Opioid Use, Pain, Postoperative, Parathyroidectomy, Thyroidectomy
Conditions
Keywords
Thyroidectomy, Parathyroidectomy, Opioid, Postoperative pain, Multimodal anesthesia
Brief summary
Unnecessary opioid prescriptions for postoperative pain can increase the risk for new, persistent opioid use and dependence. Published literature suggests that most patients undergoing thyroid or parathyroid surgery can have their pain effectively managed without opioids following hospital discharge. The purpose of this quasi-experimental, quality improvement study is to develop, implement, and measure the impact of a quality improvement bundle that consists of (1) patient education, (2) provider education, and (3) electronic health record (EHR) enhancements. The proportion of patients who receive new opioid discharge prescriptions for pain management following thyroid or parathyroid surgery at Houston Methodist Hospital for up to 6 months following bundle implementation will be compared to a historical control group.
Detailed description
BACKGROUND: New and persistent opioid use after minor and major surgery is common, and the duration of opioid use following surgery is associated with opioid dependence, abuse, and overdose. Most patients undergoing thyroid or parathyroid surgery do not require opioid discharge prescriptions for effective pain management. If opioids are prescribed for these surgeries, up to 7% of patients will use opioids 3 to 6 months after surgery. Previously published quality programs that optimized perioperative multimodal analgesia (MMA) regimens, provider education, patient education, and shared decision making successfully reduced the proportion of patients discharged with opioid prescriptions to less than 5% following thyroid and parathyroid surgery. STUDY DESIGN: This quasi-experimental, quality improvement study compares opioid discharge prescribing practices before and after implementation of the quality improvement bundle. The quality improvement bundle includes patient education, provider education, and EHR enhancements. Patients who undergo a thyroidectomy or parathyroidectomy procedure will be included in the study. The historical control group includes patients treated prior to bundle implementation. The post-implementation group includes patients treated within 4 to 6 months following bundle implementation. The primary outcome is the proportion of patients who receive new opioid discharge prescriptions at discharge following a thyroidectomy or parathyroidectomy procedure. This outcome excludes the continuation of previous, chronic opioid therapy.
Interventions
The quality improvement bundle consists of (1) patient education, (2) provider education, and (3) EHR enhancements including order sets and best practice alerts.
Sponsors
University of Houston
The Methodist Hospital Research Institute
Study design
Allocation
NON_RANDOMIZED
Intervention model
SEQUENTIAL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Intervention model description
The study consists of 2 groups: (1) the historical control group and (2) the post-implementation group. The historical control group includes 160 patients who underwent a thyroidectomy or a parathyroidectomy procedure from January 2018 to December 2019 (20 patients randomly sampled from each quarter prior to bundle implementation). The quality improvement bundle will be implemented at Houston Methodist Hospital in June 2021. The post-implementation group will include the first 80 eligible patients accrued over 4 to 6 months following bundle implementation. An estimated sample size of 80 patients in the post-implementation group and 160 patients in the historical control group will provide 80% power to detect an absolute decrease of 20% in the primary endpoint using a two-sided alpha of 0.05.
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Adult patients undergoing a primary thyroidectomy or parathyroidectomy procedure at Houston Methodist Hospital during the study period. Only index surgeries during the study time frame were included.
Exclusion criteria
* Patients with a hospital length of stay after surgery \>2 days
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| New Opioid Discharge Prescriptions | Up to 2 days | Proportion of patients who receive new opioid discharge prescriptions at discharge following a thyroidectomy or parathyroidectomy procedure. This outcome excludes continuation of previous, chronic opioid therapy. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Opioid Discharge Prescriptions Exceeding 112.5 Oral Morphine Milligram Equivalents (MMEs) | Up to 2 days | Proportion of thyroidectomy and parathyroidectomy postoperative patients with opioid discharge prescriptions exceeding the recommended dose of 112.5 oral MMEs |
| Opioid Discharge Prescriptions Exceeding 5 Days | Up to 2 days | Proportion of thyroidectomy and parathyroidectomy postoperative patients with opioid discharge prescriptions exceeding 5 days of therapy |
| New Opioid Prescriptions From the Surgeon's Office Within 7 Days of Surgery | Up to 7 days | Proportion of thyroidectomy and parathyroidectomy postoperative patients who receive new opioid prescriptions from the surgeon's office within 7 days of surgery including discharge prescriptions. This outcome excludes continuation of previous, chronic opioid therapy. |
| Opioid Prescriptions Exceeding 50 Oral MMEs/Day When New Discharge Prescriptions Are Added to Existing Opioid Therapy | Up to 2 days | Proportion of thyroidectomy and parathyroidectomy postoperative patients with opioid prescriptions exceeding 50 oral MMEs/day when new, postoperative discharge prescriptions are added to existing opioid therapy |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Historical Control Group The historical control group underwent a thyroidectomy or parathyroidectomy procedure prior to implementation of the quality improvement bundle. | 160 |
| Post-implementation Group The post-implementation group underwent a thyroidectomy or parathyroidectomy procedure after bundle implementation and received care that is enhanced by the quality improvement bundle.
