Postoperative Pain Management Among Dominican and American Health-Care Providers

Devine, Christopher A.; Yu, Amy; Kasdin, Rachel G.; Bogart, Laura M.; Davis, Aileen M.; Abreu, Luis Alcantara; Ghazinouri, Roya; Thornhill, Thomas S.; Katz, Jeffrey N.

doi:10.2106/jbjs.15.01004

Cited by 18 publications

(15 citation statements)

References 24 publications

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“…In order to better understand the analgesic prescription culture at HGPS and compare that to the practices of Op-Walk staff, Devine et al interviewed American and Dominican providers about their prescription patterns and decision-making frameworks 27 . Dominican surgeons rarely prescribed opioids because of limited availability, and adhered to a standardized pain protocol.…”

Section: Resultsmentioning

confidence: 99%

“…Notably, Op-Walk Boston’s use of qualitative studies allowed for an increased understanding of the differences in medical practices, catalyzed adaptation to cultural norms, and identified needed interventions. For example, studies on patient opioid use and physician opinions on prescription medications showed that HGPS physicians rarely prescribed opioids, and patients had limited experience with them 27,28 . These observations prompted the Op-Walk clinical leaders to reduce the role of opioids in the postoperative pain management protocols for the program, as well as to evaluate the reasoning for their prescription practices at their home institutions.…”

Section: Discussionmentioning

confidence: 99%

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A Conceptual Model for the Evaluation of Surgical Missions

Bido

Ghazinouri

Collins

et al. 2018

The Journal of Bone and Joint Surgery

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Background:Medical missions to low and middle-income countries are increasingly frequent, with an estimated 6,000 trips sponsored by U.S. organizations accounting for approximately 200,000 surgical cases and $250 million in costs annually. However, these missions have received little critical evaluation. This paper describes the research program Operation Walk (Op-Walk) Boston, and proposes an evaluation model for similar surgical missions.Methods:We propose an evaluation model, borrowing from the work of Donabedian and enriched by evidence from our research program. The model calls for evaluation of the salient contextual factors (culture and beliefs), system management (structure, process, and outcomes), and sustainability of the program’s interventions. We used these domains to present findings from the quantitative and qualitative research work of Op-Walk Boston.Results:Op-Walk’s qualitative research findings demonstrated that cultural factors are important determinants of patients’ perceptions of arthritis etiology, physical activity patterns, and treatment preferences. Quantitative assessments documented that Dominican patients had worse lower-extremity functional status (mean Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] function score of 33.6) and pain preoperatively than patients undergoing total hip or knee replacement in the U.S. (WOMAC function score of 43.3 to 54), yet they achieved excellent outcomes (50-point improvement), comparable to those of their U.S. counterparts. Assessments of the quality and sustainability of the Op-Walk program showed that the quality of care provided by Op-Walk Boston meets Blue Cross Blue Shield Centers of Excellence (Blue Distinction) criteria, and that sustainable changes were transferred to the host hospital.Conclusions:Our proposed model offers a method for formal assessment of medical missions that addresses the call for evidence of their merit. We suggest that surgical missions adopt quantitative and qualitative strategies to document their impact, identify areas of improvement, and justify program continuation, growth, and support.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

A Conceptual Model for the Evaluation of Surgical Missions

Bido

Ghazinouri

Collins

et al. 2018

The Journal of Bone and Joint Surgery

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“…27 In other countries, opioids are rarely used after surgeries that routinely merit an opioid prescription when performed in the United States. 5,13 Geographic variation in approaches to postoperative pain relief highlights the need for the standardization of prescribing practices and nationwide prescriber education on the topic. National, comprehensive educational programs coupled with procedure-specific quantitative guidelines would help to mitigate the cultural and geographic variation in prescriber behaviors.…”

Section: Figmentioning

confidence: 99%

“…10,21 This conflict has contributed to overprescribing, often leaving patients with leftover narcotic pills after surgery. 12,19,28 The push to reduce opioid prescriptions is further supported by the lack of an association between increased opioid dosage and pain relief, 5,13,25 multiple side effects (including death), 4 an association with postoperative complications, 4,8 and the legal ramifications of careless prescribing. 7 The American Academy of Orthopaedic Surgeons has called for the standardization of opioid prescribing practices in an attempt to decrease overprescribing and the number of pills available for diversion.…”

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confidence: 99%

An institutional intervention to modify opioid prescribing practices after lumbar spine surgery

