Opioid Stewardship Programs for Surgical Patients Produce Strategic Value Dividends

Despite congressional and public awareness efforts such as the recently passed SUPPORT for Patients and Communities Act, opioid prescribing in the primary care setting remains highly variable. Consequently, complex surgical patients with long presurgical care pathways may present a challenge to specialists and health systems managing patients further downstream. While opioid stewardship programs often incorporate provider and patient education as well as prescription monitoring, progressive organizations are partnering with providers to implement 3 high-impact strategies specifically designed for surgical patients:

  • Long-term postoperative opioid use risk identification
  • Preoperative pain tolerance and mitigation strategies
  • Multimodal analgesia techniques and postoperative prescription guidelines

These components not only help address the opioid crisis but also produce dividends for value-focused hospitals and health systems. Examples include improved quality (fewer complications and readmissions), improved cost of care efficiency, and improved care coordination and System of CARE communication infrastructure.

Pay for Performance Recognizes Quality Is Not Defined by Absence of Pain

Removal of pain management and related communication questions from the HCAHPS survey (effective with October 2019 discharges) allows physicians, hospitals and health systems to redefine quality in pain communication and management. A new Vizient survey of 90 hospital and health system members found nearly two-thirds of hospitals increased their investment in opioid medication management in the past 12 months, with the most commonly cited programs involving prescriber education and prescription monitoring. For surgical patients, however, starting the discussion when the patient presents at the hospital means starting the race well after the horse has left the gate. Preoperative care pathways that include risk identification for opioid use disorder and preoperative pain mitigation are an emerging best practice with this complex population.

Optimize and Identify Patients at Risk to Realize Value Dividends

To support providers and health systems in risk identification and management, most industry associations and societies now offer online resources with patient education, screening tools and departmental policy development guidance (eg, the AAOS comprehensive online Pain Relief Toolkit). Health systems and specialty providers that integrate opioid use disorder risk screening often use existing program navigators to kick off the process, though some may add staff to assist with post-op prescription monitoring. Some orthopedic and spine programs have also incorporated preoperative weaning programs for eligible patients, resulting in improved postoperative outcomes.

Physical Therapy Effective for Mitigation, Albeit With Financial Barriers

In addition to lower opioid use, a recent study found that low-back pain patients who saw a physical therapist prior to or in lieu of other specialists had lower prescription expenses and fewer imaging and ED visits and hospitalizations than those who either did not see a physical therapist or saw one later in the care timeline.

Despite the evidence, value dividends associated with early physical therapy are often unrealized due to patient financial and access barriers. These 2 areas are prime for innovation, and mHealth and patient wearables companies are ready to respond (eg, the recent Zimmer Biomet and Apple collaboration). Outpatient rehabilitation programs, however, have been slow to migrate to virtual health, which may disadvantage systems looking to deliver on value-based contracts, such as bundled payment, or secure exclusive value contracts (eg, self-insured contracts, narrow network preferred status, payer designations).

Anesthesia Advancements and Discharge Guidelines Enhance Cost Efficiency and Quality

Specialists and health systems working to reduce prolonged exposure to opioids are partnering with anesthesiologists to define procedure-specific protocols and patient discharge education. Multimodal analgesia and Enhanced Recovery After Surgery programs continue to grow in popularity as strategies to reduce perioperative and postoperative opioid utilization, shorten length of stay, and improve patient satisfaction with pain experience.

In addition to anesthesia advancements, a recently published multidisciplinary panel consensus on opioid-prescribing guidelines for common surgical procedures provides recommendations on discharge prescriptions at the procedure level. Novant Health’s system-wide opioid stewardship program has quickly resulted in significant reduction of prescription variation and opioid discharge volume.

Next Steps

Organizations looking to reap opioid stewardship value dividends should consider the following next steps:

  • Start the discussion on surgical patient opioid prescribing at your organization if you haven’t already, and understand current procedure and provider prescription variation compared to the aforementioned opioid-prescribing guidelines.
  • Consider opportunities to incorporate opioid stewardship and surgery-specific program features into current or future value-based care incentive structures or comanagement agreements.
  • Partner with providers to review care pathways and identify resources to assist with preoperative, perioperative and postoperative pain management. Consider adding a preoperative opioid risk assessment such as the MD+Calc Opioid Risk Tool for Narcotic Abuse to identify at-risk patients.
  • Identify and deploy resources throughout the System of CARE for high-risk patients.
  • Evaluate the financial and operational impact of a traditional opioid stewardship program, as well as key surgery program components such as patient screening and education, physical and virtual therapy, advanced anesthesia techniques, and prescription monitoring programs.
  • Monitor and track patient and prescriber compliance with care pathways.

Responding to the opioid crisis with improved quality, improved cost of care efficiency, and improved care coordination and communication provides a strategic advantage for surgical programs looking to excel in value-based care. Sg2 is proud to work with our members who seek to redefine quality in surgical pain experience.

Additional Sg2 Member Resources:

Not a member yet? Contact us today to talk about how we can work with you on high-impact strategies specifically designed for surgical patients and to learn more about Novant Health’s opioid stewardship efforts.


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