Surgical Outcomes Program News

Reducing life-threatening risks for patients undergoing colon surgery by predicting risk of leaks

June 26, 2019

A colectomy is a surgery to remove part of or the entire colon. Up to 20% of the time, when the remaining sections of intestine are reconnected, a leak occurs, which can be life-threatening.

Using a temporary external fecal port (ostomy) to divert waste allows the surgical site to heal before having to resume function. However, ostomies carry their own risks and are not always the right choice.

Surgical Outcomes Program fellow Nicholas P. McKenna, M.D., and other researchers in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery partnered with the Division of Colon and Rectal Surgery to develop and validate a risk score to predict an individual's risk of anastomotic leak after elective left-sided surgery.

Using data from the American College of Surgeons National Surgical Quality Improvement Program, research team members analyzed demographic and operative characteristics of 37,950 patients. They identified eight preoperative factors and three intraoperative factors that led to increased leak risk.

In addition to mapping distinct risk levels, the team was able to show how often diversions are used inappropriately.

The Mayo Clinic Department of Surgery is evaluating how to disseminate and implement this new tool, and other researchers in the Mayo Clinic Kern Center for the Science of Health Care Delivery are planning an economic analysis to determine potential health care savings from using the tool.

Read the study abstract on PubMed.

Historically "safer" tramadol more likely than other opioids to result in prolonged use

May 14, 2019

Surgical patients receiving the opioid tramadol have a somewhat higher risk of prolonged use than those receiving other common opioids, new Mayo Clinic research finds. However, the Drug Enforcement Administration (DEA) classifies tramadol as a Schedule IV controlled substance, meaning it's considered to have a lower risk of addiction and abuse than Schedule II opioids, such as oxycodone and hydrocodone.

"This data will force us to reevaluate our postsurgical prescribing guidelines," says lead author Cornelius Thiels, D.O. "And while tramadol may still be an acceptable option for some patients, our data suggests we should be as cautious with tramadol as we are with other short-acting opioids."

The Mayo Clinic team of physicians and researchers used the OptumLabs Data Warehouse to examine the records of 444,764 patients who underwent 20 common surgeries across the U.S. between Jan. 1, 2009, and June 30, 2018.

The team found that 357,884 filled a prescription for opioids after surgery.

Among them:

  • "Additional use," defined by the team as at least one refill 90-180 days after surgery, was at 7%.
  • "Persistent use," which the team defined as a prescription refill 180-270 days after surgery, was observed in 1% of patients.
  • "Long-term use," or 10 or more prescription fills or 120 or more days' supply, occurred in 0.5% of patients.

And, the team discovered, patients in all three categories were more likely to have received a prescription for tramadol.

Read the study abstract on PubMed.

Clearer discharge instructions decrease readmissions, study finds

Jan. 9, 2019

When patients leave the hospital following an injury, stroke, surgery or other event, they are often loaded down with paperwork on how to take care of themselves. It can be overwhelming, and Mayo Clinic researchers found that much of it can be at a higher reading level than patients can comprehend.

Read the study abstract on PubMed.

The research team then revised patients' discharge instructions to make them more readable, and found not only that there were many fewer phone calls from patients asking for clearer instructions, but also that there were fewer readmissions.

Read the study abstract on PubMed.

Since then, the team has revised all templates for discharge instructions in the Division of Trauma, Critical Care and General Surgery to lower than an eighth-grade reading level. The team is pleased with the results so far.

"We can indeed enhance patient understanding, and this leads to positive outcomes for both the patients and the providers," says Martin D. Zielinski, M.D., the medical director of trauma clinical research at Mayo Clinic.

"The Mayo Clinic Kern Center for the Science of Health Care Delivery provides outstanding resources with knowledgeable people who are on the cutting edge of the science of health care delivery," says Dr. Zielinski. "They are invaluable contributors without whom we could not have been successful on ensuring our patients receive the best care possible."

Almost 1 in 3 patients used no opioids prescribed after surgery, Mayo Clinic survey finds

April 19, 2018

Nearly a third of patients responding to a Mayo Clinic survey said they used none of the opioids they were prescribed after surgery. The research findings also show that only about 8% of patients disposed of their remaining opioids.

The researchers also found that:

  • At discharge, 92% of patients received an opioid prescription.
  • Of the opioids prescribed, 63% went unused.
  • Patients reported satisfaction with their pain control in 90% of cases.
  • Of the patients, 28% said they were prescribed too many opioids, while 8% said they were prescribed too few.
  • The median amount of opioids consumed per patient equaled about six pills of 5-milligram oxycodone.

The number of opioids patients needed after discharge also varied significantly depending on the type of surgery. To conduct the research, a cross-specialty team of physicians and researchers surveyed 1,907 patients who underwent 25 common surgeries at three academic medical centers.

"This research provides a road map for physicians and surgical departments. It shows there are certain surgeries and types of patients who are likely receiving significantly more opioids than needed," says Elizabeth B. Habermann, Ph.D., senior author on the study and the Robert D. and Patricia E. Kern Scientific Director for Surgical Outcomes.

In addition, the findings identify factors that can help develop guidelines and optimize opioid prescriptions patients receive after surgery. Based on this research and the team's previous findings, Mayo Clinic has implemented evidence-based opioid prescribing guidelines specific to surgical areas, beginning with the Department of Orthopedic Surgery.

There, the guidelines already have led to a considerable reduction in opioid prescriptions. For example, the median amount prescribed dropped by half for total knee and total hip surgeries.

Read the study abstract on PubMed.

New Mayo guidelines cut some opioid prescriptions by half

April 16, 2018

Mayo Clinic researchers are studying the clinic's opioid prescribing practices after surgery, discovering areas for improvement based on that evidence, and applying their findings to optimize care for individual patients.

In the Mayo Clinic Department of Orthopedic Surgery, the result is a 48% reduction in the amount of opioids prescribed for hip and knee replacement surgery. The team also noted that the prescription refill rate remained the same.

"These findings show that simply creating and adhering to procedure-specific opioid prescribing guidelines based on scientific research can yield significant results," says lead author Cody C. Wyles, M.D., a Mayo Clinic orthopedic surgical resident.

The work to refine opioid prescriptions after surgery began with a collaborative effort among Mayo Clinic physicians, pharmacists, pain medicine specialists, nurses and research scientists in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. The cross-specialty research team looked at opioid prescriptions written at Mayo Clinic for 25 common surgeries, and found areas for improvement.

To address the issues, the team created opioid prescribing guidelines for the common surgeries, which were first implemented by the Department of Orthopedic Surgery.

The study compared opioid prescriptions and refill rates for patients undergoing knee or hip replacement surgery on the Rochester, Minnesota, campus of Mayo Clinic who hadn't received a prescription in the previous 90 days. The team compared 751 patients during the five months after the guidelines took effect (August-December 2017) to the 1,822 patients who had hip or knee replacement surgery during 2016 who met those criteria.

The authors found that the median prescription dropped 48%, from the equivalent of roughly 95 pills of 5-milligram oxycodone to about 50 pills. Overall, the middle 50% range of prescriptions decreased from about 70-115 pills to 45-50 pills. They also report no statistically significant change in refill rates.

Read the article in Clinical Orthopaedics and Related Research.