Variations in Current Practice and Protocols of Intraoperative Multimodal Analgesia: A Cross-Sectional Study Within a Six-Hospital US Health Care System
Authors: Graham Laura A. , Illarmo Samantha S. , Wren Sherry M. , Odden Michelle C. , Mudumbai Seshadri C. 
Published: October 2024

BACKGROUND:
Multimodal analgesia (MMA) aims to reduce surgery-related opioid needs by adding nonopioid pain medications in postoperative pain management. In light of the opioid epidemic, MMA use has increased rapidly over the past decade. We hypothesize that the rapid adoption of MMA has resulted in variation in practice. This cross-sectional study aimed to determine how MMA practices have changed over the past 6 years and whether there is variation in use by patient, provider, and facility characteristics.

METHODS:
Our study population includes all patients undergoing surgery with general anesthesia at 1 of 6 geographically similar hospitals in the United States between January 1, 2017 and December 31, 2022. Intraoperative pain medications were obtained from the hospital’s perioperative information management system. MMA was defined as an opioid plus at least 2 other nonopioid analgesics. Frequencies, χ2 tests (χ2), range, and interquartile range (IQR) were used to describe variation in MMA practice over time, by patient and procedure characteristics, across hospitals, and across anesthesiologists. Multivariable logistic regression was conducted to understand the independent contributions of patient and procedural factors to MMA use.

RESULTS:
We identified 25,386 procedures among 21,227 patients. Overall, 46.9% of cases met our definition of MMA. Patients who received MMA were more likely to be younger females with a lower comorbidity burden undergoing longer and more complex procedures that included an inpatient admission. MMA use has increased steadily by an average of 3.0% each year since 2017 (95% confidence interval =2.6%–3.3%). There was significant variation in use across hospitals (n = 6, range =25.9%–68.6%, χ2 = 3774.9, P < .001) and anesthesiologists (n = 190, IQR =29.8%–65.8%, χ2 = 1938.5, P < .001), as well as by procedure characteristics. The most common MMA protocols contained acetaminophen plus regional anesthesia (13.0% of protocols) or acetaminophen plus dexamethasone (12.2% of protocols). During the study period, the use of opioids during the preoperative or intraoperative period decreased from 91.4% to 86.0% of cases; acetaminophen use increased (41.9%–70.5%, P < .001); dexamethasone use increased (24.0%–36.1%, P < .001) and nonsteroidal anti-inflammatory drugs (NSAIDs) increased (6.9%–17.3%, P < .001). Gabapentinoids and IV lidocaine were less frequently used but also increased (0.8%–1.6% and 3.4%–5.3%, respectively, P < .001).

CONCLUSIONS:
In a large integrated US health care system, approximately 50% of noncardiac surgery patients received MMA. Still, there was wide variation in MMA use by patient and procedure characteristics and across hospitals and anesthesiologists. Our findings highlight a need for further research to understand the reasons for these variations and guide the safe and effective adoption of MMA into routine practice.