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Opioid-free colorectal surgery: a method to improve patient & financial outcomes in surgery

  • 2018 SAGES Oral
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Opioids are a mainstay for postsurgical pain management, but have associated complications and costs, and contribute to the opioid epidemic. While efforts to reduce opioid use exist, little study has been done on opioid utilization and its impact across surgical approaches. Our goal was to evaluate the impact of opioid utilization on quality measures and costs after open and laparoscopic colorectal surgery.

Methods

The Premier database was reviewed for inpatient colorectal procedures from January 01, 2014, to September 30, 2015. Procedures were stratified into open and laparoscopic approaches, then “opioid” and “opioid-free” groups within each approach. Univariate analysis compared demographics, outcomes, and cost by opioid use and surgical approach. In the “opioid” groups, opioid consumption and duration were assessed across platforms. Multivariate regression analyzed the association between opioid use and surgical approach on costs and quality outcomes.

Results

50,098 procedures were evaluated—40.4% laparoscopic and 59.6% open. 6.6% of laparoscopic and 5.3% of open cases were “opioid free.” Across both approaches, patients over 65 were most likely opioid free, while the obese and cancer patients were most likely to use opioids. Length of stay was shorter, and post-discharge nursing needs and total costs were lower in the “opioid-free” group in both approaches (all p < 0.001). The median daily and total opioid consumption were lower with a laparoscopic approach (p < 0.001), which also had a shorter duration of use versus open cases (p < 0.001). Opioids were 20% more likely in open cases. Total costs were 16% greater with opioids and 24% greater in open surgery. Complications were 89% more likely in open surgery. Readmissions were increased by 14% with both opioid use and open surgery.

Conclusions

Opioid-free colorectal surgery results in improved outcomes, and laparoscopy further improves these results. Continued efforts to increase laparoscopy are key for reducing opioids and improving outcomes as we transition to value-based care.

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Author information

Authors and Affiliations

  1. Division of Colon and Rectal Surgery, Department of Surgery, NewYork-Presbyterian, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, 8th Floor, New York, NY, 10032, USA

    Deborah S. Keller

  2. Minimally Invasive Therapies Group, Medtronic, Inc, Boulder, CO, USA

    Jianying Zhang

  3. GENIE Centre, University College London, London, UK

    Manish Chand

Authors
  1. Deborah S. Keller
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  2. Jianying Zhang
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  3. Manish Chand
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Corresponding author

Correspondence to Deborah S. Keller.

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Disclosures

Ms. Zhang is employed by Medtronic, who provided access to the data source for the analysis. No products or services from Medtronic were relevant to this work, and there was no payment for the work. Deborah S. Keller and Manish Chand have no conflicts of interest or financial ties to disclose.

Appendices

Appendix 1: case selection and exclusions codes for colorectal surgery

Inclusion

DRG codes

329, 330, 331

ICD-9 procedure codes

 Open

45.71, 45.72, 45.73, 45.74, 45.75, 45.76, 45.79, 45.82, 45.83

 Laparoscopic

17.31, 17.32, 17.33, 17.34, 17.35, 17.36, 17.39, 45.81

CPT/HCPCS codes for colectomy

 Open

44140, 44141, 44143, 44144, 44,145, 44146, 44150, 44151, 44155, 44156, 44157, 44158, 44160, 45113, 45121

 Laparoscopic

44204, 44205, 44206, 44207, 44208, 44210, 44211, 44212

Exclusion

 Robotic assistance

 

 ICD-9 (add-on procedure code)

17.41, 17.42, 17.43, 17.44, 17.45, 17.49

 CPT/HCPCS

S2900

  1. CPT/HCPCS current procedural terminology/healthcare common procedure coding system
  2. ICD-9 International Classification of Disease, Ninth edition
  3. DRG diagnostic-related group

Appendix 2: complications

General category

ICD-9-CM code

Ileus/small bowel obstruction (including constipation and PONV)

560.1, 560.2, 560.81, 560.89, 560.9, 997.4, 787.01, 564.3, 564.09, E937.9

Anastomotic leak. Organ space SSI

569.5, 567.22, 566, 567.21, 567.23, 567.29, 567.89, 567.9, 599.0, 996.64, 567.38

Superficial SSI and wound complications (hematoma/ seroma, wound infection, dehiscence)

682.2, 682.8, 682.9, 686.8, 686.9, 998.59, 958.3, 998.30, 998.31, 998.32, 998.33, 998.13, 998.51, 998.59, 998.6, 729.91, 998.12

Clostridium difficile colitis

 008.45

Pulmonary infection

481, 482.0, 482.1, 482.2, 482.30, 482.31, 482.32, 482.39, 482.40, 482.41, 482.42, 482.49, 482.81, 482.82, 482.83, 482.89, 482.9, 483.0 485, 486, 507.0, 997.31, 997.32, 997.3, 518.5

Deep venous thrombosis

453.40, 453.41, 453.42, 453.82, 453.83

Urinary tract infection

599.0, 996.64, 788.2

Dehydration/acute renal failure

 584.9, 276.51

Bleeding

998.11, 578.9, 285.1, 459.0, 285.1, 998.12, 569.3, 568.81, 569.3

Bleeding requiring transfusion

99.00, 99.01, 99.02, 99.03, 99.04, 99.05, 99.06, 99.07, 99.09

Peritonitis

567.38, 567.39, 567.2, 567.21, 567.22, 567.39, 567.8, 567.89, 567.9, 568.81

GI complications (Fistula)

997.4, 569.81, 593.82, 599.1, 596.1

Delirium/confusion/accidental fall

780.09, 293.9, 780.97, E884.4

  1. SSI superficial site infection

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Keller, D.S., Zhang, J. & Chand, M. Opioid-free colorectal surgery: a method to improve patient & financial outcomes in surgery. Surg Endosc 33, 1959–1966 (2019). https://doi.org/10.1007/s00464-018-6477-5

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