Can ERAS reduce postoperative opioid dependence?

August 7, 2018
Judith M. Orvos, ELS
Judith M. Orvos, ELS

a BELS-certified medical writer and editor, and an editorial consultant for Contemporary OB/GYN

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Ben Schwartz
Ben Schwartz

Ben Schwartz is Associate Editor, Contemporary OB/GYN.

To fight the opioid epidemic, ob/gyns, like all physicians, are looking for ways to help prevent substance use disorders and enhanced recovery programs (ERAS) could play a role. PLUS: Are EDs screening adolescents with PID for HIV, syphilis? ALSO: Results of a new retrospective study show that a woman’s race may impact how likely she is to have a myomectomy-and alarmingly, whether the procedure is likely to result in morbidity.

To fight the opioid epidemic, ob/gyns, like all physicians, are looking for ways to help prevent substance use disorders. One recent study, published in Obstetrics & Gynecology, sheds light on the role that enhanced recovery after surgery (ERAS) programs may play in this effort. 

For the study, the researchers compared perioperative outcomes with a focus on intraoperative and postoperative opioid consumption in women undergoing surgery before and after implementation of an ERAS program. The ERAS program was at the University of Texas MD Anderson Cancer Center. All 607 patients in the study underwent open gynecologic surgery, 74 before the ERAS pathway was in use and 533 after that point. Median patient age was 58 (range 18-85 years). 

The authors found that patients in the ERAS pathway had a 72% reduction in median opioid consumption from postoperative Day 0 to Day 3 compared to the pre-ERAS patients. In addition, 86 patients (16%) on the ERAS pathway were opioid-free from the first to third postoperative day compared to none of the pre-ERAS patients. 

Furthermore, despite the lower usage of opioids in the ERAS group, pain scores were not significantly higher (= .80). In the ERAS group, fatigue during the hospital stay was also lower (= .01), there was less interference with walking during hospitalization (= .003), and less total interference with work, activity, walking, enjoyment of life, mood, and relations with others during hospitalization (= .008). 

Median length of stay after surgery was 25% shorter in patients in the ERAS group (3 vs 4 days, < .001).Following hospital discharge, those patients had no or mild interference with walking at a median of 5 days (95% CI 2.2-7.8 days) compared to 13 days (95% CI 4.5-21.5 days, = .003) in the pre-ERAS group. 

 

The authors believe their findings illustrate the benefits of implementing ERAS with gynecologic procedures. Given the current opioid epidemic, their findings that decreasing opioid use during postoperative recovery did not affect pain scores or length of stay are particularly promising. They noted, however, that ERAS programs must be continuously audited for performance to ensure that patient care and ERAS pathway compliance remain high.

NEXT: Are EDs screening adolescents with PID for HIV, syphilis?

Are EDs screening adolescents with PID for HIV, syphilis?

Patients with pelvic inflammatory disease (PID) are known to be at increased risk for HIV and syphilis. But screening by hospitals for those two diseases in adolescents with PID may not be adequate, according to results of new research funded by the National Institutes of Child Health and Human Development.

Published in Pediatrics, the retrospective cohort study was performed by investigators from Washington, DC, using data from the Pediatric Health Information System (PHIS) for 2010 to 2015. PHIS is an administrative database containing data from 48 children’s hospitals in the United States affiliated with the Children’s Hospital Association. The hospitals are pediatric tertiary-care centers in 27 states, including the District of Columbia.

The researchers looked at all emergency department visits for female patients aged 12 to 21 with a diagnosis of PID to determine the frequency of HIV and syphilis screening in that population. They performed multivariable logistic regression analyses to identify factors associated with screening. 

Between 2010 and 2015, 10,698 cases of PID in adolescents were represented in the database. Mean age of the study population was 16.7 years. Of the adolescents, 70.5% were publicly insured and 54.2% were non-Hispanic African American. In 69.2% of cases, the patients were seen in larger-sized hospitals.

Twenty-two percent of the adolescents with PID were screened for HIV, 27.7% were screened for syphilis and 18.4% were screened for both HIV and syphilis. Rates of screening for HIV increased from 16.3% in 2010 to 26.1% in 2015 (P< .001) and rates of screening for syphilis increased from 22.9% in 2010 to 31.9% in 2015 (P< .001). During the study period, overall rates of HIV screening by hospital ranged from 2.6% to 60.4% and for syphilis screening from 2.9% to 62.2%. 

Multivariable logistic regression analyses showed that patients aged 12 to 16 were more likely to be screened for HIV than were the older adolescents, as were non-Hispanic African Americans. The same was the case for those who were not privately insured or who were uninsured. Visits that resulted in hospital admission or that occurred in smaller hospitals also were more likely to result in HIV screening. The same trends were seen for syphilis screening, with the exception of the relationship with hospital size.

The authors concluded that “when adolescents are diagnosed with PID, they are underscreened for HIV and syphilis, with a wide variability of screening rates across hospitals.” Limitations of their research, they said, were an inability to determine whether the patients had previously been diagnosed with HIV and reliance on coding of administrative data. 

While cautioning that the results may not be generalizable to adolescents treated in nonpediatric hospitals, the researchers said they suggest “an opportunity to improve HIV and syphilis screening in this population.” Their data, they believe, “could help inform development of innovative methods by which to improve screening among this high-risk population, including the implementation of electronic alerts, decision support, and clinical pathways through the electronic health record.” 

NEXT: Are myomectomy rates and outcomes linked to race?

Are myomectomy rates and outcomes linked to race?

Results of a new retrospective study show that a woman’s race may play a role in how likely she is to have a myomectomy-and alarmingly, whether the procedure is likely to result in morbidity. The findings, by investigators from the University of Pennsylvania, were published in Obstetrics & Gynecology.

Using data from the American College of Surgeons National Surgical Quality Improvement Program Database, the researchers identified 8,438 women undergoing myomectomy between January 1, 2012 and December 31, 2015. They used Current Procedural Terminology coding to determine myoma burden and approach to myomectomy. Surgical approach and perioperative morbidity in African-American, Asian-American, and Hispanic-American women were compared with that in non-Hispanic Caucasian women used as the referent population. 

Included in the study were data for 2,533 Caucasian, 3,359 African-American, 664 Asian-American, and 700 Hispanic-American women. Rates of hypertension, smoking status, body mass index (BMI), myoma burden, and anemia varied by race (< 0.001 for all comparisons). 

After adjusting for confounding factors (age, ethnicity, BMI, myoma burden, preoperative anemia, hypertension, smoking, and operative time), the researchers found that African-American women were twice as likely to undergo abdominal myomectomy (adjusted OR 1.9, 95% CI 1.7-2.0) than Caucasian women. Asian-American women were more than twice as likely (adjusted OR 2.3, 95% CI, 1.8-2.8) and Hispanic-American women were 50% more likely to undergo abdominal myomectomy (adjusted OR 1.5, 95% CI 1.2-1.9) than Caucasian women. 

In addition to increased likelihood of myomectomy, non-Caucasian women were also more likely to experience composite morbidity following abdominal myomectomy. African-American women were 50% more likely (adjusted OR 1.5, 95% CI 1.2-1.7) to experience composite morbidity compared to Caucasian women. Asian-American women were more than three times as likely (adjusted OR 1.5, 95% CI 1.2-1.7) to experience composite morbidity after laparoscopic myomectomy. There was no difference in composite morbidity in Hispanic-American women. 

The authors believe their research shows an increased likelihood that minority women will undergo abdominal myomectomy and increased odds of morbidity following surgery for them compared to Caucasian women. However, more research into the prevention and etiology of these disparities is necessar