Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Burnout in Graduate Medical Education: Uncovering Resident Burnout Profiles Using Cluster Analysis

Background Burnout is common among residents and negatively impacts patient care and professional development. Residents vary in terms of their experience of burnout. Our objective was to employ cluster analysis, a statistical method of separating participants into discrete groups based on response patterns, to uncover resident burnout profiles using the exhaustion and engagement sub-scales of the Oldenburg Burnout Inventory (OLBI) in a cross-sectional, multispecialty survey of United States medical residents. Methods The 2017 ACGME resident survey provided residents with an optional, anonymous addendum containing 3 engagement and 3 exhaustion items from the OBLI, a 2-item depression screen (PHQ-2), general queries about health and satisfaction, and whether respondents would still choose medicine as a career. Gaussian finite mixture models were fit to exhaustion and disengagement scores, with the resultant clusters compared across PHQ-2 depression screen results. Other variables were used to demonstrate evidence for the validity and utility of this approach. Results From 14 088 responses, 4 clusters were identified as statistically and theoretically distinct: Highly Engaged (25.8% of respondents), Engaged (55.2%), Disengaged (9.4%), and Highly Exhausted (9.5%). Only 2% of Highly Engaged respondents screened positive for depression, compared with 8% of Engaged respondents, 29% of Disengaged respondents, and 53% of Highly Exhausted respondents. Similar patterns emerged for the general query about health, satisfaction, and whether respondents would choose medicine as a career again. Conclusion Clustering based on exhaustion and disengagement scores differentiated residents into 4 meaningful groups. Interventions that mitigate resident burnout should account for differences among clusters

Stages of Milestones Implementation: A Template Analysis of 16 Programs Across 4 Specialties

BACKGROUND: Since 2013, US residency programs have used the competency-based framework of the Milestones to report resident progress and to provide feedback to residents. The implementation of Milestones-based assessments, clinical competency committee (CCC) meetings, and processes for providing feedback varies among programs and warrants systematic examination across specialties. OBJECTIVE: We sought to determine how varying assessment, CCC, and feedback implementation strategies result in different outcomes in resource expenditure and stakeholder engagement, and to explore the contextual forces that moderate these outcomes. METHODS: From 2017 to 2018, interviews were conducted of program directors, CCC chairs, and residents in emergency medicine (EM), internal medicine (IM), pediatrics, and family medicine (FM), querying their experiences with Milestone processes in their respective programs. Interview transcripts were coded using template analysis, with the initial template derived from previous research. The research team conducted iterative consensus meetings to ensure that the evolving template accurately represented phenomena described by interviewees. RESULTS: Forty-four individuals were interviewed across 16 programs (5 EM, 4 IM, 5 pediatrics, 3 FM). We identified 3 stages of Milestone-process implementation, including a resource-intensive early stage, an increasingly efficient transition stage, and a final stage for fine-tuning. CONCLUSIONS: Residency program leaders can use these findings to place their programs along an implementation continuum and gain an understanding of the strategies that have enabled their peers to progress to improved efficiency and increased resident and faculty engagement

Stages of Milestones Implementation: A Template Analysis of 16 Programs Across 4 Specialties.

BackgroundSince 2013, US residency programs have used the competency-based framework of the Milestones to report resident progress and to provide feedback to residents. The implementation of Milestones-based assessments, clinical competency committee (CCC) meetings, and processes for providing feedback varies among programs and warrants systematic examination across specialties.ObjectiveWe sought to determine how varying assessment, CCC, and feedback implementation strategies result in different outcomes in resource expenditure and stakeholder engagement, and to explore the contextual forces that moderate these outcomes.MethodsFrom 2017 to 2018, interviews were conducted of program directors, CCC chairs, and residents in emergency medicine (EM), internal medicine (IM), pediatrics, and family medicine (FM), querying their experiences with Milestone processes in their respective programs. Interview transcripts were coded using template analysis, with the initial template derived from previous research. The research team conducted iterative consensus meetings to ensure that the evolving template accurately represented phenomena described by interviewees.ResultsForty-four individuals were interviewed across 16 programs (5 EM, 4 IM, 5 pediatrics, 3 FM). We identified 3 stages of Milestone-process implementation, including a resource-intensive early stage, an increasingly efficient transition stage, and a final stage for fine-tuning.ConclusionsResidency program leaders can use these findings to place their programs along an implementation continuum and gain an understanding of the strategies that have enabled their peers to progress to improved efficiency and increased resident and faculty engagement