Alexander S. Chiu

Trainees as Agents of Change in the Opioid Epidemic: Optimizing the Opioid Prescription Practices of Surgical Residents

OBJECTIVEnOpioid abuse has become an epidemic in the United States, causing nearly 50,000 deaths a year. Postoperative pain is an unavoidable consequence of most surgery, and surgeons must balance the need for sufficient analgesia with the risks of overprescribing. Prescribing narcotics is often the responsibility of surgical residents, yet little is known about their opioid-prescribing habits, influences, and training experience.nnnDESIGNnAnonymous online survey that assessed the amounts of postoperative opioid prescribed by residents, including type of analgesia, dosage, and number of pills, for a series of common general surgery procedures. Additional questions investigated influences on opioid prescription, use of nonnarcotic analgesia, degree of engagement in patient education on opioids, and degree of training received on analgesia and opioid prescription.nnnSETTINGnAccreditation Council for Graduate Medical Education accredited general surgery program at a university-based tertiary hospital.nnnPARTICIPANTSnCategorical and preliminary general surgery residents of all postgraduate years.nnnRESULTSnThe percentage of residents prescribing opioids postprocedure ranged from 75.5% for incision and drainage to 100% for open hernia repair. Residents report prescribing 166.3 morphine milligram equivalents of opioid for a laparoscopic cholecystectomy, yet believe patients will only need an average of 113.9 morphine milligram equivalents. The most commonly reported influences on opioid-prescribing habits include attending preference (95.2%), concern for patient satisfaction (59.5%), and fear of potential opioid abuse (59.5%). Only 35.8% of residents routinely perform a narcotic risk assessment before prescribing and 6.2% instruct patients how to properly dispose of excess opioids. More than 90% of residents have not had formal training in best practices of pain management or opioid prescription.nnnCONCLUSION AND RELEVANCEnSurgical trainees are relying almost exclusively on opioids for postoperative analgesia, often in excessive amounts. Residents are heavily influenced by their superiors, but are not receiving formal opioid-prescribing education, pointing to a great need for increased resident education on postoperative pain and opioid management to help change prescribing habits.

Association of Lowering Default Pill Counts in Electronic Medical Record Systems With Postoperative Opioid Prescribing

Importance Reliance on prescription opioids for postprocedural analgesia has contributed to the opioid epidemic. With the implementation of electronic medical record (EMR) systems, there has been increasing use of computerized order entry systems for medication prescriptions, which is now more common than handwritten prescriptions. The EMR can autopopulate a default number of pills prescribed, and 1 potential method to alter prescriber behavior is to change the default number presented via the EMR system. Objective To investigate the association of lowering the default number of pills presented when prescribing opioids in an EMR system with the amount of opioid prescribed after procedures. Design, Setting, and Participants A prepost intervention study was conducted to compare postprocedural prescribing patterns during the 3 months before the default change (February 18 to May 17, 2017) with the 3 months after the default change (May 18 to August 18, 2017). The setting was a multihospital health care system that uses Epic EMR (Hyperspace 2015 IU2; Epic Systems Corporation). Participants were all patients in the study period undergoing 1 of the 10 most common operations and discharged by postoperative day 1. Intervention The default number of opioid pills autopopulated in the EMR when prescribing discharge analgesia was lowered from 30 to 12. Main Outcomes and Measures Linear regression estimating the change in the median number of opioid pills and the total dose of opioid prescribed was performed. Opioid doses were converted into morphine milligram equivalents (MME) for comparison. The frequency of patients requiring analgesic prescription refills was also evaluated. Results There were 1447 procedures (mean [SD] age, 54.4 [17.3] years; 66.9% female) before the default change and 1463 procedures (mean [SD] age, 54.5 [16.4] years; 67.0% female) after the default change. After the default change, the median number of opioid pills prescribed decreased from 30 (interquartile range, 15-30) to 20 (interquartile range, 12-30) per prescription (Pu2009<u2009.001). The percentage of prescriptions written for 30 pills decreased from 39.7% (554 of 1397) before the default change to 12.9% (183 of 1420) after the default change (Pu2009<u2009.001), and the percentage of prescriptions written for 12 pills increased from 2.1% (29 of 1397) before the default change to 24.6% (349 of 1420) after the default change (Pu2009<u2009.001). Regression analysis demonstrated a decrease of 5.22 (95% CI, −6.12 to −4.32) opioid pills per prescription after the default change, for a total decrease of 34.41 (95% CI, −41.36 to −27.47) MME per prescription. There was no statistical difference in opioid refill rates (3.0% [4 of 135] before the default change vs 1.5% [2 of 135] after the default change, Pu2009=u2009.41). Conclusions and Relevance Lowering the default number of opioid pills prescribed in an EMR system is a simple, effective, cheap, and potentially scalable intervention to change prescriber behavior and decrease the amount of opioid medication prescribed after procedures.

