Breast
Sudheer Vemuru, MD
Resident
University of Colorado Anschutz Medical Center
Aurora, Colorado, United States
Sudheer Vemuru, MD
Resident
University of Colorado Anschutz Medical Center
Aurora, Colorado, United States
Vanessa Richardson, MS
Instructor
University of Colorado School of Public Health, United States
Evan Carey, PhD, MS
Associate Professor
University of Colorado School of Public Health, United States
Victoria Huynh, MD
Resident
University of Colorado School of Medicine, Department of Surgery, United States
Madeline Huey, MD
Resident
University of Colorado School of Medicine, Department of Surgery, United States
Monica Adams, MA
Graduate Research Assistant
University of Colorado Denver, United States
Nicole Christian, MD
Assistant Professor
University of Colorado School of Medicine, Department of Surgery, United States
Gretchen Ahrendt, MD
Professor
University of Colorado School of Medicine, Department of Surgery
Aurora, Colorado, United States
Inge Tamm-Daniels, MD
Associate Professor
University of Colorado School of Medicine, Department of Anesthesiology, United States
Christodoulos Kaoutzanis, MD
Associate Professor
University of Colorado School of Medicine, Department of Surgery, United States
Ethan Cumbler, MD
Professor
University of Colorado Anschutz Medical Campus, United States
Sarah E.A. Tevis, MD
Associate Professor
University of Colorado School of Medicine, United States
Implementation of standardized prescribing guidelines has shown promise in reducing excess opioid pills prescribed at discharge after surgery. In January 2021, the University of Colorado breast surgery multidisciplinary team implemented pathways to standardize preoperative, postoperative, and discharge analgesic orders for patients who underwent breast surgery. In this study, we evaluated the impact of these pathways on opioid prescribing at discharge after breast surgery.
Methods: We performed a retrospective analysis of adult female patients who underwent excisional biopsy, lumpectomy, or mastectomy with or without reconstruction between January 2018 and December 2022. Patients with a documented history of chronic opioid use or liver or kidney disease were excluded. Patients were divided into three groups: prior to implementation (January 2018-December 2020), during implementation (January 2021-November 2021), and after implementation (December 2021-December 2022). Outcomes of interest were morphine dose equivalents (MDE) prescribed at discharge and proportion of patients discharged without opioids. We utilized an interrupted time series analysis using negative binomial models under a Bayesian framework to identify the association between exposure to the pathways and discharge opioid prescribing.
Results: The study cohort included 2,366 cases: 1163 prior to implementation, 570 during implementation, and 633 after implementation. Prior to implementation, there was a downtrend in average discharge MDE from 2018 to 2020. Once the pathways were implemented, there were additional decreases beyond what was expected if pre-implementation trends continued for average MDE prescribed (Figure 1) and the proportion of patients receiving zero opioids. During implementation, the proportion of patients receiving zero opioids was 0.15 (95% CI: 0.09-0.22) higher than what was expected based on the pre-implementation trend. After implementation, the average MDE at discharge was 16.57 lower (95% CI: 0.5-35.2) and the proportion of patients receiving zero opioids was 0.26 (95% CI: 0.19- 0.32) higher than what was expected based on the pre-implementation trend.
Conclusions: Implementation of standardized perioperative analgesic pathways for patients undergoing breast surgery was associated with a reduction in opioids prescribed at discharge. These pathways may be effective in influencing surgeons’ opioid prescribing habits. Further work is needed to evaluate the impact of these pathways on outpatient opioid refill requests and patients’ quality of life.