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Wagner Z, Kirkegaard A, Mariano LT, Doctor JN, Yan X, Persell SD, Goldstein NJ, Fox CR, Brummett CM, Romanelli RJ, Bouskill K, Martinez M, Zanocco K, Meeker D, Mudiganti S, Waljee J, Watkins KE. Peer Comparison or Guideline-Based Feedback and Postsurgery Opioid Prescriptions: A Randomized Clinical Trial. JAMA HEALTH FORUM 2024; 5:e240077. [PMID: 38488780 PMCID: PMC10943416 DOI: 10.1001/jamahealthforum.2024.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/29/2023] [Indexed: 03/18/2024] Open
Abstract
Importance Excess opioid prescribing after surgery can result in prolonged use and diversion. Email feedback based on social norms may reduce the number of pills prescribed. Objective To assess the effectiveness of 2 social norm-based interventions on reducing guideline-discordant opioid prescribing after surgery. Design, Setting, and Participants This cluster randomized clinical trial conducted at a large health care delivery system in northern California between October 2021 and October 2022 included general, obstetric/gynecologic, and orthopedic surgeons with patients aged 18 years or older discharged to home with an oral opioid prescription. Interventions In 19 hospitals, 3 surgical specialties (general, orthopedic, and obstetric/gynecologic) were randomly assigned to a control group or 1 of 2 interventions. The guidelines intervention provided email feedback to surgeons on opioid prescribing relative to institutionally endorsed guidelines; the peer comparison intervention provided email feedback on opioid prescribing relative to that of peer surgeons. Emails were sent to surgeons with at least 2 guideline-discordant prescriptions in the previous month. The control group had no intervention. Main Outcome and Measures The probability that a discharged patient was prescribed a quantity of opioids above the guideline for the respective procedure during the 12 intervention months. Results There were 38 235 patients discharged from 640 surgeons during the 12-month intervention period. Control-group surgeons prescribed above guidelines 36.8% of the time during the intervention period compared with 27.5% and 25.4% among surgeons in the peer comparison and guidelines arms, respectively. In adjusted models, the peer comparison intervention reduced guideline-discordant prescribing by 5.8 percentage points (95% CI, -10.5 to -1.1; P = .03) and the guidelines intervention reduced it by 4.7 percentage points (95% CI, -9.4 to -0.1; P = .05). Effects were driven by surgeons who performed more surgeries and had more guideline-discordant prescribing at baseline. There was no significant difference between interventions. Conclusions and Relevance In this cluster randomized clinical trial, email feedback based on either guidelines or peer comparison reduced opioid prescribing after surgery. Guideline-based feedback was as effective as peer comparison-based feedback. These interventions are simple, low-cost, and scalable, and may reduce downstream opioid misuse. Trial Registration ClinicalTrials.gov NCT05070338.
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Affiliation(s)
| | | | | | - Jason N. Doctor
- Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Xiaowei Yan
- Palo Alto Medical Foundation, Palo Alto, California
| | - Stephen D. Persell
- Division of General Internal Medicine, Department of Medicine, Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Noah J. Goldstein
- Anderson School of Management, Department of Psychology, and Geffen School of Medicine, University of California at Los Angeles, Los Angeles
| | - Craig R. Fox
- Anderson School of Management, Department of Psychology, and Geffen School of Medicine, University of California at Los Angeles, Los Angeles
| | | | - Robert J. Romanelli
- Palo Alto Medical Foundation, Palo Alto, California
- RAND Europe, Westbrook Centre, Cambridge, United Kingdom
| | | | | | - Kyle Zanocco
- Section of Endocrine Surgery, Division of General Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Daniella Meeker
- Keck School of Medicine, USC Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, California
- Yale School of Medicine, New Haven, Connecticut
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Alessio-Bilowus D, Luby AO, Cooley S, Evilsizer S, Seese E, Bicket M, Waljee JF. Perioperative Opioid-Related Harms: Opportunities to Minimize Risk. Semin Plast Surg 2024; 38:61-68. [PMID: 38495063 PMCID: PMC10942841 DOI: 10.1055/s-0043-1778043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Although substantial attention has been given to opioid prescribing in the United States, opioid-related mortality continues to climb due to the rising incidence and prevalence of opioid use disorder. Perioperative care has an important role in the consideration of opioid prescribing and the care of individuals at risk for poor postoperative pain- and opioid-related outcomes. Opioids are effective for acute pain management and commonly prescribed for postoperative pain. However, failure to align prescribing with patient need can result in overprescribing and exacerbate the flow of unused opioids into communities. Conversely, underprescribing can result in the undertreatment of pain, complicating recovery and impairing well-being after surgery. Optimizing pain management can be particularly challenging for individuals who are previously exposed to opioids or have critical risk factors, including opioid use disorder. In this review, we will explore the role of perioperative care in the broader context of the opioid epidemic in the United States, and provide considerations for a multidisciplinary, comprehensive approach to perioperative pain management and optimal opioid stewardship.
