïve patients hospitalized for COVID and to identify the risk factors associated with a new prescription at discharge. In this retrospective study of patients across 39 Michigan hospitals from March to November 2020, we identified 857 opioid‐ and benzodiazepine‐naïve patients admitted with COVID‐19 not requiring mechanical ventilation. Of these, 22% received opioids, 13% received benzodiazepines, and 6% received both during the hospitalization. At discharge, 8% received an opioid prescription, and 3% received a benzodiazepine prescription. After multivariable adjustment, receipt of an opioid or benzodiazepine prescription at discharge was associated with the length of inpatient opioid or benzodiazepine exposure. These findings suggest that hospitalization represents a risk of opioid or benzodiazepine initiation among naïve patients, and judicious prescribing should be considered to prevent opioid‐related harms.
➢ Opioid use for chronic and acute musculoskeletal pain is common.➢ Orthopaedic surgeons are frequent opioid prescribers.➢ Opioids are commonly prescribed for acute pain, with high variation.➢ Opioid alternatives for acute pain are effective, and the incorporation of multimodal pain management in the perioperative period can decrease opioid use.➢ Although opioids are effective for the management of acute musculoskeletal pain, the morbidity and mortality related to opioid analgesics reinforce the need for robust, evidence-based guidelines.➢ Providers should evaluate patient risk preoperatively, should prescribe judiciously with multimodal pain management plans, and should integrate a preoperative discussion on opioid usage.➢ Future research should include procedure-specific pain management strategies, as well as the comparative efficacy of pharmacologic and nonpharmacologic methods of pain management.
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