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Sokmen S, Bisgin T, Yildirim Y, Keskin AY, Dogan T, Sahin Bİ, Aydin C, Benek DE, Tiras HN, Arslangilay M, Aslangilay M, Yaytokgil M, Capar MA, Yazgan Y, Bektas S, Alagoz AC, Dagsali AE, Izgis A, Uzel K, Soytas M, Cakir N, Askin AE, Azboy I, Sabuncu K, Aslan M, Sahin M, Oncel M, Okkabaz N, Sivrikaya RK, Saylar A, Saylar A, Yasar M, Erginoz E, Bozkir HO, Zengin K, Ozcelik MF, Uludag SS, Ozdemir Z, Sibic O, Telci H, Bozkurt MA, Kara Y, Tepe MD, Gündoğdu A, Akın B, Pehlivan D, Guner A, Baysallar D, Yıldız B, Cepe H, Reis ME, Yuzgec AN, Kıralı N, Kodalak TA, Ulusahin M, Selim K, Kale A, Gecici ME, Ozbilen M, Düzyol Z, Gemici A, Korkmaz E, Şen E, Taşcı ME, Camkıran E, Elieyioğlu G, Kayabaş İ, Uprak TK, Aral C, Saraçoğlu A, Uğurlu MÜ, Baltacı ZH, Akkaya EN, Fergar C, Tabak EZ, Kocyigit GZ, Kayilioglu I, Polat S, Çolak E, Kara ME, Candan M, Uyanık MS, Sarı AC, Ulkucu A, Certel AT, Dindar A, Durdu B, Bayram C, Kaya E, Akdere H, Cakcak IE, Yavuz I, Omur M, Ajredini M, Aydoğdu EO, Şenödeyici E, Koksoy UC, Kazbek BK, Korkmaz DS, Yavuz D, Yilmaz H, Cetınkaya ZS, Durmus E, Tuzuner F, Hokelekli F, Mutlu M, Akbuz SO, Kus ZC, Kus ZC, Farrell M, Craig-Lucas A, Painter M, Titan A, Narayan A, Fariyike B, Knowlton L, Yue T, Benham E, Nimeri A, Werenski H, Kaiser N, Reinke C. Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries. Br J Surg 2024; 111:znad421. [PMID: 38207169 PMCID: PMC10783642 DOI: 10.1093/bjs/znad421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/29/2023] [Accepted: 12/05/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures. METHODS This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge. RESULTS The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not. CONCLUSION Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely.
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Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries. Br J Surg 2024; 111:znad370. [PMID: 38029386 PMCID: PMC10771257 DOI: 10.1093/bjs/znad370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/10/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. METHODS The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. RESULTS A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). CONCLUSION Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).
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