阿片类药物安全性应用指南对全膝关节置换术患者的影响
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Impact of an Opioid Safety Initiative on Patients Undergoing Total Knee Arthroplasty ：A Time Series Analysis
背景与目的
阿片类药物安全指南旨在减少大剂量药物使用。这项研究试图检验这种干预(即阿片类药物安全指南)对接受全膝关节置换术的患者的疼痛评分和阿片类药物处方的影响。
方 法
这是一项连续72个月(2010年1月至2015年12月)每月对700至850名患者进行的群体水平数据的研究。作者研究了阿片类药物安全指南(2013年10月)实施前和实施后的干预组的特征。每个月，作者在群体水平上汇总每个患者的平均术后疼痛评分与术前疼痛评分之间的差异(平均超过6个月)，并记录在术前和术后使用阿片(和非阿片类药物)处方超过3个月的患者比例(每1000人)。作者比较了干预后趋势与基于干预前措施预测的趋势。
结 果
阿片类药物安全指南实施后，患者年龄稍微偏大，病情更重，但死亡率较低(干预后n=28，509 vs干预前n=31，547)。术后疼痛评分略高，阿片类药物使用减少具有统计学意义，即减少了871名(95% CI, 474至1268)术后长期服用处方的患者(95%CI，474-1，268)。在时间序列分析中，平均术后减去术前的疼痛评分从0.65增加到0.81，增加了0.16分(95%CI，0.05-0.27)。术后长期服用阿片类药物的患者和术前长期服用阿片类药物的患者的比例分别下降了20%(n=3，355vs.预期n=4，226)和13%(n=5，861vs.预期n=6，724)。非阿片类镇痛药使用增加。敏感性分析证实了所有的发现。
结 论
指南倡议有效地减少接受全膝关节置换术的人群使用阿片类药物，同时对疼痛评分的影响最小。
原始文献摘要
Qi Chen, M.D, Hung-Lun Hsia, Robert Overman. Impact of an Opioid Safety Initiative on Patients Undergoing Total Knee Arthroplasty ：A Time Series Analysis[J].ANESTHESIOLOGY 2019; 131:369–380.
Background: The Opioid Safety Initiative decreased high-dose prescriptions across the Veterans Health Administration. This study sought to examine the impact of this intervention (i.e., the Opioid Safety Initiative) on pain scores and opioid prescriptions in patients undergoing total knee arthroplasty.
Methods: This was an ecological study of group-level data among 700 to 850 patients per month over 72 consecutive months (January 2010 to December 2015). The authors examined characteristics of cohorts treated before versus after rollout of the Opioid Safety Initiative (October 2013). Each month, the authors aggregated at the group-level the differences between mean postoperative and preoperative pain scores for each patient (averaged over 6-month periods), and measured proportions of patients (per 1,000) with opioid (and nonopioid) prescriptions for more than 3 months in 6-month periods, preoperatively and postoperatively. The authors compared postintervention trends versus trends forecasted based on preintervention measures.
Results: After the Opioid Safety Initiative, patients were slightly older and sicker, but had lower mortality rates (postintervention n = 28,509 vs. preintervention n = 31,547). Postoperative pain scores were slightly higher and the decrease in opioid use was statistically significant, i.e., 871 (95% CI, 474 to 1,268) fewer patients with chronic postoperative prescriptions. In time series analyses, mean postoperative minus preoperative pain scores had increased from 0.65 to 0.81, by 0.16 points (95% CI, 0.05 to 0.27). Proportions of patients with chronic postoperative and chronic preoperative opioid prescriptions had declined by 20% (n = 3,355 vs. expected n = 4,226) and by 13% (n = 5,861 vs. expected n = 6,724), respectively. Nonopioid analgesia had increased. Sensitivity analyses confirmed all findings.
Conclusions: A system-wide initiative combining guideline dissemination with audit and feedback was effective in significantly decreasing opioid prescriptions in populations undergoing total knee arthroplasty, while minimally impacting pain scores.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：代东君 编辑：何幼芹 审校：王贵龙