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J Surg Res. 2018 Aug;228:160-169. doi: 10.1016/j.jss.2018.03.029. Epub 2018 Apr 11.

Utilization and effectiveness of multimodal discharge analgesia for postoperative pain management.

Author information

1
Department of Medicine, Stanford University, Stanford, California.
2
Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California.
3
Department of Medicine, Stanford University, Stanford, California; Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California.
4
Stanford School of Medicine, IRT Research Technology, Stanford, California.
5
Department of Surgery, VA Palo Alto Health Care System, Menlo Park, California; Department of Surgery, Stanford University, Stanford, California.
6
Department of Medicine, Stanford University, Stanford, California; Department of Surgery, Stanford University, Stanford, California; Department of Biomedical Data Science, Stanford University, Stanford, California. Electronic address: Boussard@stanford.edu.

Abstract

BACKGROUND:

Although evidence-based guidelines recommend a multimodal approach to pain management, limited information exists on adherence to these guidelines and its association with outcomes in a generalized population. We sought to assess the association between discharge multimodal analgesia and postoperative pain outcomes in two diverse health care settings.

METHODS:

We evaluated patients undergoing four common surgeries associated with high pain in electronic health records from an academic hospital (AH) and Veterans Health Administration (VHA). Multimodal analgesia at discharge was characterized as opioids in combination with acetaminophen (O + A) and nonsteroidal antiinflammatory (O + A + N) drugs. Hierarchical models estimated associations of analgesia with 45-d follow-up pain scores and 30-d readmissions.

RESULTS:

We identified 7893 patients at AH and 34,581 at VHA. In both settings, most patients were discharged with O + A (60.6% and 54.8%, respectively), yet a significant proportion received opioids alone (AH: 24.3% and VHA: 18.8%). Combining acetaminophen with opioids was associated with decreased follow-up pain in VHA (Odds ratio [OR]: 0.86, 95% confidence interval [CI]: 0.79, 0.93) and readmissions (AH OR: 0.74, CI: 0.60, 0.90; VHA OR: 0.89, CI: 0.82, 0.96). Further addition of nonsteroidal antiinflammatory drugs was associated with further decreased follow-up pain (AH OR: 0.71, CI: 0.53, 0.96; VHA OR: 0.77, CI: 0.69, 0.86) and readmissions (AH OR: 0.46, CI: 0.31, 0.69; VHA OR: 0.84, CI: 0.76, 0.93). In both systems, patients receiving multimodal analgesia received 10%-40% less opioids per day compared to opioids only.

CONCLUSIONS:

A majority of surgical patients receive a multimodal pain approach at discharge yet many receive only opioids. Multimodal regimen at discharge was associated with better follow-up pain and all-cause readmissions compared to the opioid-only regimen.

PMID:
29907207
PMCID:
PMC6476628
DOI:
10.1016/j.jss.2018.03.029
[Indexed for MEDLINE]
Free PMC Article

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