Improving inguinal hernia outcomes by measuring quality:
We constantly look at ways to improve the care we provide our patients. We tirelessly work to improve our patients’ experience throughout the entire process - from initial call to final postoperative visit. This occasionally includes small changes to the actual procedures we perform and the medications we prescribe. Our aim is to provide the highest overall quality of care and patient experience in the Boston area and beyond.
An important aspect of improving care is to measure our patients’ outcomes. Over three years ago, we started the process of investigating how our patients recover from surgery. We wanted to look at results that matter the most to our patients. We used conventional tools routinely used in medical research as well as tools specifically designed for our patients undergoing hernia surgery. Our goals were to obtain objective information about recovery to pass on to future patients and to learn areas of care that we can improve.
We wanted to answer several questions about hernia surgery:
How much pain do our patients experience after surgery?
How many prescription opioid tablets do patients take after surgery?
How many days of work do patients miss?
Are patients restricted in their daily activity after inguinal hernia surgery?
Highlights of our study’s outcomes:
Over half (59.5%) of our patients did not require prescription opioid medications to manage their pain after surgery.
None of our patients were taking prescription opioid medications 1-2 weeks after surgery
Of the patients that did take prescription opioid medications for their pain after surgery, most took 4 pills or less. As a result we changed our prescription from 10 to six tablets for most patients
Almost 2/3 of our patients were able to return to work after missing only 3 days or less.
All of our patients were able to return to their daily activity within 2-3 weeks, one a few had some persistent discomfort. This is an excellent marker for a low risk of chronic pain after hernia surgery. Since Chronic pain affects more than 10% of inguinal hernia patients in the USA, our patients may experience a significantly lower risk of this common problem.
What we learned from our study and how it has changed our hernia practice:
Many of our patients can manage postoperative pain with over the counter medications such as tylenol and advil, and we counsel them before surgery to avoid opioid medications if possible.
Even if patients did use the opioid medications, they very rarely required the full prescription we were giving them (10 tablets). Since completing this study, we have reduced our prescriptions to six opioid tablets.
Recent medical research suggested prescribing 15 tablets instead of 30 Tablets for hernia surgery. Prescribing 15 tablets may still be overprescribing by 300%. By prescribing only six tablets of opioids we are reducing the number of tablets that potentially can be abused.
Details of our study including all of our results are published online in the Journal Surgery at this link :
As a result of our study, Massachusetts General Hospital and Newton Wellesley Hospital put out this press release which can be accessed at this website and the text is written below. Many other news outlets have picked up our study:
Study finds patients needed fewer opioid tablets than prescribed after hernia surgery
More than half the participants in Mass. General/Newton-Wellesley study totally relied on nonopioid medications to control postoperative pain
A study by investigators from Massachusetts General Hospital (MGH) and Newton-Wellesley Hospital(NWH) found that patients prescribed opioid medications after inguinal (groin) hernia surgery used significantly fewer tablets than prescribed, even though they had received fewer than typically administered for such surgery. Not only did 86 percent of patients use less than half the prescribed tablets, 60 percent of them used no opioids at all, relying totally on other types of pain medication.
“The implication of our study is that, even though surgeons have been careful to limit the number of opioid tablets that we prescribe following operations, we may still be prescribing more medication than is actually needed by our patients,” says Peter Masiakos, MD, Department of Pediatric Surgery, MassGeneral Hospital for Children, senior author of the paper that has been published online in the journal Surgery. “While these results need to be replicated in other practices and institutions, we have initiated a change in our prescribing practices in light of these findings.”
Noting the significant impact of the opioid epidemic throughout society – with a quadrupling of deaths caused by prescription opioid overdoses during the past decade – the authors cite recent data indicating that the risk of postoperative opioid prescriptions leading to dependence may be as high as 6 percent and even higher if patients are prescribed longer-term, higher-dose opioid treatment. While several studies have traced opioid overprescribing to primary care physicians, the authors note that surgeons may also overprescribe. One recent study reported that patients routinely were prescribed an average of 30 opioid tablets after inguinal hernia repair surgery and recommended a reduction to 15 tablets.
Since the conclusions of that study were not based on patients’ reports of their actual need for opioid treatment, the research team – including Michael Reinhorn, MD, an NWH general surgeon who specializes in hernia repair – surveyed 186 patients treated in Reinhorn’s practice from October 2015 through September 2016. Participants were adults who had elective inguinal hernia repair under local anesthesia with intravenous sedation. For postoperative pain relief, each patient was given a prescription for 10 tablets of the opioid medication Vicodin but also was encouraged to use nonopioid medications like acetaminophen or ibuprofen to manage their pain whenever possible.
At their follow-up appointments two to three weeks after surgery, participants were surveyed regarding the levels of postoperative pain they experienced, how it had affected their functioning and how many opioid tablets they had taken. While 13 patients reported needing nine or more opioid tablets, 159 (86 percent) took four or fewer tablets, and 110 (60 percent) took none. No patient reported taking any Vicodin during the week before the follow-up visit.
Asked how much their pain had interfered with their daily lives, 67 percent reported no interference, 23 percent indicated only slightly restricting their activities because of pain, and only five patients reported a significant effect of postoperative pain on their daily activities. The patients who reported taking no opioid tablets were least likely to report having experienced a high level of pain or curtailing their daily activities because of pain.
“We’ve been informally asking postoperative patients about their use of opioids for years, so we expected to see about 50 percent of our patients using opioids,” says Reinhorn. “While we were quite pleased to have our suspicions confirmed, it was surprising that, of the 40 percent who did take opioids, most only took two to four pills, and most reported only needing Vicodin to help them sleep comfortably at night.”
Masiakos says, “These results suggest that we should take a detailed look at our patient’s experiences and our prescribing habits to really determine how much opioid medication we should provide our patients. Writing smaller prescriptions should help reduce the number of extra opioid tablets that could be diverted or abused. Patients who experience more pain than expected or need more pain tablets than they are prescribed would alert us to the possibility of a postoperative problem that might need attention.”
Masiakos is an associate professor of Surgery at Harvard Medical School, and Reinhorn is an associate clinical professor of Surgery at Tufts University School of Medicine. Konstantinos Mylonas, MD, of MGH Surgery, is lead and corresponding author of the Surgery paper. Additional co-authors are Lauren Ott, PA-C, NWH Surgery, and Maggie Westfal, MD, MPH, MGH Surgery.
Newton-Wellesley Hospital provides a wide range of services, including medical, surgical, obstetrics and gynecology, cardiovascular, emergency, orthopædic, neonatal, pediatric, hematology/oncology and psychiatric care. Newton-Wellesley has been serving its community for over a century. The medical staff of the hospital includes nearly 1,000 physicians practicing a full range of specialties. NWH is a major teaching hospital for Tufts University School of Medicine and has established postgraduate training programs for Massachusetts General Hospital and Brigham and Women’s Hospital residents, teaching hospitals of Harvard Medical School.
Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH Research Institute conducts the largest hospital-based research program in the nation, with an annual research budget of more than $800 million and major research centers in HIV/AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, genomic medicine, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, photomedicine and transplantation biology. The MGH topped the 2015 Nature Index list of health care organizations publishing in leading scientific journals, earned the prestigious 2015 Foster G. McGaw Prize for Excellence in Community Service. In August 2017 the MGH was once again named to the Honor Roll in the U.S. News & World Report list of "America's Best Hospitals."