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Kleinbart E, Tornberg H, Rivera-Pintado C, Hunter K, Kleiner MT, Miller LS, Pollard M, Fedorka CJ. Narcotic prescribing practices in shoulder surgery before and after the institution of narcotic e-prescribing. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:208-212. [PMID: 38706676 PMCID: PMC11065727 DOI: 10.1016/j.xrrt.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Background Given the current opioid epidemic, it is crucial to highly regulate the prescription of narcotic medications for pain management. The use of electronic prescriptions (e-scripts) through the hospital's electronic medical record platform allows physicians to fill opioid prescriptions in smaller doses, potentially limiting the total quantity of analgesics patients have access to and decreasing the potential for substance misuse. The purpose of this study is to determine how the implementation of e-scripts changed the quantity of opioids prescribed following shoulder surgeries. Methods For this single-center retrospective study, data were extracted for all patients aged 18 years or more who received a shoulder procedure between January 2015 and December 2020. Total milligrams of morphine equivalents (MMEs) of opioids prescribed within the 90 days following surgery were compared between 3 cohorts: preimplementation of the 2017 New Jersey Opioid laws (Pre-NJ opioid laws), post-NJ Opioid Laws but pre-escripting, and postimplementation of e-scripting in 2019 (postescripting). Any patient prescribed preoperative opioids, prescribed opioids by nonorthopedic physicians, under the care of a pain management physician, or had a simultaneous nonshoulder procedure was excluded from this study. Results There were 1857 subjects included in this study; 796 pre-NJ opioid laws, 520 post-NJ opioid laws, pre-escripting, and 541 postescripting. Following implementation of e-scripting on July 1, 2019, there was a significant decrease in total MMEs prescribed (P < .001) from a median of 90 MME (interquartile range 65, 65-130) preimplementation to a median 45 MME (interquartile range 45, 45-90) MME postimplementation Additionally, there was a statistically significant decrease in opioids prescribed for all procedures (P < .001) and for 3 (P < .001) of the 4 orthopedic surgeons included in this study. Conclusion Our study demonstrated a significant reduction in total MMEs prescribed overall, for all shoulder surgeries, and for the majority of our institution's providers in the postoperative period following the e-scripting implementation in July 2019. E-scripting is a valuable tool in conjunction with education and awareness on the national, institutional, provider, and patient levels to combat the opioid epidemic.
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Affiliation(s)
- Emily Kleinbart
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Haley Tornberg
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | - Krystal Hunter
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Matthew T. Kleiner
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Lawrence S. Miller
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Mark Pollard
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Catherine J. Fedorka
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
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Altinger G, Sharma S, Maher CG, Cullen L, McCaffery K, Linder JA, Buchbinder R, Harris IA, Coiera E, Li Q, Howard K, Coggins A, Middleton PM, Gunja N, Ferguson I, Chan T, Tambree K, Varshney A, Traeger AC. Behavioural 'nudging' interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial. BMJ Open 2024; 14:e079870. [PMID: 38548366 PMCID: PMC10982715 DOI: 10.1136/bmjopen-2023-079870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 02/08/2024] [Indexed: 04/02/2024] Open
Abstract
INTRODUCTION Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural 'nudge' interventions on low-value care for ED patients with low back pain. METHODS AND ANALYSIS NUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time. ETHICS AND DISSEMINATION This study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications. TRIAL REGISTRATION NUMBER ACTRN12623001000695.
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Affiliation(s)
- Gemma Altinger
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Sweekriti Sharma
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jeffrey A Linder
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute, Sydney, New South Wales, Australia
| | - Enrico Coiera
- Centre for Health Informatics, Macquarie University, Sydney, New South Wales, Australia
| | - Qiang Li
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Kirsten Howard
- Menzies Centre for Health Policy and Economics, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Coggins
- Discipline of Emergency Medicine, The University of Sydney School of Medicine, Sydney, New South Wales, Australia
| | - Paul M Middleton
- South Western Emergency Research Institute, Ingham Institute for Applied Medical Research, Liverpool Hospital, Liverpool, New South Wales, Australia
- South West Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Naren Gunja
- Discipline of Emergency Medicine, The University of Sydney School of Medicine, Sydney, New South Wales, Australia
- Digital Health Solutions, Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Ian Ferguson
- South West Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Trevor Chan
