With rising costs of care and new federal mandates tying value-based incentive payments to patient satisfaction, hospitals are striving to find innovative ways to improve cost efficiencies while enhancing the quality of patient care. According to recently published data in the Journal of Pain Research, a new approach to managing post-surgical pain may hold the key to improving patient outcomes while curbing per patient spending.
Post-surgical pain remains a major concern for most patients and has been highly correlated with satisfaction scores; yet, updates to pain management protocols have lagged years behind the exciting advances in minimally invasive surgical techniques. 
Currently, narcotics enjoy the status of being virtually indispensable to the standard pain management toolbox, despite risks of debilitating side effects, abuse and long-term dependence. Some clinicians would argue that until recently, the alternatives to narcotics were oral and IV NSAIDs, which do not offer comparable potency, and local analgesics, which are short-acting and require cumbersome tethering to catheters to produce long-lasting analgesia.
In 2011, the FDA approved EXPAREL® (bupivacaine liposome injectable suspension), a new formulation of the familiar local analgesic bupivacaine. The bupivacaine in EXPAREL is encapsulated in liposomes (fat molecules) which disintegrate over time to produce up to 72-hours of analgesia. Standard bupivacaine, while effective, only lasts up to eight hours and was used as a short-term fix to bridge the gap between post-anesthesia and post-surgical narcotics taking effect. However, with the liposomal formulation significantly extending the potent analgesic effect of bupivacaine, surgeons are now able to replace elastomeric pumps and rely less on narcotic-heavy regimens as the first line of defense against postsurgical pain.
Understandably, given the shrinking pharmacy budgets and increased scrutiny on spending, hospital purchasing decision makers remained cautious about adopting any new therapy without a strong case for the ROI of its use.
In order to better understand the potential ROI of EXPAREL, 13 surgeons from across the U.S., myself included, were invited to lead a series of Phase 4 clinical studies to establish a measurable value of using EXPAREL versus a standard narcotic-based pain management program in a real-world setting. The program enrolled 191 patients who underwent common abdominal soft tissue procedures including open colectomy, laparoscopic colectomy, and ileostomy reversal; 105 patients received an opioid-based postsurgical analgesic regimen via intravenous patient controlled analgesia (IV opioid PCA), and 86 patients received an Exparel-based regimen.
Investigators measured total opioid consumption, incidence of opioid-related adverse events, length of hospital stay and hospitalization costs. The results, published in the Journal of Pain Research1 found that patients in the EXPAREL-based multimodal group experienced:
- A 60-percent reduction in total narcotic consumption (38 mg versus 96 mg in the IV opioid PCA group; P < 0.0001)
- A 67-percent reduction in incidence of ORAEs (9 percent versus 27 percent in the IV opioid PCA group; P=0.0027)
- A 1.4 day reduction in median length of hospital stay (2.9 versus 4.3 days in the IV opioid PCA group; P < 0.0001)
- A $2,455 savings in mean per-patient hospitalization costs ($8,271 versus $10,726 for the IV opioid PCA group; P = 0.0109).
From a hospital perspective, shorter patient stays, lower per patient costs and high patient satisfaction ratings translate to significant cost savings on the institutional level — savings which are likely to offset any upfront incremental spending from the pharmacy budget. But economics aside, a non-narcotic, multimodal pain management approach can provide effective analgesia, reduce opioid load and minimize preventable complications associated with ORAEs — all of which meaningfully enhance patient quality of life and result in a safer, faster and more comfortable recovery experience. By staying abreast of the latest evidence-based studies on treatments and protocols that improve patient and economic outcomes, healthcare providers and institutions can ensure that patients receive the highest level of care and hospitals avoid unnecessary incremental costs.
Dr. Stephen Cohen is a colorectal surgeon based in Atlanta and an innovator, pioneer and pacesetter of emerging, developing and innovative colorectal techniques including painless hemorrhoid treatments, state-of-the-art incontinence procedures and new paradigms in postoperative care. Dr. Cohen is active in teaching, educating and collaborating with physicians both domestically and internationally, in which his passion is advocating for advances in colorectal diagnosis and treatment, promoting quality access, and maintaining affordability in the current healthcare debate.
1 Cohen, Stephen M., et al. "Liposome bupivacaine for improvement in economic outcomes and opioid burden in GI surgery: IMPROVE Study pooled analysis." Journal of pain research 7 (2014): 359.