Changes in postoperative inpatient and outpatient opioid utilization after pharmacist‐led order set standardization and education for total knee and hip replacement at an academic medical center

Abstract

Introduction: Opioid analgesics are often overprescribed after orthopedic procedures. Several strategies have been implemented nationally to curb opioid overprescription with modest success. At an institutional level, one novel idea is to implement surgery-specific guidelines limiting opioid quantities prescribed postoperatively.Objectives: The primary objective of this study was to evaluate the effect of our institution's new standardized postoperative multimodal pain regimen guidance on cumulative opioid prescribed postoperatively at discharge, as measured in morphine equivalent dose (MED). Methods: Adults (≥18 years old) who underwent total knee or total hip replacement from August 2019 through March 2020 were eligible. Patients not prescribed opioids at discharge, incarcerated, or had postoperative stays 7 or more days were excluded. A pharmacist-led standardized protocol was implemented on 21 November 2020, and provider education was completed on 18 December 2021. Patients were assigned to historical (August 2019 to November2019) or standardized (December 2019 to March 2020) cohorts based on discharge date. Secondary outcomes are cumulative and per-prescription opioid pills, morphine equivalent daily dose (MEDD) prescribed at discharge, inpatient opioid, diazepam, and gabapentin utilization, and outpatient post-op opioid and pain outcomes.Results: Forty patients preintervention and 52 patients postintervention were included. For postoperative discharge opioids prescribed, median cumulative MED decreased 46% (560.0 vs 300.0, P < .001), quantity of pills decreased 14.3% (70 vs 60, P = .03), and MEDD decreased 16.7% (60.0 vs 50.0, P < .001). Inpatient opioid exposure decreased 49% (38.1 vs 19.4, P < .001), concurrent diazepam (20.0% vs 1.9%, P = .009), and gabapentin (85.0% vs 13.5%, P < .001) use with opioids also decreased. Postoperative pain scores did not significantly differ (4.0 vs 5.0, P = .63). Conclusion:Pharmacist-led standardized protocol implementation resulted in reduced postoperative opioid prescription and exposure, and decreased concurrent

Interventions and impact of pharmacist-delivered services in perioperative setting on clinically important outcomes: a systematic review and meta-analysis

“…The majority of studies were conducted in the United States ( n = 9; 36%) 32 – 40 and China ( n = 9; 36%), 41 – 49 followed by the United Kingdom ( n = 3; 12%), 50 – 52 and one (4%) each in Australia, 53 Netherland, 54 Pakistan, 55 and Sudan 56 ( Table 1 ). Most of the studies ( n = 8; 32%) were carried out in orthopedic surgery, 35 , 37 , 38 , 41 , 44 , 47 , 49 , 52 followed by five (20%) studies each that included multiple units 43 , 53 – 56 and general surgery 39 , 42 , 46 , 50 , 51 ( Table 1 ). Three studies (12%) were conducted in bariatric surgical units, 33 , 34 , 40 and two (8%) each in cardiothoracic 36 ,…”

“…The majority of studies ( n = 20; 80%) used an uncontrolled study design, 12 (48%) retrospective, 32 – 34 , 37 , 39 , 41 , 42 , 45 , 46 , 49 , 51 , 52 5 (20%) prospective, 35 , 36 , 43 , 50 , 55 3 (12%) retro-prospective studies, 40 , 44 , 48 with a variety of observational methodological designs ( Table 1 ). The remaining five (20%) were controlled, all of which were randomized.…”

“…The studies’ sample sizes ranged between 65 47 and 1227 patients 35 ( Table 1 ). Other than specifying one or more surgical units, the majority of studies ( n = 13; 52%) focused on a particular class of medication including antibiotics ( n = 5; 20%), 36 , 48 , 49 , 55 , 56 analgesics ( n = 3, two of which on opioids), 37 , 38 , 44 and one each on anticoagulants, 41 antidiabetic drugs, 39 antiemetics, 43 proton pump inhibitor, 46 and total parenteral nutrition (TPN) 42 ( Table 2 ). Among the reminder studies, two focused on patients with mild systemic disease 50 , 51 and two on patients at higher risk for medication misadventures.…”

“… 32 , 36 , 41 , 43 , 46 , 48 , 49 Four studies (16%) reported that the pharmacist intervention was intended for medical staff, mainly surgeons with or without other healthcare providers such as nurses or anesthesiologists. 37 , 42 , 55 , 56 …”

Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews

“…Another programmatic systems approach to medication management endeavors to create a shared mental model using drug stewardship as a platform of organizational change [ 104 , 105 , 106 , 107 ]. While most stewardship programs have concentrated on rational antimicrobial use [ 108 ], recent developments have focused attention on medication classes that are frequently used in perioperative care and are high-risk for the patient, including opioids [ 109 , 110 , 111 , 112 , 113 ], anticoagulants [ 114 , 115 , 116 , 117 , 118 , 119 , 120 ], anemia management [ 121 , 122 , 123 , 124 , 125 ], and glycemic control with insulin [ 126 , 127 ], among others [ 4 ]. Table 5 summarizes recommendations for preventing VTE, SSI, PONV, POI, and PoD [ 128 ].…”