Dr. Mallory Perez - Best of the Best in Pediatric Surgery 2025

We're going to move on to the next one. Um, so uh also from Apsa, uh Mallory Perez from Lorry Children's Hospital, the second one from Lorry today. Um, Heating the black box leveraging National Security Surgical quality improvement project pediatric for hospital level assessment of opioid prescribing. Hi, I'm Mallory Perez, clinical resident at UAB and research fellow at Larry Children's. Thank you for the opportunity to present our opioid stewardship research. This work was funded by the NICHD through a 2-year R21. Over 3 million children undergo surgery each year in the United States, many of whom receive opioids. Yet we still have no nationally recognized opioid prescribing benchmarks. The AAP has issued a challenge to surgeons to decrease opioid utilization by 50% at discharge. However, stewardship efforts must balance adequate pain control with risk of opioid related harm. To strike this balance, we need a better understanding of the extent and the drivers of opioid prescribing practice variation across hospitals. The FDA provides guidance on opioid prescribing, but compliance is not nationally benchmarked. Guidance is issued in the form of contraindications and warnings. Contraindications apply when a product is not recommended due to the potential for harm, never events. While warnings are alerts on emerging concerns calling for increased caution. We hypothesized that opioid prescribing practices at discharge and compliance with FDA guidance vary significantly across hospitals and subspecialties. Our study utilized expanded Nsquip P data from all four Illinois Children's hospitals participating in the program. Children 5 to 18 years of age undergoing any operation in the sampling frame were considered for inclusion. We define three outcomes. First, whether an opioid was prescribed a discharge, a marker of the extent of opioid discharge exposures. Second, the total morphine milligram equivalents prescribed a discharge, representing the dose intensity. And third, the proportion of patients for whom a hospital was FDA compliant. Finally, among those receiving opioids, we conducted a multivariable linear regression to identify factors associated with increased total MME. Our cohort included nearly 1700 patients of which 34% received opioids discharged from 26 to 44% across hospitals. In this table, we explore the proportion of patients exposed to opioid a discharge, stratified by the three most common subspecialties. The final column, the percent change, exemplifies the degree of hospital variation. For general surgery, we see 15% were prescribed opioids overall, and there was a 300% change across hospitals from 5 to 20%. For our next outcome, mean total MME at discharge was 97. This graph highlights the importance of looking at both the discharge exposure, the left Y- axis, and the dose intensity, the right Y- axis. Orthopedic surgery, plastics, and gynecology most frequently prescribed opioids a discharge, while general surgery, neurosurgery and orthopedic surgery were the highest total MME prescribers. Stated another way, for general surgery, opioids while infrequently prescribed, were often prescribed at a greater intensity than many other specialties. Our linear regression showed hospital site, adolescent age, orthopedic surgery, neurosurgery and multimodal analgesia use, like preoperative non-opioid agents and regional blocks were associated with increased total MME. For FDA compliance, you'll see by the overwhelming green on this table that compliance with contra indications was overall really strong with most at 100%. However, compliance with the warning on concurrent benzodiapine and opioid prescribing was highly variable from 46 to 93%. We talk a lot as a community about opioids. So how did these results apply to a national sample? This study uniquely covers multi specialty hospital level variation. However, the findings represent our Illinois population of which 73% were privately insured. While a crucial step forward, the generalizability of the state level data remains unknown. As shown in the map on the right for all patients, adults and children, Illinois is among the moderate dispensing states in the United States. Thus we surmised that national variation likely exceeds that which was observed in this study. Excitingly, ACS Nquip P as of January 2023 has started collecting more detailed opioid data for the greater than 150 hospitals in its program. To conclude, through this study, we've shown that detailed data collection on opioid stewardship is essential and feasible. And going forward to consider both discharge exposure and dose intensity. We observed that many Nquip P patients over 1/3 are going home on opioids, compliance with FDA contraindications was overall encouraging and national benchmarking is on the horizon. We've already begun to study and hope to present in 2025 some of the next steps that arose from this work, including exploring specialty and procedure level variation, identifying factors associated with benzodiapine and opioid co prescribing, and inve investigating the paradoxical relationship between use of multimodal analgesia and higher total MME at discharge. Thank you for your time to the participating hospitals and our dedicated research team. Thank you, Dr. Perez. Um, the the question that I always wonder, I mean the fear of this was, I believe opioids has been one of the biggest changes in my practice in the last 15 years. That and maybe Gibbs procedure. Those are the two biggest changes I've made. Um, because I used to think everyone and now I almost never do and I never get calls back. So the call back is what has to be assessed, right? So when you're doing it by general surgery or pediatric surgery, um, to create those benchmarks, I just am curious how the call back number or the return back for inadequate pain control happens by specialty. Um, but I don't know how they factor that into their benchmarking, but it's a great paper. Thank you so much for your question and for the opportunity to present and listen to everybody's presentations. Um, I think what you're talking about is what we looked at as balancing measures um to see as we reduce or minimize opioid use, how often are patients having poorly controlled pain that results in a followup. And so in our study, the additional variables that we collected on top of what Nquip pediatric already had included followup for pain, which may have involved ED visits, clinic visits, telephone or EHR my chart. And what we found is that there was no association with decreased use of opioids and increased followup. In fact, what we actually saw is that those who were prescribed opioids were more likely to have pain control challenges. And that's across all specialties? Yes, so unfortunately, it's a great point that you make. We haven't looked at that at a level of uh sub specialties or specialties and part of that is challenged by the overall number of patients that saw follow-up care. So in our total cohort it was only 8% for pain related issues. You know, we've quickly, we've recognized in lots of things that if you provide standardization, you improve outcomes and we've had lots of divisions here in our institution that have standardized their opioid opioid approach and seen dramatic reductions. Is there an opportunity to work through the national organizations for these various different sub specialties to implement that kind of guideline? I love that idea and I certainly hope so. I think what we need more right now is to have data that's convincing to drive practice because um as we look at specific procedures, and we have to acknowledge that some procedures may be appropriate for no opioids at all, while others may be targeting more of that MME category where we really need to look at reducing the amount but not um the absence of opioid use. Exactly. Yeah, like orthopedics versus an umbilical hernia is a bit different. All right, awesome. Thank you so much.