Opioid-free surgery in the midst of a crisis — 3 insights from Dr. Dan Low

Researchers at Seattle Children's and the University of Washington published a series of papers examining opioid-free surgery in the context of the opioid crisis.

Dan Low, MD, chief medical officer of MDmetrix and one of the research authors, told Becker's ASC Review how his team leveraged real-world outcomes data to learn and improve care for pediatric tonsillectomy and adenotonsillectomy surgery patients.

Note: Responses were lightly edited for length and style.

Question: According to your study published in Pediatric Anesthesia, Bellevue (Wash.) Surgery Center decreased the percentage of pediatric T&A patients receiving perioperative morphine from 100 percent to 20 percent. How does this reduction affect the ASC and its patients?

Dr. Dan Low: For clarification, the percentage of [pediatric T&A] patients administered morphine in the perioperative period did indeed drop from 100 percent to 20 percent. It should be noted that the intraoperative administration of morphine went from 100 percent to 0 percent during this time; the percentage of patients needing morphine in the postoperative period was just under 20 percent.

I believe that payers are increasingly concerned about the impacts of the opioid crisis, and that many would welcome opportunities to reduce opioid usage. I recently met the leader of a health insurance company on the East Coast who is very interested in partnering to reduce opioid usage and dependency.

Our evidence so far indicates that reducing opioid usage has been positive for patients' care experience. The most common side effect of anesthesia is postoperative nausea and vomiting. The incidence we report now is less than 0.5 percent, [which] compares extremely favorably against the literature where incidences in excess of 30 percent have been reported. The safety data is in line with the published evidence. It shows the new protocol is as safe as the old protocol, as measured by the return-to-operating-room rate within 30 days (remains below 1 percent).

Q: How can other ASCs apply the findings of this study at their own centers? What actions should they take?

DL: There are at least four ways that ASCs around the country should apply our study. First, I think it's vital to realize that opioids may not be as "necessary" for surgery as we've all been assuming for decades. With the ongoing opioid crisis — and now with evidence indicating 5 percent of surgery patients become persistent opioid users — this study should encourage us all to be open to the possibility of new approaches. This is a true paradigm shift for anesthesia and surgical practice in the U.S.

Second, and more specifically, this study adds weight to previous studies describing the efficacy and safety of dexmedetomidine and ketorolac for outpatient pediatric tonsillectomies.

Third, this study highlights the importance of using real-world data to evaluate the effectiveness of drug protocols. Of course, clinicians have long recognized the gap between trial-reported "efficacy" and real-world "effectiveness." In our study, we used MDmetrix's data analytics software to understand our patients' actual experience as we steadily improved our approach to care. Every clinician should have quick and easy access to data across their patients, so they can best understand what is most effective in their own particular practice environments.

Fourth, we all know how hard it can be to persuade physicians to change their long-established practices. Working through this improvement initiative, however, we had a critical insight: When physicians can easily see and review their patients' data, they can be confident that a "change" is truly an "improvement." All physicians want to provide the best possible care to their patients, and we can improve care by giving clinicians the data analytics tools they need to determine what actually works best for their real-world patient population.

Q: Do other studies or publications reinforce the study's key findings? 

Several older studies do reinforce the finding that pediatric T&As utilizing dexmedetomidine and ketorolac provide effective analgesia without increasing recovery times or reoperation rates:

  • Olutoye OA, Glover CD, Diefenderfer JW, et al. The effect of intraoperative dexmedetomidine on postoperative analgesia and sedation in pediatric patients undergoing tonsillectomy and adenoidectomy. Anesth Analg. 2010;111(2):490‐495.
  • Chan DK, Parikh SR. Perioperative ketorolac increases post‐tonsillectomy hemorrhage in adults but not children. Laryngoscope. 2014;124:1789‐1793.

Given these previous studies, why hasn't our practice in this country shifted more quickly toward an opioid-sparing approach for T&As? Historically, a key inhibitor of physician adoption of research findings has been that physicians were unable to see how a change in protocol actually affects outcomes outside a tightly scripted clinical trial environment. 

For our work, we used MDmetrix software to give clinicians the easy visibility into their own real-world data that they needed in order to feel confident shifting away from their established protocols. ASC leaders and quality improvement leaders need to realize that it's not enough just to share the results of clinical studies like ours with their clinicians. To really engage their clinicians, a best practice is to provide them meaningful access to data in a way that allows them to quickly look across their patients to evaluate the effectiveness of specific practices in their own clinical environment.

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ASCs, value-based care and the race to the bottom: key thoughts on what makes a winning bundled payment

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