Patient-Reported Opioid Consumption and Pain Intensity After Common Orthopedic and Urologic Surgical Procedures With Use of an Automated Text Messaging System

Abstract

IMPORTANCE Surgeons must balance management of acute postoperative pain with opioid stewardship. Patient-centered methods that immediately evaluate pain and opioid consumption can be used to guide prescribing and shared decision-making.OBJECTIVE To assess the difference between the number of opioid tablets prescribed and the selfreported number of tablets taken as well as self-reported pain intensity and ability to manage pain after orthopedic and urologic procedures with use of an automated text messaging system. DESIGN, SETTING, AND PARTICIPANTSThis quality improvement study was conducted at a large, urban academic health care system in Pennsylvania. Adult patients (aged Ն18 years) who underwent orthopedic and urologic procedures and received postoperative prescriptions for opioids were included. Data were collected prospectively using automated text messaging until postoperative day 28, from May 1 to December 31, 2019. MAIN OUTCOMES AND MEASURESThe primary outcome was the difference between the number of opioid tablets prescribed and the patient-reported number of tablets taken (in oxycodone 5-mg tablet equivalents). Secondary outcomes were self-reported pain intensity (on a scale of 0-10, with 10 being the highest level of pain) and ability to manage pain (on a scale of 0-10, with 10 representing very able to control pain) after orthopedic and urologic procedures. RESULTSOf the 919 study participants, 742 (80.7%) underwent orthopedic procedures and 177 (19.2%) underwent urologic procedures. Among those who underwent orthopedic procedures, 384 (51.8%) were women, 491 (66.7%) were White, and the median age was 48 years (interquartile range [IQR], 32-61 years); 514 (69.8%) had an outpatient procedure. Among those who underwent urologic procedures, 145 (84.8%) were men, 138 (80.7%) were White, and the median age was 56 years (IQR, 40-67 years); 106 (62%) had an outpatient procedure. The mean (SD) pain score on day 4 after orthopedic procedures was 4.72 (2.54), with a mean (SD) change by day 21 of −0.40 (1.91). The mean (SD) ability to manage pain score on day 4 was 7.32 (2.59), with a mean (SD) change of −0.80 (2.72) by day 21. The mean (SD) pain score on day 4 after urologic procedures was 3.48 (2.43), with a mean (SD) change by day 21 of −1.50 (2.12). The mean (SD) ability to manage pain score on day 4 was 7.34(2.81), with a mean (SD) change of 0.80 (1.75) by day 14. The median quantity of opioids prescribed for patients who underwent orthopedic procedures was high compared with self-reported consumption (20 tablets [IQR,[15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] vs 6 tablets used [IQR, 0-14 tablets]), similar to findings for patients who underwent urologic procedures (7 tablets [IQR,[5][6][7][8][9][10] vs 1 tablet used [IQR,[0][1][2][3][4]). Over the study period, 9452 of 15 581 total tablets prescribed (60.7%) were unused. A total of 589 patients (64.1%) used less than half of the amount prescribed, and 256 patients (27.8%) Key PointsQuestion Are the quantities of shortterm opioid prescr...

Effect of Mailing an At-home Disposal Kit on Unused Opioid Disposal After Surgery

“…All patients 18 years or older undergoing an orthopedic or urologic procedure and prescribed an opioid replied through a text messaging platform using an established protocol. 5 Patients without access to a short messaging service–capable device or who did not speak English were excluded. Participants were electronically block randomized in groups of 2 or 4 to usual care or a mailed at-home disposal kit immediately after consent (eMethods in Supplement 2 ).…”

Nonresponse adjustment using clinical and perioperative patient characteristics is critical for understanding post-discharge opioid consumption

“…Nonetheless, we chose to use our telephone-based consumption data as a reference for comparison since it is a commonly used method for collecting opioid consumption data in prior studies, had a high response rate of 60% in our study, and its accuracy has been validated by previous work demonstrating that it aligns closely with in-person based consumption estimates. 8,9,11,12 While our SMS-based survey had a comparatively lower response rate as expected, 18,39,40 the automated nature of this survey method may limit recall bias. We were able to automatically contact patients on a weekly basis after discharge, while studies using telephone and other labor-intensive survey methods have waited up to 12 months after discharge to survey patients on their pain and opioid consumption after surgery.…”

“…18 To our knowledge, no opioid consumption surveys have adjusted their consumption estimates for nonresponse bias. 11,12,18 The accuracy and generalizability is largely unknown for surveys in which nonresponse bias has not been examined.…”

“…A recent study measuring post-discharge opioid consumption among patients undergoing orthopedic and urologic surgery using an SMS-based survey found that the presence of comorbidities were associated with nonresponse, however nonresponse adjustment was not performed. 18 To our knowledge, no opioid consumption surveys have adjusted their consumption estimates for nonresponse bias. 11,12,18 The accuracy and generalizability is largely unknown for surveys in which nonresponse bias has not been examined.…”

“…Few prior opioid consumption surveys describe the characteristics of survey respondents in terms of these perioperative characteristics, or adjust for characteristics that may significantly alter survey results. 11,12,18 In this study we take a comprehensive approach to adjusting for nonresponse bias by describing the characteristics of non-responders using perioperative factors from the electronic health record (EHR) and then adjusting for these characteristics to capture the complex relationship between health system data, survey response, and opioid consumption.…”