The Daily Briefing's Aly Seidel sat down with Sarah Kampman, a managing director with the Advisory Board Company's Research and Development team, and Julie Riley, a senior consultant with the Advisory Board's Physician Executive Council, to talk about how hospitals can improve their opioid prescribing practices.
There seems to be a growing consensus that opioid misuse is a problem that needs to be addressed. Just a few weeks ago, FDA announced it would overhaul its painkiller approval policy, and many providers say they're recommending alternative methods of pain management to their patients. What does the research say about managing opioid use—and patient pain—at the inpatient level?
Sarah Kampman: From an objective perspective, we see huge amounts of opportunity for providers to improve their practices and cut down on unnecessary opioid use. We ran a study looking at data from more than 400 Crimson Continuum of Care hospitals on 17 different common inpatient conditions—from cesarean and vaginal deliveries to spine surgeries, bowel surgeries, and knee and hip replacements—that all require some amount of pain medication.
What we found when we looked within our database was that, even stratified within a particular condition and a particular kind of patient, there are dramatic differences between hospitals in terms of which medications they prescribe, the dosage, and the days when patients are receiving them.
Learn more: How your system can save over $1M by decreasing opioid usage
For patients within the same diagnosis-related group, some hospitals use very few opioids; instead, they're using a multi-modal pain regimen that depends on a variety of non-narcotic pain medications.
But at the other end, you've got some hospitals in which nearly every patient of that type gets very high doses of opioids.
Q: Why is that a problem?
Kampman: We saw a big difference in both complications and length of stay in patients who received higher dosages of opioids. There were many opioid-related complications: The big two were gastrointestinal complications and respiratory complications—the most severe of which was respiratory failure.
Julie Riley: There are big benefits to multi-modal pain management. You can reduce the number of patients who receive high dosages of opioids, which can prevent complications and reduce length of stay.
Kampman: These complications can be costly. Our analysis also showed that clinical leaders can maximize savings by prioritizing where they implement multi-modal approaches to reduce high-dose opioids—with major small and large bowel procedures being the biggest opportunity. Each additional complication after major bowel procedures raises charges by over $70,000.
In fact, we estimate that the average 250-bed facility can reduce unreimbursed charges by more than $1 million dollars per year by reducing opioid use in these surgeries.
We also heard from several of our top-performing members that the lower opioid doses allowed patients to begin physical therapy sooner—even the day after surgery. Alert, engaged patients are able to participate in their own recovery, which speeds time to discharge.
Riley: This is especially true for joint replacement—many organizations are building pathways that have patients start physical therapy the same day as their surgery. Opioids can make patients too sleepy to participate, so using multi-modal regimens can reduce reliance on opioids. So pain management can have a big impact on adherence to the rest of the pathway.
Q: If complications are so prevalent with opioids, why are hospitals still relying on them in surgery?
Kampman: Basic opioids—such as fentanyl and morphine—are so frequently used that it's easy to forget that these medications that get dispensed every day to almost every surgical patient have pretty significant clinical side effects.
But the multi-modal approach isn't opioid dependent. The leading-edge health systems we talked with prefer to use many different classes of drugs in tandem—peripheral nerve block, NSAIDs, local anesthesia. The idea is that you layer the types of pain medication and get ahead of the pain while lowering the complications that come from opioids.
Q: So if decreasing opioid use can save money and reduce complications, why aren't more hospitals implementing multi-modal pain regimens?
Kampman: I think there are lots of different stakeholders involved in these decisions. That can make it difficult to identify how much variation exists within a system, or even within a particular area. A couple of people in finance may realize that there's a high amount of spending, the pharmacy folks may see certain drugs being ordered more often—but there might not be a channel for surfacing these observations with providers.
Riley: This implementation challenge is on the clinical side, too: The anesthesiologist, the surgeon, other clinicians—there are just so many different people involved in pain management at each part of the care pathway. Even when a single care protocol exists, establishing adherence across different stakeholder groups can be difficult.
Q: Let's switch tracks for a moment and talk about pain. How do multi-modal regimens measure up to opioids when it comes to decreasing patients' post-operative pain?
Kampman: Multi-modal approaches aren't new, and aren't restricted to just a couple of hospitals. Lots of providers use them, because a carefully designed regimen can work just as well as one that depends on narcotics. But communication matters, too. A few of the surgeons we talked with stressed the importance of setting expectations. Some surgeons are uncomfortable talking with patients about pain ahead of time. Everybody would love to believe that their patients will be pain-free, but that isn't realistic. Surgeons need to set the expectation with patients that they'll be in pain, it'll be managed as well as possible, and they'll get past it. That communication can help lessen patient-requested increases in medication, but can also help set the stage for starting physical therapy as soon as possible.
Q: So what should surgeons be taking away from your research?
Kampman: There are a couple of recommendations that make sense for everybody, such as setting the expectations around pain management and ensuring that there's a process in place to get ahead of pain, so that patients aren't entering into crisis mode.
Ultimately, hospitals have to analyze their own needs. Our research can be very helpful there, but I don't think that we can dictate or will know what the outcome will be for a specific provider.
My recommendation would be to bring together all the surgeons within an area to compare notes, to see what the others are using, what their outcomes look like.
I think that care is a very local thing in some ways: It might be standardized across the hospital or the system, but in order for changes to stick and be effective, the surgeons themselves should be very involved in the process.
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