Regional variation in breast cancer surgery: Results from the National Cancer Database (NCDB)

BACKGROUNDnEarly studies have shown significant regional differences in the utilization of breast-conserving therapy (BCT) and mastectomy with reconstruction. It is expected that with the passage of time and the adoption of national treatment guidelines, these disparities would disappear.nnnMETHODSnPatients with non-metastatic breast cancer who underwent surgery between 2004 and 2013 were analyzed using the National Cancer Database (NCDB). Trends in BCT and reconstruction were evaluated and multivariate logistic regression performed.nnnRESULTSnThe highest rate of BCT was in New England (69%) and the lowest in East South Central (49%), pxa0<xa00.001. The rate of reconstruction was highest in the Middle Atlantic (44%) and the lowest in East South Central (26%), pxa0<xa00.001. Compared to East South Central, the odds ratio (OR) for BCT in New England was 2.2 (95% CI 2.1-2.3), and the OR for reconstruction in Middle Atlantic was 1.7 (95% CI 1.6-1.8).nnnCONCLUSIONnThere continue to be significant regional differences in breast surgery.

Trends of ureteral stent usage in surgery for diverticulitis

BACKGROUNDnMany believe that the use of ureteral stents in colorectal surgery for diverticulitis aids prevention and easier identification of ureteral injuries; others argue that the added time, cost, and risks of stent placement negate potential benefits. Even among providers who use stents, selective use is common. Among unclear consensus, it remains unknown if the use of stents is growing.nnnMATERIALSnPatients in the National Inpatient Sample who underwent a partial colectomy or anterior rectal excision for diverticulitis between 2000 and 2013 were included (nxa0=xa0811,071). Trends in ureteral stent use, multivariate logistic regression of factors influencing stent placement, and linear regression of length of stay (LOS) and costs associated with stent use were examined.nnnRESULTSnUsage of ureteral stents increased from 6.66% in 2000 to 16.30% in 2013 (Pxa0<xa00.0001). Rates of stent usage were higher with laparoscopic surgery (19.31% versus 12.31% open, Pxa0<xa00.0001). Regression demonstrated patients in the Northeast (Midwest odds ratio (OR) 0.49 [0.37-0.66] Pxa0<xa00.0001, South OR 0.60 [0.45-0.80] Pxa0=xa00.0004, West OR 0.30 [0.22-0.41], Pxa0<xa00.0001), and those whose admission was elective (OR 2.37 [2.08-2.69], Pxa0<xa00.0001) were more likely to receive stents. Stent use was associated with an increased LOS (0.55xa0days, Pxa0<xa00.0001) and cost (

US Public Perceptions About Cancer Care Provided by Smaller Hospitals Associated With Large Hospitals Recognized for Specializing in Cancer Care

1,983, Pxa0<xa00.0001).nnnCONCLUSIONSnThe use of ureteral stents in surgery for diverticulitis has steadily increased since 2000, despite the lack of consensus of their overall benefit. Stent usage is associated with laparoscopic surgery and varies widely among regions of the country. Further studies are required to truly understand the risk-benefit ratio of ureteral stenting and to determine if its increased use is warranted.

Recurrent Falls Among Elderly Patients and the Impact of Anticoagulation Therapy

US Public Perceptions About Cancer Care Provided by Smaller Hospitals Associated With Large Hospitals Recognized for Specializing in Cancer Care Over the past 5 years, smaller hospitals have developed formal relationships with larger hospitals at a historic rate, with more than 100 new mergers, acquisitions, and affiliations being filed each year in the United States.1,2 Applying the brand of a larger hospital to smaller, affiliated hospitals has become commonplace.3 This brand sharing has the potential to influence patient decisions about where to pursue care, particularly for complex conditions such as cancer.4 However, the extent to which patients perceive the care at the smaller hospitals to be affected by affiliation is unclear. In an effort to understand patient expectations associated with brand sharing for complex cancer care at smaller hospitals, we surveyed a nationally representative sample in the United States.

