Previous studies have found that typically half or more of opioid prescriptions families receive after surgery go unused.1,2 “There has been a great amount of data in the last few years that have shown that most children undergoing surgery who receive an opioid prescription receive more opioids than are actually necessary,” Dr. Kelley-Quon said. She noted that half of the hospitals in the study already had a protocol in place to minimize prescribing opioids to children after appendectomy, but the remainder had no standardized protocol for prescribing opioids and the practice varied among surgeons.
Study details
The protocol used recently published guidelines, which Dr. Kelley-Quon coauthored, for opioid prescribing in pediatric surgery patients.3 The implementation was focused around three pillars, Dr. Kelley-Quon explained:
- educating health care providers about the risks of misuse and abuse related to unused prescription opioids
- emphasizing use of over-the-counter non-opioid pain medicine, such as acetaminophen and ibuprofen
- engaging families in the child’s post-surgery pain management
Study findings and conclusions
After the QI program was implemented the researchers reported that:
- 4% of children went home with opioid prescriptions compared with 18.2% beforehand (p<0.001), a decrease of 78% on average.
- In the hospitals that didn’t have a prescribing protocol, the reduction was similarly significant: from 37.9% before implementation to 8.8% after (p<0.001), a 77% reduction.
- The reduction was even significant in hospitals that had a protocol: from 2.7% before to 0.8% after (p=0.003), a 70% change.
The researchers note that some providers send children home after an appendectomy with opioid prescriptions to prevent emergency room visits for pain flares, even though another study reported that children who received opioids had higher rates of ER visits a month after surgery.4 In the study by Dr. Kelley-Quon and colleagues, ER visits were essentially unchanged after the QI program:
- 8.9% before vs. 9.9% after (p=0.54).
- Also, average pain management satisfaction scores were high after the intervention: 4.7 on a scale of 0 to 5.
“The study provides important information for both pediatric and general surgeons, as both specialists perform appendectomies and other surgical procedures for children,” said Mary E. Fallat, MD, FACS, FAAP, professor at the University of Louisville School of Medicine and medical director, surgical quality, at Norton Children’s Hospital in Louisville, Kentucky, who was not involved in the study.
“General surgeons may not be as attuned to advances in postoperative pain control in children’s hospitals. Due to heightened awareness of opioid abuse, many pediatric and pediatric subspecialty surgeons have embraced the concept of moving completely away from narcotic use after outpatient procedures [hernias] and short-stay procedures [appendectomy and cholecystectomy] and recommend acetaminophen alternating with nonsteroidal anti-inflammatory drugs to augment local and regional anesthesia use in the operating room,” said Dr. Fallat, who is also Vice Chair of the ACS Children’s Surgery Verification Program.
Dr. Kelley-Quon noted that use of ACS NSQIP Pediatric was pivotal in implementing the study intervention. “NSQIP has really helped surgeons see how an individual hospital can compare itself with other hospitals in the country,” she said. “What our project did was take that one step farther to enable a group of hospitals to use the platform in real time to really change practice for a specific quality improvement initiative across several hospitals at once.”
Added Dr. Fallat, “The study confirms the use of NSQIP pediatric as a valuable database for doing research studies that can lead to improved patient care. The hospital consortium model allows for research studies like this with the accrual of a much larger population of patients.” She noted that most of the hospitals involved in the study are either verified or in the process of achieving verification in the ACS Children's Surgery Verification program. An update of that program, to take effect later in the year, will include an opioid stewardship model. “This model will identify an approach and its feasibility for those hospitals that have yet to embrace it,” she said. The new standards are available online.
Dr. Kelley-Quon’s coauthors are Shadassa Ourshalimian, MPH; Justin Lee, MD; Katie W. Russell, MD, FACS; Karen Kling, MD, FACS; Stephen B. Shew, MD, FACS; Claudia Mueller, PhD, MD, FACS; Aaron R. Jensen, MD, MEd, MS, FACS; Lan Vu, MD, FACS; Benjamin Padilla, MD, FACS; Daniel Ostlie, MD, FACS; Caitlin Smith, MD, FACS; Thomas Inge, MD, FACS; Jonathan Roach, MD, FACS; Romeo Ignacio, MD, FACS; Katrine Lofberg, MD, FACS; Stephanie Radu, MCR; Autumn Rohan; and Kasper S. Wang, MD, FACS.
Dr. Kelley-Quon and coauthors have no financial relationships to disclose. Dr. Fallat has no relevant disclosures.
“FACS” designates that a surgeon is a Fellow of the American College of Surgeons.
Citation: A Multi-Institutional Quality Improvement Project to Minimize Opioid Prescribing in Children after Appendectomy Using [ACS] NSQIP-Pediatric. Journal of American College of Surgeons. DOI: 10.1097/XCS.0000000000000056
- Van Cleve WC, Grigg EB. Variability in opioid prescribing for children undergoing ambulatory surgery in the United States. J Clin Anesth. 2017;41:16-20.
- Monitto CL, Hsu A, Gao S, et al. Opioid prescribing for the treatment of acute pain in children on hospital discharge. Anesth Analg. 2017;125(6):2113-2122.
- Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion. JAMA Surg. 2021;156(1):76-90.
- Anderson KT, Bartz-Kurycki MA, Ferguson DM, et al. Too much of a bad thing: Discharge opioid prescriptions in pediatric appendectomy patients. J Pediatr Surg. 2018;53(12):2374-2377.