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Affiliation(s)
- Dominic Alessio-Bilowus
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Opioid Prescribing Engagement Network, Ann Arbor, Michigan
| | - Alexandra O. Luby
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | | | | | | | - Mark Bicket
- Opioid Prescribing Engagement Network, Ann Arbor, Michigan
- Division of Pain Research, Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan
| | - Jennifer F. Waljee
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Opioid Prescribing Engagement Network, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
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Khouja T, Shah NH, Suda KJ, Polk DE. Trajectories of opioid prescribing by general dentists, specialists, and oral and maxillofacial surgeons in the United States, 2015-2019. J Am Dent Assoc 2024; 155:7-16.e7. [PMID: 37988047 PMCID: PMC10870999 DOI: 10.1016/j.adaj.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Despite decreases in opioid prescribing from 2016 through 2019, some dentists (general, specialists, oral and maxillofacial surgeons) in the United States continue to prescribe opioids at high rates. The authors' objective was to define dentists' trajectories of opioid prescribing. METHODS The authors identified actively prescribing dentists from the IQVIA Longitudinal Prescription data set, from 2015 through 2019. Group-based trajectory modeling identified opioid prescribing trajectories on the basis of dentists' annual prescribing rates for the overall sample (model 1) and for high prescribers (model 2). The authors used χ2 or Mann-Whitney U tests to characterize the model 2 trajectory groups. RESULTS In model 1 (n = 199,145 prescribers), group-based trajectory modeling identified 8 trajectories that were grouped into 5 categories. A total of 14.8% were nonprescribers who composed less than 1% of all prescriptions, low prescribers (3 groups; 46.0%) prescribed at low rates (2015: 5.5%-16.9%; 2019: 1.5%-11.9%), decliners (7.3%) decreased prescribing rapidly (2015: 29.4%; 2019: 5.1%), moderately high prescribers (2 groups; 28.5%) prescribed moderately (2015: 28.7% and 39.2%; 2019: 18.1% and 28.8%), and consistently high prescribers (3.4%) prescribed at high rates (2015: 54.6%; 2019: 44.7%). In model 2, from consistently high prescribers (n = 6,845), 4 trajectories were identified. Of these 4 groups, 1 group (7.5%) declined prescribing rapidly. The groups did not differ meaningfully; however, the rapid decliners included fewer oral and maxillofacial surgeons (13.0% vs 18.4%), saw more Medicaid patients (2.5% vs 1.0%), and had higher opioid prescribing rates in 2015 (95.5% vs 91.6%) (P < .001 for all). CONCLUSIONS The authors identified variations in dentists' opioid prescribing rates. Although 60% of dentists decreased prescribing rates by 30% through 83%, 3.4% of dentists consistently prescribed at high rates. PRACTICAL IMPLICATIONS Some dentists continue to prescribe opioids at high levels, indicating that additional information is needed to better inform policy and clinical decision making.
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Zhang J, Waljee JF, Nguyen TD, Bohnert AS, Brummett CM, Bicket MC, Chua KP. Opioid Prescribing by US Surgeons, 2016-2022. JAMA Netw Open 2023; 6:e2346426. [PMID: 38060230 PMCID: PMC10704275 DOI: 10.1001/jamanetworkopen.2023.46426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023] Open
Abstract
This cross-sectional study investigates the rate and dosing of opioid prescriptions among US surgeons from 2016 to 2022.
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Affiliation(s)
- Jason Zhang
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor
| | - Jennifer F Waljee
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
- Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor
| | - Thuy D Nguyen
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Amy S Bohnert
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
- Opioid Research Institute, University of Michigan, Ann Arbor
| | - Chad M Brummett
- Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
- Opioid Research Institute, University of Michigan, Ann Arbor
| | - Mark C Bicket
- Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Kao-Ping Chua
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
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Shuey B, Zhang F, Rosen E, Goh B, Trad NK, Wharam JF, Wen H. Massachusetts' opioid limit law associated with a reduction in postoperative opioid duration among orthopedic patients. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad068. [PMID: 38756368 PMCID: PMC10986237 DOI: 10.1093/haschl/qxad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/24/2023] [Accepted: 11/30/2023] [Indexed: 05/18/2024]
Abstract
Postoperative orthopedic patients are a high-risk group for receiving long-duration, large-dosage opioid prescriptions. Rigorous evaluation of state opioid duration limit laws, enacted throughout the country in response to the opioid overdose epidemic, is lacking among this high-risk group. We took advantage of Massachusetts' early implementation of a 2016 7-day-limit law that occurred before other statewide or plan-wide policies took effect and used commercial insurance claims from 2014-2017 to study its association with postoperative opioid prescriptions greater than 7 days' duration among Massachusetts orthopedic patients relative to a New Hampshire control group. Our sample included 14 097 commercially insured, opioid-naive adults aged 18 years and older undergoing elective orthopedic procedures. We found that the Massachusetts 7-day limit was associated with an immediate 4.23 percentage point absolute reduction (95% CI, 8.12 to 0.33 percentage points) and a 33.27% relative reduction (95% CI, 55.36% to 11.19%) in the percentage of initial fills greater than 7 days in the Massachusetts relative to the control group. Seven-day-limit laws may be an important state-level tool to mitigate longer duration prescribing to high-risk postoperative populations.