Primary Salivary Type Lung Cancers in the National Cancer Database

BackgroundFalls are the leading source of injury and trauma-related hospital admissions for elderly adults in the USA. Elderly patients with a history of a fall have the highest risk of falling again, and the decision on whether to continue anticoagulation after a fall is difficult. To inform this decision, we evaluated the rate of recurrent falls and the impact of anticoagulation on outcomes.MethodsAll patients of age u2009≥u200965 years and hospitalized for a fall in the first 6 months of 2013 and 2014 were identified in the nationwide readmission database, a nationally representative all-payer database tracking patient readmissions. Readmissions for a recurrent fall within 6 months, and mortality and bleeding injuries (intracranial hemorrhage, solid organ bleed, and hemothorax) during readmission were identified. Logistic regression evaluated factors associated with mortality on repeat falls.ResultsOf the 331,982 patients admitted for a fall, 15,565 (4.7%) were admitted for a recurrent fall within 6 months. The median time to repeat fall was 57 days (IQR 19–111 days), and 9.0% (1406) of repeat fallers were on anticoagulation. The rate of bleeding injury was similar regardless of anticoagulation status (12.8 vs. 12.7% not on anticoagulation, pu2009=u20090.97); however, among patients with a bleeding injury, those on anticoagulation had significantly higher mortality (21.5 vs. 6.9% not on anticoagulation, pu2009<u20090.01).ConclusionAmong patients hospitalized for a fall, 4.7% will be hospitalized for a recurrent fall within 6 months. Patients on anticoagulation with repeat falls do not have increased rates of bleeding injury but do have significantly higher rates of death with a bleeding injury. This information is essential to discuss with patients when deciding to restart their anticoagulation.

Delayed discharge does not decrease the cost of readmission after pulmonary lobectomy

BACKGROUNDnPrimary salivary type lung cancers such as adenoid cystic carcinoma (ACC) and mucoepidermoid carcinoma (MEC) are uncommon primary lung tumors that, given their rarity, remain incompletely understood. This study aimed to characterize the management and outcomes associated with these less common pulmonary malignancies.nnnMETHODSnPatients in the National Cancer Database diagnosed with primary lung and bronchial (not tracheal) MEC and ACC between 2004 and 2014 were identified. Adjusted mortality risk of surgically managed patients was evaluated in multivariable Cox proportional hazards regression models.nnnRESULTSnIn all, 699 MEC patients and 424 ACC patients were identified. The MEC tumors were smaller (mean size 3.1 cm versus 3.8 cm, p < 0.001), less likely to have lymph node metastases (16% versus 38%, p < 0.001), and less likely to undergo pneumonectomy (9% versus 39%, pxa0< 0.001) compared with ACC. Adjusted Cox models of the surgically managed subset of MEC patients identified high tumor grade (hazard ratio [HR] 3.0, 95% confidence interval [CI]: 1.31 to 7.1, pxa0= 0.01), tumor size greater than 4 cm (HR 6.7, 95% CI: 2.0 to 22.0, pxa0= 0.01), and wedge resection (HR 3.7, 95% CI: 1.1 to 12.0, pxa0= 0.03) to be associated with increased risk of death. For ACC patients, incomplete tumor resection, R1 versus R0 (HR 4.0, 95% CI: 1.5 to 10.6, pxa0= 0.006), and distant metastases (HR 12.6, 95% CI: 2.5 to 64.4, pxa0= 0.002) were associated with increased mortality.nnnCONCLUSIONSnPulmonary MEC and ACC appear to have distinct physical and oncologic attributes in the National Cancer Database. Although the overall prognosis appears to be favorable, there are subsets of primary salivary type lung cancers with increased mortality risk, and efforts should be made to completely resect these tumors.

When good operations go bad: The additive effect of comorbidity and postoperative complications on readmission after pulmonary lobectomy

Background: Readmission after pulmonary lobectomy has become a potentially avoidable source of excess health care costs. Initiatives that focus on expedited discharge after lobectomy may decrease costs, but a criticism of this approach is that expedited discharge may be associated with more frequent and more expensive readmissions. We explored whether patients are at greater risk for costly readmission after expedited discharge. Methods: The Nationwide Readmission Database was queried for cases of lobectomy for lung cancer between 2010 and 2014. Patients 65 years of age and older were categorized into three groups: patients discharged between hospital day 1 and 3 (expedited), between hospital days 4 and 7 (routine), or discharge after day 8 (late). Risk‐adjusted 90‐day readmission rates and hospital costs for readmission were compared among groups. Results: A total of 104,905 patients underwent lobectomy for lung cancer during the study period. There were 18,652 (17.8%) expedited discharges, 54,551 (52.0%) routine discharges, and 31,702 (30.2%) late discharges. Compared with the expedited group, patients in the routine discharge group had a 3.2% greater risk‐adjusted readmission rate (P < .0001), and patients in the late discharge group had 12.7% greater risk‐adjusted readmission rate (P < .0001). After adjustment, expedited discharge was associated with a

Spontaneous regionalization of esophageal cancer surgery: an analysis of the National Cancer Database

4,066 decrease in index hospital costs compared with routine discharge, and a