Lovecchio

Stepan

Premkumar

et al. 2019

Journal of Neurosurgery: Spine

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OBJECTIVEPatients with lumbar spine pathology are at high risk for opioid misuse. Standardizing prescribing practices through an institutional intervention may reduce the overprescribing of opiates, leading to a decrease in the risk for opioid misuse and the number of pills available for diversion. Without quantitative data on the “minimum necessary quantity” of opioids appropriate for postdischarge prescriptions, the optimal method for changing existing prescribing practices is unknown. The purpose of this study was to determine whether mandatory provider education and prescribing guidelines could modify prescriber behavior and lead to a decreased amount of opioids prescribed at hospital discharge following lumbar spine surgery.METHODSQualified staff were required to attend a mandatory educational conference, and a consensus method among the spine service was used to publish qualitative prescribing guidelines. Prescription data for 2479 patients who had undergone lumbar spine surgery were captured and compared based on the timing of surgery. The preintervention group consisted of 1177 patients who had undergone spine surgery in the period before prescriber education and guidelines (March 1, 2016–November 1, 2016). The postintervention group consisted of 1302 patients who had undergone spine surgery after the dissemination of the guidelines (February 1, 2017–October 1, 2017). Surgeries were classified as decompression or fusion procedures. Patients who had undergone surgeries for infection and patients on long-acting opioids were excluded.RESULTSFor all lumbar spine surgeries (decompression and fusion), the mean amount of opioids prescribed at discharge was lower after the educational program and distribution of prescribing guidelines (629 ± 294 oral morphine equivalent [OME] preintervention vs 490 ± 245 OME postintervention, p < 0.001). The mean number of prescribed pills also decreased (81 ± 26 vs 66 ± 22, p < 0.001). Prescriptions for 81 or more tablets dropped from 65.5% to 25.5%. Tramadol was prescribed more frequently after prescriber education (9.9% vs 18.6%, p < 0.001). Refill rates within 6 weeks were higher after the institutional intervention (7.6% vs 12.4%, p < 0.07).CONCLUSIONSQualitative guidelines and prescriber education are effective in reducing the amount of opioids prescribed at discharge and encouraging the use of weaker opioids. Coupling provider education with prescribing guidelines is likely synergistic in achieving larger reductions. The sustainability of these changes is yet to be determined.

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“…variation in analgesic prescribing among countries for similar injuries remains poorly understood 7 . Although there have been several international studies of opioid prescribing practices in the Dominican Republic, the Netherlands, and China, these studies have been qualitative or retrospective, or have not addressed opioid prescribing after operative management [7][8][9] . We are aware of only a single quantitative comparative study of international postoperative opioid prescribing, which compared the U.S. and the Netherlands 10 .…”

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confidence: 99%

Cross-Cultural Comparison of Postoperative Discharge Opioid Prescribing After Orthopaedic Trauma Surgery

Young

Bhashyam

Qudsi

et al. 2019

The Journal of Bone and Joint Surgery

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Background: The extent of variation in analgesic prescribing following musculoskeletal injury among countries and cultural contexts is poorly understood. Such an understanding can inform both domestic prescribing and future policy. The aim of our survey study was to evaluate how opioid prescribing by orthopaedic residents varies by geographic context. Methods: Orthopaedic residents in 3 countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the U.S.) responded to surveys utilizing vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for post-discharge analgesia. We standardized opioid prescriptions in the surveys by conversion to morphine milligram equivalents (MMEs). We then constructed multivariable regressions with generalized estimating equations to describe differences in opiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases. Results: U.S. residents prescribed significantly more total MMEs per case (mean [95% confidence interval] = 383 [331 to 435]) compared with residents from the Netherlands (229 [160 to 297]) and from Haiti (101 [52 to 150]) both overall (p < 0.0001) and for patients treated for injuries of the femur (452 [385 to 520], 315 [216 to 414], and 103 [37 to 169] in the U.S., the Netherlands, and Haiti, respectively), tibial plateau (459 [388 to 531], 280 [196 to 365], and 114 [46 to 183]), tibial shaft (440 [380 to 500], 294 [205 to 383], and 141 [44 to 239]), wrist (239 [194 to 284], 78 [36 to 119], and 63 [30 to 95]), and ankle (331 [270 to 393], 190 [100 to 280], and 85 [42 to 128]) (p = 0.0272). U.S. residents prescribed significantly more MMEs for patients <40 years old (432 [374 to 490]) than for those >70 years old (327 [270 to 384]) (p = 0.0019). Conclusions: Our results demonstrate greater prescribing of postoperative opioids at discharge in the U.S. compared with 2 other countries, 1 low-income and 1 high-income. Our findings highlight the high U.S. reliance on opioid prescribing for postoperative pain control after orthopaedic trauma. Clinical Relevance: Our findings point toward a need for careful reassessment of current opioid prescribing habits in the U.S. and demand reflection on how we can maximize effectiveness in pain management protocols and reduce provider contributions to the ongoing opioid crisis. M usculoskeletal injuries are responsible for a large global burden of preventable injuries, disability, and death 1,2. In the U.S., opioid prescribing for such conditions is currently considered problematic and appears to be a major factor contributing to what is considered an opioid epidemic by bodies such as the Centers for Disease Control and Prevention (CDC) 3-5. Over the past 20 years, U.S. opioid prescriptions and opioid-related deaths have increased greatly 5. U.S. physicians and policymakers have attempted to address the opioid crisis by curtailing the freq...

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Postoperative Pain Management Among Dominican and American Health-Care Providers

Cited by 18 publications

References 24 publications

A Conceptual Model for the Evaluation of Surgical Missions

A Conceptual Model for the Evaluation of Surgical Missions

An institutional intervention to modify opioid prescribing practices after lumbar spine surgery

Cross-Cultural Comparison of Postoperative Discharge Opioid Prescribing After Orthopaedic Trauma Surgery

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