Readmissions after general surgery: a prospective multicenter audit

Background: Readmission rates after surgical procedures are viewed as a marker of quality of care and as a driver to improve outcomes in the United Kingdom, they are not remunerated. However, readmissions are not wholly avoidable. The aim of this study was to develop a regional overview of readmissions to determine the proportion that might be avoidable and to examine predictors of readmissions at a unit level. Methods: We undertook a prospective multicenter audit of readmissions following National Health Service funded general surgical procedures in five National Health Service hospitals and three independent sector providers over a 2-wk period. Basic demographic and procedure data were captured. Readmissions to hospitals were identified through acute admissions lists. Reason for readmission was identified, and the readmission data assessed by a senior surgical doctor as to whether it was avoidable. Results: We identified 752 operations in the study period with all followed up to 30 d. The overall rate of readmissions was 4.7%, with 40% of these judged as being potentially avoidable. Pain and wound problems accounted for the vast majority of avoidable readmissions. The number of unavoidable readmissions was correlated with the workload of each center (r ¼ 0.63, P ¼ 0.06) and as with the higher (British United Provident Association) complexity of surgery (r ¼ 0.90, P ¼ 0.01). Patient and demographic factors were not associated with readmissions. Conclusions: This prospective audit describes readmission rates after general surgery. Volume and complexity of work are associated with readmission rates. A large proportion of readmissions could be reduced by attention to analgesia and outpatient arrangements for wound management

Treatment and Survivorship Interventions to Prevent Poor Body Image Outcomes in Breast Cancer Survivors

Body image concerns often arise during and after treatment and are a major concern in up to 67% of breast cancer survivors. Negative changes in body image are a predictor of worse satisfaction with appearance and poor quality of life outcomes. Opportunities to mitigate the negative impact of cancer treatment on a patient's body image present during preoperative education or in the neoadjuvant setting, or during surgical management, adjuvant therapy delivery, and survivorship. The surgical management of breast cancer has evolved from breast amputations to procedures that provide improved cosmesis without compromising the oncologic outcome. The advent of the sentinel lymph node biopsy and lymphatic reconstruction techniques has led to decreased axillary morbidity. Modified radiation techniques and systemic therapies tailored to subtype limit unnecessary exposure to skin and systemic toxicities. Finally, incorporating prehabilitation and survivorship support optimizes the physical and psychosocial well-being of these patients. Setting expectations, treatment de-escalation when appropriate, morbidity risk reduction and improved screening and management of psychological sequelae during survivorship can decrease breast cancer treatment's negative impact on body image. The following review synthesizes interventions during preoperative planning, local and systemic treatment, and survivorship to prevent poor body image outcomes without compromising oncologic success

Reassessing Opioid Use in Breast Surgery

This study aims to assess multimodal pain management and opioid prescribing practices in patients undergoing breast surgery. A retrospective review of patients undergoing breast surgery at an academic medical center between April 1, 2018 and September 30, 2019, was performed. Patients with a history of recent opioid use or conditions precluding use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (APAP) were excluded. Opioid-sparing pain regimens were assessed. Opioids prescribed on discharge were recorded as oral morphine equivalents (OMEs) and concordance with the Opioid Prescribing Engagement Network (OPEN) determined. The total study population consisted of 518 patients. 358 patients underwent minor outpatient procedures (sentinel lymph node biopsy, lumpectomy, and excisional biopsy), 10-40% of whom were appropriately prescribed as per the OPEN. Perioperatively, 53.9% of patients received APAP, 24.6% NSAIDs, 20.4% gabapentin, and 0.3% blocks; intraoperatively, 95.8% received local anesthetic and 25.7% ketorolac. For mastectomy without reconstruction, 63-88% of prescriptions were concordant with the OPEN. For mastectomy with reconstruction, discharge opioids ranged from 25 to 400 OMEs with a mean of 134.4 OMEs; 25% of patients received a refill. Of all patients undergoing mastectomy ± reconstruction, 62.5% received APAP, 18.8% NSAIDs, 38.8% pregabalin, and 20.6% locoregional block perioperatively; 37.5% received local anesthetic and 15.6% ketorolac intraoperatively. Of 143 inpatient stays, 89% received APAP, 38% NSAID, and 29% benzodiazepines; 29 patients received no opioids inpatient but were still prescribed 25-200 OMEs on discharge. There is need for a multidisciplinary approach to pain management with the use of enhanced recovery after surgery protocols as potential means to standardize perioperative regimens and mitigate opioid overprescription. •A persistence in opioid overprescription exists despite established guidelines.•Perioperative multimodal pain regimens are not currently optimized.•Enhanced recovery after surgery presents opportunity for standardization.•Further study of the opioid use in immediate reconstruction is needed

Evaluation of opioid prescribing preferences among surgical residents and faculty

Background: Residents report that faculty preference is a significant driver of opioid prescribing practices. This study compared opioid prescribing preferences of surgical residents and faculty against published guidelines and actual practice and assessed perceptions in communication and transparency around these practices. Methods: Surgical residents and faculty were surveyed to evaluate the number of oxycodone tablets prescribed for common procedures. Quantities were compared between residents, faculty, Opioid Prescribing Engagement Network guidelines, and actual opioids prescribed. Frequency with which faculty communicate prescribing preferences and the desire for feedback and transparency in prescription practices were assessed. Results: Fifty-six (72%) residents and 57 (59%) faculty completed the survey. Overall, faculty preferred a median number of tablets greater than recommended by Opioid Prescribing Engagement Network in 5 procedures, while residents did so in 9 of 14 procedures. On average, across all operations, faculty reported prescribing practices compliant with Opioid Prescribing Engagement Network 56.1% of the time, whereas residents did so 47.6% of the time (P 1/4 .40). Interestingly, opioids actually prescribed were significantly less than recommended in 7 procedures. Among faculty, 62% reported often or always specifying prescription preferences to residents, while only 9% of residents noted that faculty often did so. Residents (80%) and faculty (75%) were amenable to seeing regular reports of personal opioid prescription practices, and 74% and 65% were amenable to seeing practices compared with peers. Only 34% of residents and 44% of faculty wanted prescription practices made public. Conclusion: There is a disconnect between opioid prescribing preferences and practice among surgical residents and faculty. Increased transparency through individualized reports and education regarding Opioid Prescribing Engagement Network guidelines with incorporation into the electronic medical record as practice advisories may reduce prescription variability. (c) 2021 Published by Elsevier Inc

Resident Opioid Prescribing Habits Do Not Reflect Best Practices in Post-Operative Pain Management: An Assessment of the Knowledge and Education Gap

To evaluate deficiencies in knowledge and education in opioid prescribing and to compare surgical resident opioid-prescribing practices to Opioid Prescribing Engagement Network (OPEN) procedure-specific guidelines. Anonymous web-based survey distributed to all general surgery residents to evaluate prior education received and confidence in knowledge in opioid prescribing. The number of 5 milligram oxycodone tablets prescribed for common procedures was assessed and compared with OPEN for significance using Wilcoxon signed rank tests. General surgery residency program within large university-based tertiary medical center. Categorical general surgery residents of all postgraduate years. Fifty-six of 72 (78%) categorical residents completed the survey. Few reported receiving formal education in opioid prescribing in medical school (32%) or residency (16%). While 82% of residents felt confident in opioid side effects, fewer felt the same with regards to opioid pharmacokinetics (36%) or proper opioid disposal (29%). Opioids prescribed varied widely with residents prescribing significantly more than recommended by OPEN in 9 of 14 procedures. Tackling the evolving opioid epidemic requires a multidisciplinary approach that addresses prescribing at all steps of the process, starting with trainee education