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Affiliation(s)
- Bryant Shuey
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
- Present address: Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
| | - Edward Rosen
- Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
| | - Brian Goh
- Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
- Present address: Department of Orthopedic Surgery, Emory University School of Medicine, Atlanta, GA 30329, United States
| | - Nicolas K Trad
- Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - James Franklin Wharam
- Department of Medicine, Duke University, Durham, NC 27710, United States
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC 27708, United States
| | - Hefei Wen
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
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Chua KP, Nguyen TD, Brummett CM, Bohnert AS, Gunaseelan V, Englesbe MJ, Waljee JF. Changes in Surgical Opioid Prescribing and Patient-Reported Outcomes After Implementation of an Insurer Opioid Prescribing Limit. JAMA HEALTH FORUM 2023; 4:e233541. [PMID: 37831460 PMCID: PMC10576220 DOI: 10.1001/jamahealthforum.2023.3541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/04/2023] [Indexed: 10/14/2023] Open
Abstract
Importance Insurers are increasingly limiting the duration of opioid prescriptions for acute pain. Among patients undergoing surgery, it is unclear whether implementation of these limits is associated with changes in opioid prescribing and patient-reported outcomes, such as pain. Objective To assess changes in surgical opioid prescribing and patient-reported outcomes after implementation of an opioid prescribing limit by a large commercial insurer in Michigan. Design, Setting, and Participants This was a cross-sectional study with an interrupted time series analysis. Data analyses were conducted from October 1, 2022, to February 28, 2023. The primary data source was the Michigan Surgical Quality Collaborative, a statewide registry containing data on opioid prescribing and patient-reported outcomes from adults undergoing common general surgical procedures. This registry is linked to Michigan's prescription drug monitoring program database, allowing observation of opioid dispensing. The study included 6045 adults who were covered by the commercial insurer and underwent surgery from January 1, 2017, to October 31, 2019. Exposure Policy limiting opioid prescriptions to a 5-day supply in February 2018. Main Outcomes and Measures Among all patients, segmented regression models were used to assess for level or slope changes during February 2018 in 3 patient-reported outcomes: pain in the week after surgery (assessed on a scale of 1-4: 1 = none, 2 = minimal, 3 = moderate, and 4 = severe), satisfaction with surgical experience (scale of 0-10, with 10 being the highest satisfaction), and amount of regret regarding undergoing surgery (scale of 1-5, with 1 being the highest level of regret). Among patients with a discharge opioid prescription and a dispensed opioid prescription (prescription filled within 3 days of discharge), additional outcomes included total morphine milligram equivalents in these prescriptions, a standardized measure of opioid volume. Results Among the 6045 patients included in the study, mean (SD) age was 48.7 (12.6) years and 3595 (59.5%) were female. Limit implementation was not associated with changes in patient-reported satisfaction or regret and was associated with only a slight level decrease in patient-reported pain score (-0.15 [95% CI, -0.26 to -0.03]). Among 4396 patients (72.7%) with a discharge and dispensed opioid prescription, limit implementation was associated with a -22.3 (95% CI, -32.8 to -11.9) and -26.1 (95% CI, -40.9 to -11.3) level decrease in monthly mean total morphine milligram equivalents of discharge and dispensed opioid prescriptions, respectively. These decreases corresponded approximately to 3 to 3.5 pills containing 5 mg of oxycodone. Conclusions This cross-sectional analysis of data from adults undergoing general surgical procedures found that implementation of an insurer's limit was associated with modest reductions in opioid prescribing but not with worsened patient-reported outcomes. Whether these findings generalize to other procedures warrants further study.
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Affiliation(s)
- Kao-Ping Chua
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Thuy D. Nguyen
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor
| | - Amy S. Bohnert
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Vidhya Gunaseelan
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor
| | - Michael J. Englesbe
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor
- Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Jennifer F. Waljee
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor
- Department of Surgery, University of Michigan Medical School, Ann Arbor
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Brummett CM, Wagner Z, Waljee JF. Best Practice Alerts: A Poke in the Eye or an Efficient Method for Safer Prescribing? Anesthesiology 2023:138340. [PMID: 37327362 DOI: 10.1097/aln.0000000000004623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Affiliation(s)
- Chad M Brummett
- Department of Anesthesiology Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan
| | | | - Jennifer F Waljee
- Opioid Prescribing Engagement NetworkDepartment of Surgery, University of Michigan, Ann Arbor, Michigan
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