Richard Frazee M.D.

Frazee, R., E. Garmon, C. Isbell, E. Bird and H. Papaconstantinou (2020). “Postoperative Opioid Prescription Reduction Strategy in a Regional Healthcare System.” J Am Coll Surg 230(4): 631-635.

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BACKGROUND: The CDC reported in 2017 that the largest increments in probability of continued use were observed after days 5 and 31 on opioid therapy. This study demonstrates the correlation between a system-wide pain management and opioid stewardship effort with reductions in discharge prescriptions for elective surgical patients. STUDY DESIGN: Discharge prescriptions were monitored through the electronic health record. Baseline prescribing patterns were established for the first quarter of 2018, preceding the first intervention in the multipronged opioid reduction initiative. Beginning in the second quarter of 2018, a series of pain management and opioid stewardship educational conferences were provided. Enhanced Recovery after Surgery protocols were simultaneously implemented system-wide. In the third quarter of 2018, a quality metric linked to compensation rewarded surgeons for limiting postoperative discharge prescriptions to 5 or fewer days. Opioid prescriptions were compared by quarter from January 2018 to March 2019 using chi-square and Kruskal-Wallis test with significance of p < 0.05. RESULTS: There were 31,814 patients who underwent elective surgical procedures during the study period. At baseline, the rate of postoperative opioid prescriptions of 5 or fewer days was 81%. This rate increased to 82%, 86%, 89%, and 92% in each successive quarter (p < 0.0001 for quarters 3 to 5). CONCLUSIONS: A system-wide, multipronged pain management and opioid reduction program significantly reduced opioid discharge prescriptions written for more than 5 days. This approach can serve as a model for other healthcare systems attempting to reduce opioid prescribing and combat the opioid crisis in the US.

Frazee, R., C. C. Burlew, J. Regner, R. McIntyre, E. Peltz, C. Cribari, J. Dunn, L. Butler, P. Reckard, S. Dissanaike, K. Karimi, C. Behnfield, N. Melo and D. Margulies (2017). “Outpatient laparoscopic appendectomy can be successfully performed for uncomplicated appendicitis: A southwestern surgical congress multicenter trial.” Am J Surg 214(6): 1007-1009.

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BACKGROUND: Many laparoscopic procedures are now performed on an outpatient basis. We hypothesize laparoscopic appendectomy can be safely performed as an outpatient procedure. METHODS: Seven institutions adopted a previously described outpatient laparoscopic appendectomy protocol for uncomplicated appendicitis. Patients were dismissed unless there was a clinical indication for admission. Patient demographics, success with outpatient management, time of dismissal, morbidity, and readmissions were analyzed. RESULTS: Two hundred six men and one hundred seventy women with a mean age of 35.4 years were included in the protocol. Seventy-eight patients (21%) had pre-existing comorbidities. 299 patients (80%) were managed as outpatients. There were no conversions to open appendectomy. Postoperative morbidity was 5%. The time of patient dismissals was evenly distributed throughout the day and night. Twelve patients (3%) required readmission. Outpatient follow-up occurred in 63% of patients. CONCLUSIONS: An outpatient laparoscopic appendectomy protocol was successfully applied at multiple institutions with low morbidity and low readmission rates. Application of this practice nationally could reduce length of stay and decrease overall health care costs for acute appendicitis.