Quality improvement bundle: The quality improvement bundle consists of (1) patient education, (2) provider education, and (3) EHR enhancements including order sets and best practice alerts. | 80 |
| Total | 240 |
Baseline characteristics
| Characteristic | Total | Post-implementation Group | Historical Control Group |
|---|---|---|---|
| Age, Continuous | 57 years STANDARD_DEVIATION 14 | 57 years STANDARD_DEVIATION 14 | 56 years STANDARD_DEVIATION 14 |
| Ethnicity (NIH/OMB) Hispanic or Latino | 35 Participants | 14 Participants | 21 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 205 Participants | 66 Participants | 139 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Opioid use within 1 week prior to surgery | 10 Participants | 2 Participants | 8 Participants |
| Race/Ethnicity, Customized Race Asian | 16 Participants | 6 Participants | 10 Participants |
| Race/Ethnicity, Customized Race Black or African American | 56 Participants | 23 Participants | 33 Participants |
| Race/Ethnicity, Customized Race Other | 10 Participants | 2 Participants | 8 Participants |
| Race/Ethnicity, Customized Race White | 158 Participants | 49 Participants | 109 Participants |
| Sex: Female, Male Female | 197 Participants | 65 Participants | 132 Participants |
| Sex: Female, Male Male | 43 Participants | 15 Participants | 28 Participants |
| Surgery performed Parathyroidectomy | 121 Participants | 39 Participants | 82 Participants |
| Surgery performed Thyroidectomy | 136 Participants | 46 Participants | 90 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 0 | 0 / 0 |
| other Total, other adverse events | 0 / 0 | 0 / 0 |
| serious Total, serious adverse events | 0 / 0 | 0 / 0 |
Outcome results
Primary
New Opioid Discharge Prescriptions
Proportion of patients who receive new opioid discharge prescriptions at discharge following a thyroidectomy or parathyroidectomy procedure. This outcome excludes continuation of previous, chronic opioid therapy.
Time frame: Up to 2 days
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Control Group | New Opioid Discharge Prescriptions | 128 Participants |
| Post-implementation Group | New Opioid Discharge Prescriptions | 28 Participants |
Secondary
New Opioid Prescriptions From the Surgeon's Office Within 7 Days of Surgery
Proportion of thyroidectomy and parathyroidectomy postoperative patients who receive new opioid prescriptions from the surgeon's office within 7 days of surgery including discharge prescriptions. This outcome excludes continuation of previous, chronic opioid therapy.
Time frame: Up to 7 days
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Control Group | New Opioid Prescriptions From the Surgeon's Office Within 7 Days of Surgery | 0 Participants |
| Post-implementation Group | New Opioid Prescriptions From the Surgeon's Office Within 7 Days of Surgery | 0 Participants |
Secondary
Opioid Discharge Prescriptions Exceeding 112.5 Oral Morphine Milligram Equivalents (MMEs)
Proportion of thyroidectomy and parathyroidectomy postoperative patients with opioid discharge prescriptions exceeding the recommended dose of 112.5 oral MMEs
Time frame: Up to 2 days
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Control Group | Opioid Discharge Prescriptions Exceeding 112.5 Oral Morphine Milligram Equivalents (MMEs) | 52 Participants |
| Post-implementation Group | Opioid Discharge Prescriptions Exceeding 112.5 Oral Morphine Milligram Equivalents (MMEs) | 8 Participants |
Secondary
Opioid Discharge Prescriptions Exceeding 5 Days
Proportion of thyroidectomy and parathyroidectomy postoperative patients with opioid discharge prescriptions exceeding 5 days of therapy
Time frame: Up to 2 days
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Control Group | Opioid Discharge Prescriptions Exceeding 5 Days | 27 Participants |
| Post-implementation Group | Opioid Discharge Prescriptions Exceeding 5 Days | 5 Participants |
Secondary
Opioid Prescriptions Exceeding 50 Oral MMEs/Day When New Discharge Prescriptions Are Added to Existing Opioid Therapy
Proportion of thyroidectomy and parathyroidectomy postoperative patients with opioid prescriptions exceeding 50 oral MMEs/day when new, postoperative discharge prescriptions are added to existing opioid therapy
Time frame: Up to 2 days
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Historical Control Group | Opioid Prescriptions Exceeding 50 Oral MMEs/Day When New Discharge Prescriptions Are Added to Existing Opioid Therapy | 9 Participants |
| Post-implementation Group | Opioid Prescriptions Exceeding 50 Oral MMEs/Day When New Discharge Prescriptions Are Added to Existing Opioid Therapy | 0 Participants |