Variation in Intraoperative Opioid Administration by Patient, Clinician, and Hospital Contribution

This cohort study investigates the contributions of patients, clinicians, and hospitals to variation in intraoperative opioid administration for surgical procedures.


eFigure 9 :
Intraoperative opioid administration by anesthesiologist for spine surgeries.eFigure 10: Intraoperative opioid administration by anesthesiologist for upper abdominal surgeries.Intraoperative opioid administration by surgeon for cardiac surgeries.eFigure 12: Intraoperative opioid administration by surgeon for hip surgeries.Intraoperative opioid administration by surgeon for hysterectomy surgeries.eFigure14: Intraoperative opioid administration by surgeon for knee surgeries.Intraoperative opioid administration by surgeon for lower abdominal surgeries.eFigure 16: Intraoperative opioid administration by surgeon for vascular surgeries.Intraoperative opioid administration by surgeon for spine surgeries.eFigure 18: Intraoperative opioid administration by surgeon for upper abdominal surgeries.

eAppendix 1 .
Surgical Grouping by Current Procedural Terminology Code eAppendix 2. Analytical Dataset Characteristics eAppendix 3. ICD-9 and ICD-10 Codes Used to Determine Use and Abuse History Individual Hospitals Ranked by Intraoperative Opioid Administration eAppendix 9. Anesthesiologist, Surgeon, and Hospital Variation by Surgical Category eAppendix 10.Full Model Results for Generalized Linear Mixed Model With Random Intercept eAppendix 11.Adjusted Intraclass Correlation Coefficients by Surgical Group or Analgesic Category eTable 1. Surgical Grouping by Current Procedural Terminology Code eTable 2. Characteristics of Full Dataset eTable 3. ICD-9 and ICD-10 Codes Used to Determine Use and Abuse History

eTable 4. Oral Morphine Equivalency Conversions eTable 5. Full
Model Results for Generalized Linear Mixed Model With Random Intercept Individual Hospitals Ranked by Intraoperative Opioid Administration eFigure 3. Intraoperative Opioid Administration by Anesthesiologist for Cardiac Surgeries eFigure 4. Intraoperative Opioid Administration by Anesthesiologist for Hip Surgeries eFigure 5. Intraoperative Opioid Administration by Anesthesiologist for Hysterectomy Surgeries eFigure 6. Intraoperative Opioid Administration by Anesthesiologist for Knee Surgeries eFigure 7. Intraoperative Opioid Administration by Anesthesiologist for Lower Abdominal Surgeries eFigure 8. Intraoperative Opioid Administration by Anesthesiologist for Vascular Surgeries eFigure 9. Intraoperative Opioid Administration by Anesthesiologist for Spine Surgeries eFigure 10.Intraoperative Opioid Administration by Anesthesiologist for Upper Abdominal Surgeries eFigure 11.Intraoperative Opioid Administration by Surgeon for Cardiac Surgeries eFigure 12. Intraoperative Opioid Administration by Surgeon for Hip Surgeries eFigure 13.Intraoperative Opioid Administration by Surgeon for Hysterectomy Surgeries eFigure 14.Intraoperative Opioid Administration by Surgeon for Knee Surgeries eFigure 15.Intraoperative Opioid Administration by Surgeon for Lower Abdominal Surgeries eFigure 16.Intraoperative Opioid Administration by Surgeon for Vascular Surgeries eFigure 17.Intraoperative Opioid Administration by Surgeon for Spine Surgeries eFigure 18. Intraoperative Opioid Administration by Surgeon for Upper Abdominal Surgeries eFigure 19.Intraoperative Opioid Administration by Hospital for Cardiac Surgeries eFigure 20.Intraoperative Opioid Administration by Hospital for Hip Surgeries eFigure 21.Intraoperative Opioid Administration by Hospital for Hysterectomy Surgeries eFigure 22. Intraoperative Opioid Administration by Hospital for Knee Surgeries eFigure 23.Intraoperative Opioid Administration by Hospital for Lower Abdominal Surgeries eFigure 24.Intraoperative Opioid Administration by Hospital for Vascular Surgeries eFigure 25.Intraoperative Opioid Administration by Hospital for Spine Surgeries eFigure 26.Intraoperative Opioid Administration by Hospital for Upper Abdominal Surgeries eFigure 27.Intraclass Correlation Coefficients of Adjusted Intraoperative Opioid Administration by Surgical Category and Patient, Anesthesiologist, and Hospital eFigure 28.Intraclass Correlation Coefficients of Adjusted Intraoperative Opioid Administration by Surgical Category and Patient, Surgeon, and Hospital eFigure 29.Intraclass Correlation Coefficients of Adjusted Intraoperative Opioid Administration by Analgesic Category and Patient, Surgeon, and HospitalThis supplemental material has been provided by the authors to give readers additional information about their work.

