Rapid Recovery Pathway (RRP) Utilizing Intrathecal Morphine Decreases Overall Hospital Costs and Improves Quality of Care in Adolescent Idiopathic Scoliosis (AIS)

BACKGROUND CONTEXT

Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is a complex procedure for which charges can exceed $150,000. Among the total costs, inpatient and intensive unit care contributed 22%. Many institutions have implemented rapid recovery pathways (RRP) to improve patient care following scoliosis surgery. Most RRPs encourage early ambulation, feeding, and stooling in combination with patient-controlled analgesia (PCA).

PURPOSE

This study aims to determine the effects of a multimodal RRP, utilizing intrathecal morphine (ITM) in combination with oral pain medication, on hospital costs and patient management.

STUDY DESIGN/SETTING

Retrospective review.

PATIENT SAMPLE

AIS patients undergoing posterior spinal fusion between 2013 and 2019.

OUTCOME MEASURES

Surgical outcomes and associated costs.

METHODS

Patients after February 2018 were placed in the RRP group. These patients received ITM as part of their multimodal analgesia. Fusion level-matched control patients, treated before February 2018, received hydromorphone PCA as the mainstay of their postoperative pain management. At discharge PCA patients received 14-day prescriptions for oxycodone compared to 7-day prescriptions in the ITM group. Perioperative data, requests for opioid refill, and overall costs were compared using McNemar's and Wilcoxon Signed-Rank tests.

RESULTS

A total of 363 patients were included (PCA: 255, RRP/ITM: 108). BMI (p = 0.786) and median preoperative Cobb angle (p = 0.343) were similar between both groups. RRP patients had a significantly shorter length of stay (3 days vs 5 days, p <0.001) and 65.2% of RRP patients ambulated by postoperative day (POD) 1 compared to 43.4% of PCA patients (p < 0.001). The fraction of patients who requested opioid refills was similar between both groups (p = 0.082). The cost of intraoperative anesthesia was significantly higher for RRP patients ($2,286.87 v $1,958.70, p<0.001). Perioperative hospital stay ($39,990.00 vs $55,680.00, p<0.001) was significantly lower for the RRP patients. Due to different prescription durations, the cost of home opioid medications was $98.94 for PCA patients vs $56.28 for RRP, based on standard Medicaid costs.

CONCLUSIONS

The RRP protocol following PSF had lower total hospital costs and lower home opioid requirements after surgery than the traditional PCA protocol.

FDA DEVICE/DRUG STATUS

intrathecal morphine, oxycodone: Approved.