K. Piper1, K. J. Baxter1, M. Wetzel3, C. McCracken3, C. Travers3, B. Slater4, S. B. Cairo5, D. H. Rothstein5,9, R. Cina6, M. Dassinger7, P. Bonasso7, A. M. Lipskar8, N. Denning8, K. F. Heiss1, M. V. Raval2 1Emory University School Of Medicine,Division Of Pediatric Surgery, Department Of Surgery, Children’s Healthcare Of Atlanta,Atlanta, GA, USA 2Feinberg School Of Medicine – Northwestern University,Department Of Surgery, Division Of Pediatric Surgery, Ann & Robert H. Lurie Childen’s Hospital Of Chicago,Chicago, IL, USA 3Emory University School Of Medicine,Department Of Pediatrics, Children’s Healthcare Of Atlanta,Atlanta, GA, USA 4The University of Chicago Medical Center,Department Of Pediatric Surgery,Chicago, IL, USA 5John R. Oishei Children’s Hospital of Buffalo,Department Of Pediatric Surgery,Buffalo, NY, USA 6Medical University Of South Carolina,Division Of Pediatric Surgery,Charleston, SC, USA 7University of Arkansas for Medical Sciences,Department Of Pediatric Surgery,Little Rock, AR, USA 8Zucker School of Medicine at Hofstra/Northwell,Division Of Pediatric Surgery, Department Of Surgery, Cohen Children’s Medical Center,New Hyde Park, NY, USA 9University at Buffalo Jacobs School of Medicine,Department Of Surgery,Buffalo, NY, USA
Introduction: Surgical procedures early in life may serve as an initial contact with opioids and contribute to the current opioid epidemic in the United States. Educating adult surgical providers about their opioid prescribing practices has been shown to reduce overprescribing following a variety of procedures. Our objective was to improve opioid stewardship for umbilical hernia repair in children.
Methods: An educational presentation intervention was conducted at 6 centers with 52 surgeons. The presentation highlighted the importance of opioid stewardship, demonstrated practice variation, provided prescribing guidelines, encouraged non-opioid analgesics and limiting doses/strength if opioids were prescribed. Three months of pre- and post-intervention prescribing practices for umbilical hernia repair were compared.
Results: A total of 224 patients were identified in the pre-intervention cohort (median age = 5 years) and 218 in the post-intervention cohort (median age = 5 years). Baseline opioid use varied from 22% of patients to 100% across the 6 centers. Overall, the percent of patients receiving narcotics at discharge decreased after the intervention from 73.2% to 45.4% (p < 0.001). After adjusting for age, sex, umbilicoplasty, and hospital site, the odds ratio for opioid prescribing in the post-intervention period versus the pre-period was 0.28 (p < 0.001; 95% confidence interval (CI) = 0.18-0.45). There was no evidence for the intervention having hospital-specific effects (p = 0.77). All hospitals demonstrated improved opioid stewardship with the magnitude of the decrease in percent of patients prescribed opioids ranging from 24% to 100% (Figure). Among patients receiving narcotics, the number of doses prescribed decreased slightly after the intervention (median doses 12.4 to 10, p = 0.002), and the morphine equivalents per kg per dose decreased (median 0.14 to 0.10, p < 0.001). Among the entire cohort of patients, the total number of doses prescribed decreased by 50% when compared with the number that would have been prescribed before the educational intervention. No patients required a refill (pre- or post-intervention) and there were no differences in returns to clinic or emergency departments or hospital readmissions.
Conclusion: Opioid stewardship can be improved after pediatric umbilical hernia repair using a low-fidelity educational intervention. Pediatric surgeons appear receptive to these efforts supporting expansion to more procedures and populations.
