69.02 Statewide Utilization of Multimodal Analgesia and Length of Stay After Colectomy

A. C. De Roo1,2, J. V. Vu1,2, S. E. Regenbogen1,2,3  1University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA 2University Of Michigan,Department Of General Surgery,Ann Arbor, MI, USA 3University Of Michigan,Division Of Colorectal Surgery,Ann Arbor, MI, USA

Introduction:
Multimodal analgesia is a critical component of both enhanced recovery protocols (ERP) and efforts to reduce opioid misuse after surgery. Postoperative multimodal pain therapy, using more than one class of pain medication: opioids, acetaminophen, non-steroidal anti-inflammatories (NSAIDs), gabapentinoids, and regional and epidural anesthesia, has been associated with lower pain scores, decreased opioid use, and avoidance of opioid inhibition of gut motility. Whether multimodal analgesia is widely used in practice remains unknown, and its effect on hospital length of stay has not been evaluated outside of controlled trials.

Methods:
Within the population-based, statewide Michigan Surgical Quality Collaborative (MSQC), we evaluated all adult patients undergoing elective colorectal resection between 2012 and 2015. Colectomy has been a targeted procedure for ERP implementation and MSQC collects ERP-specific data elements for colectomy, including details of perioperative analgesia. The primary outcome was mean postoperative hospital length of stay (LOS). To reduce bias from rare, extremely prolonged hospitalizations, we winsorized LOS at 30 days which excluded 27 patients. T-tests were used to evaluate associations between LOS and opioid-only vs multimodal therapy, defined as two or more classes of pain medication used.

Results:
Among the 7249 patients who underwent elective colectomy, 6746 received opioids (93.1%), and 2391 patients (33.0%) received no other analgesia besides opioids. Acetaminophen was used by 2701 (37.2%) patients, NSAIDs in 2551 (35.2%), and epidural, spinal, or regional anesthesia in 1400 (19.3%) patients. Average LOS for patients receiving multimodal analgesia (5.4 days, 95% CI 5.3-5.5) was significantly shorter than for patients receiving opioids alone (6.0 days, 95% CI 5.8-6.2; p<0.001).

Conclusion:
One third of patients undergoing colectomy in the state of Michigan received solely opioid analgesia. Ongoing improvement efforts will aim for near-universal use of opioid sparing pain regimens, in order to reduce opioid-related adverse effects and opioid exposure. Use of opioid-sparing multimodal analgesia, compared with opioids alone, is associated with a small reduction in hospital LOS, perhaps from improved pain control and lower rates of ileus, and could therefore accrue cost savings at a population level.  Multimodal analgesia is also an essential component of efforts to combat opioid use disorders related to surgical encounters and Michigan hospitals have room for improvement.