David Grabski, MD - Best of the Best in Pediatric Surgery 2024

OK. Moving forward on to the second presenter for ABSA, we've got Doctor David Grabsy, um, presenting the work on postoperative opioid reduction protocols to reduce racial disparity of clinical outcomes very timely after our recent discussion. So let's see what he has to say. Thank you for the opportunity to present our work. My name is David Gradsky. I'm currently a pediatric surgery fellow at Loy Children's Hospital in Chicago. Though this work was completed while I was a surgery resident at the University of Virginia under the direction of Sandra Kapagambe and Jeffrey Gander. We have nothing to disclose. We implemented a multimodal intervention to reduce postoperative opiate use in children at our institution based on IV Tylenol, directed post-operative pain education seminars for related faculty and staff, and standardized post-surgical sign out. The results of our primary investigation was previously presented at several APS meetings. The purpose of the current investigation was to determine if a difference in opiate prescribing patterns existed by race in our historical cohort, and whether our intervention and more specifically the standardization of care had an effect on any potential racial disparity that was identified. Our investigation included 250 children under 1 year old who underwent non-emergent abdominal surgery in either the NICU or the acute care floor across our study period. We used a historical and retrospective pre-intervention cohort group and a prospectively collected post-intervention or treatment group to compare the effect of our intervention on postoperative opiate prescribing patterns, pain scores, and secondary outcomes, including, uh, clinical safety profiles. Our primary analysis were process control charts. The figure represents a time series of all children in our investigation. Post-operative morphine equivalents are represented on the Y axis. Time is represented on the x axis beginning in January of 2011 through January of 2021. Our intervention occurred in January 2016 and is denoted by the blue vertical line. This figure re-establishes that the intervention itself was successful in reducing post-operative opiate use by 98% in our study population. This is the exact same data, but now plotted by race. White children are denoted in blue, black children in orange, and Hispanic children are represented in gray. Of note, there were not enough Asian children in our study to include in the time series. Several trends can immediately be seen by this figure. First, concentrating on the pre-intervention cohort to the left of the blue vertical line, it is clear that black children were prescribed significantly higher postoperative opiates than their peers. For numerical comparison, the median postoperative morphine equivalence for black children was 13 mg per kilogram, while for white children, it was 2, in Hispanic children, it was 3.5. This represents a sixfold increase in post-operative opiate use in black children compared to their white peers. Now concentrating on the post-intervention cohort to the right of the blue vertical line, it is also clear that the intervention successfully reduced postoperative opiate use in all racial groups. Specifically, the median postoperative morphine equivalence in black children reduced to just above 0 mg per kilogram, while for white children, it was 0.05, and Hispanic children, it was 0.1. These findings in the post-intervention cohort were statistically equivalent. In summary, the data is consistent with a racial disparity specifically highlighted in black children in our pre-intervention cohort, which was eliminated following our intervention. Important to the main findings was that there was no statistical difference in either of demographic or clinical variables in our pre-intervention or post-intervention cohort when analyzed by race. This is a busy table slide that serves to highlight this point with rows representing different demographic variables analyzed by race. Additionally, the data, though the data is not presented here, the type of surgery performed in each cohort were proportionally equivalent by race, and there was no difference in postoperative pain scores in any racial group. We similarly analyze secondary clinical outcomes associated with the opiate reduction, uh, intervention, again analyzed by both cohort and race. This data is total length of stay and days represented on the y axis. The pre-intervention cohort data is represented by blue. The post-intervention cohort is represented by orange. The, excuse me, the x axis is total length of stay in each racial category. The median total length of stay for black children in the pre-intervention cohort was 45 days, while for white children, it was 16 days. Once again, a specific statistical difference in the racial disparity of clinical outcomes in our pre-intervention cohort. However, following the intervention, the total length of stay for black children was 8 days, which was identical to white children. Though I'm not presenting the data here, we also found a racial disparity in our pre-intervention cohort and other secondary outcomes, including length of post-operative intubation and TPN usage, both of which were eliminated following our clinical protocol. In conclusion, the data of our investigation again is consistent with the racial disparity in opiate prescribing patterns and associated clinical outcomes in our pre-intervention cohort, which were eliminated following the implementation of a clinical protocol and standardization of care. I would like to thank the senior authors of the investigation, once again, Doctor Jeffrey Gander and Doctor Sandra Kapagabe for their insights and mentorship on the project. Thank you for such an amazing project. I feel like talking about opioid reduction has been another theme of today, um, and standardization of care and some of these quality improvement projects have just been amazing. What other avenues have you guys thought about or, um, interacted with to have similar equity outcomes across racial disparity? Um, thanks. The, the other thing that we're looking at now is, uh, standardization of, um, regional anesthesia, which we have some preliminary data that, that there might be a disparity in that as well. So, One of the aspects that I think is, is critical to at least this work was just standardization at all levels. So pre, you know, pre-surgery, surgery, post-surgery, and throughout the NICU phase. So this data represented the post-surgical course, but we're trying to implement this now in the, the pre-intervention phase as well. So, David, thanks for the presentation. Um, I'm somewhat speechless. I, look, I see a paper, it's called Disparities in Opioid Use. I was thinking, of course, there's gonna be a disparity. Almost everything we study, there's always a disparity. I was not expecting to see that profound of a disparity. Um, it's almost, uh, it just opens up this big like, why? Why more opioids for a certain racial or ethnic group. The reason we need to understand that is, yes, in this study you were able to, to shut things like that one chart says it all, like the, the drastic change post-intervention, but we've gotta understand the why because how do we, I'm assuming this, those numbers are everywhere now, right? That same graph you showed is probably represented in every hospital. So what, what happens in that we should be aware of as clinicians to mitigate that disparity? I Doctor Bons, what was challenging about this is that our, our paper, we tried to be as objective as possible and we didn't do that qualitative analysis. So this is just opinion. It's not, it's not based on any, any, you know, data that we generated from the presentation. But what was interesting about The racial disparity data is that it, it's the exact same patients, exact same surgeries, you know, their clinical presentation was the same. And then really, you know, we, the, the data wasn't included, but we started to dig into socioeconomic status associated with race, and, and that was also likely significant. And so what I suspect is just Parents at bedside help. It, it helps with consoling, it helps driving care. I think that there was a um That That that level of presence in the NICU was probably important. Um, it, it brings up the question about what ends up overall forgetting this like what usually dictates how much opioids a patient gets. Is it the bedside nurse? Is it the, is it the, uh, the is it the, the doctors? Is it the parents? Is it, what is it that leads to the district the The administration of opioids at, at, at UVA during this study and at Laurie Children's now, oftentimes it's PRNs delivered by the bedside nurses. So that was implicated by the bedside nurse. Yeah, I don't, I don't wanna implicate them, of course, but that, but that is the, the, the delivery of the, the PRNs themselves, at least at UVA was, was a, um, that we, we use the NAS pain score and if it reached a threshold, um, uh, a PRN usually was fentanyl at, at UVA was delivered. I mean, are parents involved in the asking of the bedside nurse, I mean, I just, we've got it, I would love a follow-up study to figure out actually what happens qualitatively so that we can mitigate it. Cause I'm, I have a fear that no matter, just knowing this isn't gonna be enough. Um, but I, congratulations. Obviously an incredibly provocative study, more than I thought I was gonna be provoked. So, uh, thanks for putting this together. Thank you guys so much. Thank you.