JMIR Publications

ABSTRACT

Background:

Exposure to opioids after surgery is the first point of contact for some people who develop chronic opioid use disorder. Hence, effective postoperative pain management, with less reliance on opioids, is critical. The Perioperative Opioid Quality Improvement (POQI) program developed and implemented 1) a digital health platform leveraging patient-reported risk factors from surveys and 2) a post-surgical pain risk stratification algorithm to personalize perioperative care planning through the integration of several commercially available digital health solutions into one combined POQI platform. As a result of the COVID-19 pandemic, the POQI platform development was reduced in scope.

Objective:

This was a pilot study to assess the screening performance of the risk algorithm, quantify the utilization of the POQI platform, and evaluate clinicians’ and patients’ perceptions of utility and benefit.

Methods:

An initial prototype of the POQI platform was implemented in a quality improvement initiative at a Canadian tertiary care centre and evaluated between Jan-Sep/2022. After surgical booking, a preliminary risk stratification algorithm was applied to responses to a health history questionnaire. The resulting estimated risk guided assigning the patient to a care pathway based on low- or high-risk for persistent pain and opioid use. Demographic, procedural, and medication administration data were extracted retrospectively from the electronic medical record. Postoperative inpatient opioid usage >90 morphine milligram equivalents per day was used as the outcome to assess algorithm performance. Data were summarized and compared between low- and high-risk groups. Classification data was assessed by a confusion matrix. POQI utilization was assessed by completed surveys on postoperative days 7, 14, 30, 60, 90 and 120. Semi-structured interviews were conducted with patients and clinicians to obtain qualitative feedback on the platform.

Results:

Two hundred and seventy-six eligible patients were admitted for colorectal procedures. The risk algorithm stratified 203/276 (74%) as low-risk and 73/276 (26%) as high-risk. Among the 214/276 patients with available data, high-risk patients were younger than low-risk patients (median age 53 vs. 59 years, median difference [MD] 5 years, 95%CI 1-9, p=0.021), more often female (61.6% vs. 38.4%, odds ratio 2.5, 95%CI 1.4-4.5, p=0.002), and reported lower baseline (preoperative) quality of recovery scores (median 122 vs. 131, MD 12, 95%CI 2-23, p=0.016). The pilot risk stratification algorithm was reasonably specific (true negative rate 72%) but not sensitive (true positive rate 32%). A minority of patients (85/214; 40%) completed any postoperative quality of recovery questionnaires; 14/214 (7%) did so beyond 60 days post-surgery; and 49/214 completed post-discharge medication surveys. Interviewed participants welcomed the initiative but noted usability issues and poor platform education.

Conclusions:

An initial prototype of the POQI platform was deployed operationally; the pilot risk algorithm had reasonable specificity but poor sensitivity. Attrition was high, with a significant loss to follow-up in post-discharge survey completion. Shortcomings in the design and implementation of the platform were expressed in qualitative feedback from clinicians and patients, yet they appreciated the potential impact of pre-emptively addressing opioid exposure. Thus, an iterative platform re-design with additional available features and re-evaluation should be undertaken before broader implementation.