The Multitudinous Forms of Postoperative Multimodal Analgesia: A Pennsylvania NSQIP Program Study

INTRODUCTION: Amid the opioid epidemic, policymakers have advocated for postoperative nonopioid (ie multimodal) analgesia to reduce opioid use, including through new Centers for Medicare & Medicaid Services quality measures. However, limited guidelines exist for multimodal analgesia. We sought to characterize postoperative multimodal regimens and identify predictors of multimodal therapy. METHODS: A retrospective analysis was conducted of general, orthopaedic, vascular, and obstetric surgical procedures performed at Pennsylvania institutions in American College of Surgeons NSQIP from September 2019 to February 2020. Postoperative multimodal analgesia was defined as using ≥1 nonopioid analgesic; regimens including ≥2 nonopioid analgesics or a regional block were designated as “intensive” multimodal. Descriptive analyses were performed to characterize multimodal regimens. Multivariable logistic regression models adjusted for patient factors were used to identify predictors of any multimodal and intensive multimodal. RESULTS: Of 2,608 patients, 1,842 (70.6%) received any multimodal and 59% received intensive multimodal. There were 126 different regimens (Fig. 1). A median of 2 (interquartile range 0 to 3) multimodal agents were used, varying by procedure from 0 (aortoiliac/infrainguinal bypass, cholecystectomy) to 3 (colectomy, hysterectomy, total hip/knee replacement). Odds of multimodal use were lower among Hispanic vs non-Hispanic patients (odds ratio [OR] 0.38 [95% CI 0.21 to 0.70], p = 0.002). Procedures including total hip/knee replacement (OR 4.25 [95% CI 1.79 to 10.09], p = 0.001) had higher odds of multimodal use compared with appendectomy; others, including aortoiliac/infrainguinal bypass (OR 0.10 [95% CI 0.05 to 0.22], p < 0.001), had lower odds. Similar results were observed for intensive multimodal.Figure 1CONCLUSION: Adherence to postoperative multimodal use was high overall. However, approaches to achieving this varied widely across patients and procedures, highlighting the need for further research to understand the safety and efficacy of current approaches.