Supplemental Material 1 Surgical Grouping by Current Procedural Terminology (CPT) Primary Anesthesia CPT Description Percentage of Total Cases (%) Lower Abdomen 24.3%
Surgical Grouping by Current Procedural Terminology (CPT) Code.Exclusion criteria were applied to the overall starting population to result in the Final Dataset (n = 1,012,592).Missing data elements consist of missing patient weight, CPT codes, or case duration.Unable to calculate OME results from inappropriate medication dose and unit of measure data.OME = Oral Morphine Equivalency.Vendone, Verdrocet, Vicodin, Vicoprofen, Vopac, Wygesic, Xartemis, Xodol, Xolox, Xtampza, Xylon, Zamicet, Zerlor, Zohydro, Zolvit, Zubsolv, Zydone This list of medications is adapted from: CDC File of National Drug Codes for Selected Benzodiazepines, Muscle Relaxants, Stimulants, Opioid analgesics, and Linked Oral Morphine Milligram Equivalent Conversion Factors for Opioids, 2019 Version.Atlanta, GA: Centers for Disease Control and Prevention; 2020.Available upon request at https://www.cdc.gov/opioids/data-resources/index.htmlOne surgery may have more than one analgesic technique (e.g., neuraxial analgesia and remifentanil), except for 'Opioid Only' which was absent from all other techniques.Remifentanil has its own category due to its common intraoperative use and unique pharmacokinetics including rapid plasma metabolization and short context-sensitive half-life.Neuraxial and peripheral categories captured specific nerve blocks identified through note concepts, key word searches, and administered medications.The remifentanil category was defined as the use of the medication remifentanil between anesthesia start and anesthesia end times.The adjuvant category was defined as adjuvant medication use between one hour before anesthesia start to anesthesia end times and given by intravenous, oral, or enteric tube route of delivery Paul W., Shana Palla, Be-Lian Pei, Guddi Kaur, Karen Zhang, Jeanine Hanohano, Mark Munsell, and Eduardo Bruera."Switching from methadone to a different opioid: what is the equianalgesic dose ratio?." Journal of palliative medicine 11, no. 8 (2008): 1103-1108.
Surgeries were grouped by Current Procedural Terminology (CPT) codes into eight categories: lower abdomen, upper abdomen, cardiac, hysterectomy, orthopedic hip, orthopedic knee, orthopedic spine, and vascular).Percentage of the total cases is shown by category as well as individual CPT code.eTable2:Characteristics of the full dataset.NH=non-Hispanic.©2024Burns ML et al.JAMA Network Open.© 2024 Burns ML et al.JAMA Network Open.(SupplementalMaterial 6).Neuraxial and peripheral nerve block phenotypes were created by the coordinating center and return the values detailed below.These phenotypes search note concepts, key words within clinical notes, and medications to define neuraxial and peripheral blocks for each surgery.Neuraxial Nerve Block: Yes = any of the following as defined by the phenotype (Version 1):

Supplemental Material 8 Individual Hospitals Ranked by Intraoperative Opioid Administration eFigure
Rows are ordered by opioid administration with the lowest (top) to highest (bottom) institutional mean across 8 surgical categories (upper abdomen, lower abdomen, cardiac, hysterectomy, orthopedic hip, orthopedic knee, orthopedic spine, and vascular), each separately represented as columns in the table.Dash (-) indicates there were no surgeries at the institution within the specified surgical category.
2: Individual hospitals ranked by intraoperative opioid administration Values are unadjusted intraoperative opioid administration means (OME/kg/hr), with each row representing a de-identified hospital.The mean across the hospital is listed overall (Mean) and by procedure, with the column rank in parentheses.Heat map color is determined within each column.