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. 2024 Jan 2;7(1):e2351689.
doi: 10.1001/jamanetworkopen.2023.51689.

Variation in Intraoperative Opioid Administration by Patient, Clinician, and Hospital Contribution

Affiliations

Variation in Intraoperative Opioid Administration by Patient, Clinician, and Hospital Contribution

Michael L Burns et al. JAMA Netw Open. .

Abstract

Importance: The opioid crisis has led to scrutiny of opioid exposures before and after surgical procedures. However, the extent of intraoperative opioid variation and the sources and contributing factors associated with it are unclear.

Objective: To analyze attributable variance of intraoperative opioid administration for patient-, clinician-, and hospital-level factors across surgical and analgesic categories.

Design, setting, and participants: This cohort study was conducted using electronic health record data collected from a national quality collaborative database. The cohort consisted of 1 011 268 surgical procedures at 46 hospitals across the US involving 2911 anesthesiologists, 2291 surgeons, and 8 surgical and 4 analgesic categories. Patients without ambulatory opioid prescriptions or use history undergoing an elective surgical procedure between January 1, 2014, and September 11, 2020, were included. Data were analyzed from January 2022 to July 2023.

Main outcomes and measures: The rate of intraoperative opioid administration as a continuous measure of oral morphine equivalents (OMEs) normalized to patient weight and case duration was assessed. Attributable variance was estimated in a hierarchical structure using patient, clinician, and hospital levels and adjusted intraclass correlations (ICCs).

Results: Among 1 011 268 surgical procedures (mean [SD] age of patients, 55.9 [16.2] years; 604 057 surgical procedures among females [59.7%]), the mean (SD) rate of intraoperative opioid administration was 0.3 [0.2] OME/kg/h. Together, clinician and hospital levels contributed to 20% or more of variability in intraoperative opioid administration across all analgesic and surgical categories (adjusting for surgical or analgesic category, ICCs ranged from 0.57-0.79 for the patient, 0.04-0.22 for the anesthesiologist, and 0.09-0.26 for the hospital, with the lowest ICC combination 0.21 for anesthesiologist and hosptial [0.12 for the anesthesiologist and 0.09 for the hospital for opioid only]). Comparing the 95th and fifth percentiles of opioid administration, variation was 3.3-fold among anesthesiologists (surgical category range, 2.7-fold to 7.7-fold), 4.3-fold among surgeons (surgical category range, 3.4-fold to 8.0-fold), and 2.2-fold among hospitals (surgical category range, 2.2-fold to 4.3-fold). When adjusted for patient and surgical characteristics, mean (square error mean) administration was highest for cardiac surgical procedures (0.54 [0.56-0.52 OME/kg/h]) and lowest for orthopedic knee surgical procedures (0.19 [0.17-0.21 OME/kg/h]). Peripheral and neuraxial analgesic techniques were associated with reduced administration in orthopedic hip (51.6% [95% CI, 51.4%-51.8%] and 60.7% [95% CI, 60.5%-60.9%] reductions, respectively) and knee (48.3% [95% CI, 48.0%-48.5%] and 60.9% [95% CI, 60.7%-61.1%] reductions, respectively) surgical procedures, but reduction was less substantial in other surgical categories (mean [SD] reduction, 13.3% [8.8%] for peripheral and 17.6% [9.9%] for neuraxial techniques).

Conclusions and relevance: In this cohort study, clinician-, hospital-, and patient-level factors had important contributions to substantial variation of opioid administrations during surgical procedures. These findings suggest the need for a broadened focus across multiple factors when developing and implementing opioid-reducing strategies in collaborative quality-improvement programs.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Fisher reported formerly owning stock in Johnson & Johnson outside the submitted work. Dr Shah reported receiving grants from Blue Cross Blue Shield Medicine, the National Institutes of Health (NIH), and the Patient-Centered Outcomes Research Institute (PCORI) outside the submitted work. Dr Bicket reported receiving grants from the NIH, PCORI, Substance Abuse and Mental Health Services Administration/Michigan Department of Health and Human Services, Arnold Foundation, and Centers for Disease Control and Prevention outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Intraoperative Opioid Administration by Hospital, Anesthesiologist, and Surgeon
Intraoperative opioid administration is presented by hospital (A), anesthesiologist (B), and surgeon (C). Mean unadjusted intraoperative opioid administration is presented in oral morphine equivalents (OMEs) per kilogram per hour. Means were generated across all surgical and analgesic categories. Bars represent 95% CIs.
Figure 2.
Figure 2.. Attributable Variance by Analgesic Technique
Adjusted intraclass correlation coefficients (ICCs) of adjusted intraoperative opioid administration are displayed by analgesic category and patient, anesthesiologist, and hospital.
Figure 3.
Figure 3.. Intraoperative Opioid Administration by Surgical Category
Intraoperative opioid administration was measured as the adjusted least square mean–normalized oral morphine equivalency (OME) per kilogram per hour by surgical category. Error bars represent square error means (SEMs).
Figure 4.
Figure 4.. Intraoperative Opioid Administration by Surgical and Analgesic Category
Box and whisker plots of adjusted intraoperative opioid administration by surgical and analgesic category are presented. Intraoperative opioid administration was measured as the adjusted least square mean–normalized oral morphine equivalency (OME) per kilogram per hour by type of surgical procedure. Error bars represent square error means (SEMs).

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