- Emergency Care Institute, The Agency for Clinical Innovation, St Leonards Sydney, City of Willoughby, Australia
| | - Karen Tambree
- Consumer Advisor, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
| | - Ajay Varshney
- Consumer Advisor, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
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Gangathimmaiah V, Drever N, Evans R, Moodley N, Sen Gupta T, Cardona M, Carlisle K. What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open 2023; 13:e072762. [PMID: 37945299 PMCID: PMC10649718 DOI: 10.1136/bmjopen-2023-072762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. DESIGN A mixed-methods scoping review was conducted using the Arksey and O'Malley framework. DATA SOURCES Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. ELIGIBILITY CRITERIA Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. DATA EXTRACTION AND SYNTHESIS Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. RESULTS The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. CONCLUSION High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Magnolia Cardona
- A/Prof Implementation Science, Faculty of Health and Behavioural Sciences, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Honorary A/Prof of Research Translation, Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Shin D, Cho HJ, Alaiev D, Tsega S, Talledo J, Zaurova M, Chandra K, Alarcon P, Garcia M, Krouss M. Reducing daily dosing in opioid prescriptions in 11 safety net emergency departments. Am J Emerg Med 2023; 71:63-68. [PMID: 37343340 DOI: 10.1016/j.ajem.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/16/2023] [Accepted: 06/04/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND The United States continues to face a significant issue with opioid misuse, overprescribing, dependency, and overdose. Electronic health record (EHR) interventions have shown to be an effective tool to modify opioid prescribing behaviors. This quality improvement project describes an EHR intervention to reduce daily dosing in opioid prescriptions in 11 emergency departments (ED) across the largest safety net health system in the US. MEASURES The primary outcome measure was the rates of oxycodone-acetaminophen 5-325 mg prescriptions exceeding 50 morphine milligram equivalents per day (MMED) pre- vs. post-intervention; and stratified by individual hospitals and provider type. INTERVENTION The defaults for dose and frequency were uniformly changed to 'every 6 hours as needed' and '1 tablet', respectively, across 11 EDs. OUTCOMES The percentage of prescriptions greater than or equal to 50 MMED decreased from 46.0% (1624 of 3530 prescriptions) to 1.6% (52 of 3165 prescriptions) (96.4% relative reduction; p < 0.001). All 11 hospitals had a significant reduction in prescriptions exceeding 50 MMED. Nurse practitioners had the highest relative reduction of prescriptions exceeding 50 MMED at 100% (p < 0.001), and the attendings/fellows had the lowest relative reduction at 95.6% (p < 0.001). CONCLUSIONS/LESSONS LEARNED Default nudges are a simple yet powerful intervention that can strongly influence opioid prescribing patterns.
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Affiliation(s)
- Dawi Shin
- Icahn School of Medicine, New York, NY, USA; Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Hyung J Cho
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel Alaiev
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Surafel Tsega
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Joseph Talledo
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Milana Zaurova
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Komal Chandra
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Peter Alarcon
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Mariely Garcia
- Icahn School of Medicine, New York, NY, USA; Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA
| | - Mona Krouss
- Department of Quality and Safety, NYC Health + Hospitals, New York, NY, USA; Department of Medicine, Icahn School of Medicine, New York, NY, USA.
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Grouse CK, Waung MW, Holmgren AJ, Mongan J, Neinstein A, Josephson SA, Khanna RR. Behavioral "nudges" in the electronic health record to reduce waste and misuse: 3 interventions. J Am Med Inform Assoc 2023; 30:545-550. [PMID: 36519951 PMCID: PMC9933068 DOI: 10.1093/jamia/ocac238] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/26/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
Electronic health records (EHRs) offer decision support in the form of alerts, which are often though not always interruptive. These alerts, though sometimes effective, can come at the cost of high cognitive burden and workflow disruption. Less well studied is the design of the EHR itself-the ordering provider's "choice architecture"-which "nudges" users toward alternatives, sometimes unintentionally toward waste and misuse, but ideally intentionally toward better practice. We studied 3 different workflows at our institution where the existing choice architecture was potentially nudging providers toward erroneous decisions, waste, and misuse in the form of inappropriate laboratory work, incorrectly specified computerized tomographic imaging, and excessive benzodiazepine dosing for imaging-related sedation. We changed the architecture to nudge providers toward better practice and found that the 3 nudges were successful to varying degrees in reducing erroneous decision-making and mitigating waste and misuse.
