Efficiency And Quality In Post-Surgical Pain Therapy After Discharge - EQUIPPED

摘要 术后严密有效的疼痛管理是人性化医疗的基础。 阿片类药物仍然是术后疼痛治疗的主要药物：超过80%的患者使用阿片类药物 手术后使用。在美国的一年里，超过17%的美国人至少服用一种阿片类药物 处方中，平均每日用量超过45毫克吗啡当量。在 除了常见的副作用外，阿片类药物的严重风险还包括成瘾、滥用和过量。处方 过量死亡占所有阿片类药物过量死亡的三分之一以上，并且仍然是 1999年阿片类药物的过度处方仍然非常普遍，高达90%的患者在普通 报告残留阿片类药物的外科手术在75%的情况下，未使用的阿片类药物储存在不安全的地方 并且可以创造一个储存库，为持续的阿片类药物流行提供燃料。大多数大规模的努力，如疾病预防控制中心 关于类阿片处方的指南侧重于长期使用类阿片。迫切需要增加 获得高质量，安全和可扩展的干预措施，以减少我们对阿片类药物的依赖， 出院时的手术疼痛管理。一个多元化的团队，在疼痛医学，围手术期结局， 临床试验，生物统计学和卫生经济学已经聚集在一起，进行效率和质量研究。 出院后的术后疼痛治疗“RIPPED”研究。我们的中心假设是， 手术可以而且应该以更安全、以病人为中心的方式进行，而不是目前的“一刀切"， 所有“方法。为了验证这一假设，提出了三个目标：具体目标1将测试面向提供者的EHR- 基于决策支持工具，根据住院阿片类药物需求建议门诊阿片类药物处方。 这一目标将利用一个务实的随机分组多交叉对照试验设计，在约39000 四家医院的病人。具体目标2将测试一个面向患者的健康信息学应用程序，鼓励非 阿片类药物疼痛管理策略。本研究采用随机对照试验设计，在600例手术患者中进行 患者由于不同的结果（处方阿片类药物的量），建议进行两项单独的临床试验 vs.使用的阿片类药物）和实施范围（多地点与单一地点）。面向提供者的工具将是 使用2x2设计纳入面向患者的应用程序的试验中，便于详细评估 这些干预措施的个别效果，以及在一起使用干预措施时的任何相互作用。最后， 具体目标3将包括成本效益分析，并比较单独和综合成本- 提供者面对和患者面对干预的有效性。该项目的完成将证明 阿片类药物处方量和术后出院后服用的阿片类药物量可以减少， 确保有效治疗疼痛。增加获得安全，负担得起的，高质量的疼痛治疗， 手术患者将推动这一应用程序的积极影响，这直接解决了特别强调 注意：AHRQ宣布对卫生服务研究感兴趣，以解决阿片类药物危机（NOT-HS-18-015）。

Abstract Compassionate and effective pain management after surgery represents a foundation of humane medical care. Opioids still present the mainstay of post-surgical pain therapy: more than 80% of patients are prescribed opioids for use following surgery. During one year in the U.S., more than 17% of Americans fill at least one opioid prescription, and, per prescription, the average daily amount exceeded 45 milligram morphine equivalents. In addition to common side effects, serious risks of opioids include addiction, abuse, and overdose. Prescription overdose deaths contribute to more than one-third of all opioid overdose deaths and remain five-fold higher than in 1999. Over-prescription of opioids remains extremely common, with up to 90% of patients after common surgical procedures reporting leftover opioids. Unused opioids are stored in unsecured locations in 75% of cases and can create a reservoir that fuels the ongoing opioid epidemic. Most large-scale efforts, such as the CDC guidelines for prescribing opioids, have focused on chronic opioid use. There is an urgent need to increase access to high-quality, safe, and scalable interventions to reduce our reliance on opioids for effective post- surgical pain management at discharge. A diverse team with expertise in pain medicine, perioperative outcomes, clinical trials, biostatistics, and health economics has been assembled to conduct the Efficiency And Quality In Post-Surgical Pain Therapy After Discharge “EQUIPPED” study. Our central hypothesis is that pain therapy after surgery can and should be prescribed in a safer, patient-centered fashion, as opposed to current “one-size-fits- all” methods. To test this hypothesis, three aims are proposed: Specific Aim 1 will test a provider-facing EHR- based decision support tool that suggests outpatient opioid prescriptions based on inpatient opioid requirements. This aim will utilize a pragmatic randomized cluster multiple crossover controlled trial design in about 39,000 patients in four hospitals. Specific Aim 2 will test a patient-facing health informatics app that encourages non- opioid pain management strategies. This aim employs a randomized controlled trial design in 600 surgical patients. Two separate clinical trials are proposed because of different outcomes (amount of opioids prescribed vs. opioids used) and scopes of implementation (multisite vs. single site). The provider-facing tool will be incorporated into the trial of the patient-facing app using a 2x2 design that facilitates a detailed evaluation of the individual effects of these interventions, as well as any interactions when using the interventions together. Finally, Specific Aim 3 will include a cost-effectiveness analysis and compare the individual and combined cost- effectiveness of a provider-facing and a patient-facing intervention. Completion of this project will demonstrate that the amounts of opioids prescribed and opioids taken after discharge following surgery can be reduced while ensuring effective treatment of pain. Increasing access to safe, affordable, and high-quality pain therapy for surgical patients will drive the positive impact of this application, which directly addresses Special Emphasis Notice: AHRQ Announces Interest in Health Services Research to Address the Opioids Crisis (NOT-HS-18-015).