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Affiliation(s)
- Carrie K Grouse
- Department of Neurology, UCSF, San Francisco, California, USA
| | - Maggie W Waung
- Department of Neurology, UCSF, San Francisco, California, USA
| | - A Jay Holmgren
- Center for Clinical Informatics and Improvement Research, UCSF, San Francisco, California, USA
| | - John Mongan
- Department of Radiology, UCSF, San Francisco, California, USA
- Center for Intelligent Imaging, Department of Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
| | - Aaron Neinstein
- Division of Endocrinology, Department of Medicine, UCSF, San Francisco, California, USA
- UCSF Center for Digital Health Innovation, UCSF, San Francisco, California, USA
| | | | - Raman R Khanna
- Division of Hospital Medicine, Department of Medicine, UCSF, San Francisco, California, USA
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Real-World Observational Evaluation of Common Interventions to Reduce Emergency Department Prescribing of Opioid Medications. Jt Comm J Qual Patient Saf 2023; 49:239-246. [PMID: 36914528 DOI: 10.1016/j.jcjq.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Prior work on opioid prescribing has examined dosing defaults, interruptive alerts, or "harder" stops such as electronic prescribing of controlled substances (EPCS), which has become increasingly required by state policy. Given that real-world opioid stewardship policies are concurrent and overlapping, the authors examined the effect of such policies on emergency department (ED) opioid prescriptions. METHODS The researchers performed observational analysis of all ED visits discharged between December 17, 2016, and December 31, 2019, across seven EDs of a hospital system. Four interventions were examined in chronological order, with each successive intervention added on top of all previous interventions: 12-pill prescription default, EPCS, electronic health record (EHR) pop-up alert, and 8-pill prescription default. The primary outcome was opioid prescribing, which was described as number of opioid prescriptions per 100 discharged ED visits and modeled as a binary outcome for each visit. Secondary outcomes included prescription morphine milligram equivalents (MME) and non-opioid analgesia prescriptions. RESULTS A total of 775,692 ED visits were included in the study. Compared to the preintervention period, cumulative reductions in opioid prescribing were seen with incremental interventions, including after adding a 12-pill default (odds ratio [OR] 0.88, 95% confidence interval [CI] 0.82-0.94), after adding EPCS (OR 0.7, 95% CI 0.63-0.77), after adding pop-up alerts (OR 0.67, 95% CI 0.63-0.71), and after adding an 8-pill default (OR 0.61, 95% CI 0.58-0.65). CONCLUSION EHR-implemented solutions such as EPCS, pop-up alerts, and pill defaults had varying but significant effects on reducing ED opioid prescribing. Policy makers and quality improvement leaders might achieve sustainable improvements in opioid stewardship while balancing clinician alert fatigue through policy efforts promoting implementation of EPCS and default dispense quantities.
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Bachhuber MA, Nash D, Southern WN, Heo M, Berger M, Schepis M, Sugarman OK, Cunningham CO. Reducing Opioid Analgesic Prescribing in Dentistry Through Prescribing Defaults: A Cluster-Randomized Controlled Trial. PAIN MEDICINE 2022; 24:1-10. [PMID: 35792881 PMCID: PMC9825153 DOI: 10.1093/pm/pnac106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 06/22/2022] [Accepted: 06/29/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the effect of a uniform, reduced, default dispense quantity for new opioid analgesic prescriptions on the quantity of opioids prescribed in dentistry practices. METHODS We conducted a cluster-randomized controlled trial within a health system in the Bronx, NY, USA. We randomly assigned three dentistry sites to a 10-tablet default, a 5-tablet default, or no change (control). The primary outcome was the quantity of opioid analgesics prescribed in the new prescription. Secondary outcomes were opioid analgesic reorders and health service utilization within 30 days after the new prescription. We analyzed outcomes from 6 months before implementation through 18 months after implementation. RESULTS Overall, 6,309 patients received a new prescription. Compared with the control site, patients at the 10-tablet-default site had a significantly larger change in prescriptions for 10 tablets or fewer (38.7 percentage points; confidence interval [CI]: 11.5 to 66.0), lower number of tablets prescribed (-3.3 tablets; CI: -5.9 to -0.7), and lower morphine milligram equivalents (MME) prescribed (-14.1 MME; CI: -27.8 to -0.4), which persisted in the 30 days after the new prescription despite a higher percentage of reorders (3.3 percentage points; CI: 0.2 to 6.4). Compared with the control site, patients at the 5-tablet-default site did not have a significant difference in any outcomes except for a significantly higher percentage of reorders (2.6 percentage points; CI: 0.2 to 4.9). CONCLUSIONS Our findings further support the efficacy of strategies that lower default dispense quantities, although they indicate that caution is warranted in the selection of the default. TRIAL REGISTRATION ClinicalTrials.org ID: NCT03030469.
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Affiliation(s)
- Marcus A Bachhuber
- Correspondence to: Marcus A. Bachhuber, MD, MSHP, Section of Community and Population Medicine, Department of Medicine, Louisiana State University Health Sciences Center-New Orleans, 533 Bolivar St., 5th Fl, New Orleans, LA 70112, USA. Tel: (504) 568-5700; Fax: (504) 568-5701; E-mail:
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York (CUNY), New York, New York,Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, New York
| | - William N Southern
- Division of Hospital Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Moonseong Heo
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York,This author is now with the Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, South Carolina, New Orleans, Louisiana, USA
| | - Matthew Berger
- Montefiore Information Technology, Montefiore Medical Center, Bronx, New York
| | - Mark Schepis
- Montefiore Information Technology, Montefiore Medical Center, Bronx, New York
| | - Olivia K Sugarman
- Section of Community and Population Medicine, Department of Medicine, Louisiana State University Health Sciences Center-New Orleans, New Orleans, Louisiana, USA
| | - Chinazo O Cunningham
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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Chua KP, Thorne MC, Ng S, Donahue M, Brummett CM. Association Between Default Number of Opioid Doses in Electronic Health Record Systems and Opioid Prescribing to Adolescents and Young Adults Undergoing Tonsillectomy. JAMA Netw Open 2022; 5:e2219701. [PMID: 35771572 PMCID: PMC9247741 DOI: 10.1001/jamanetworkopen.2022.19701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE In prior studies, decreasing the default number of doses in opioid prescriptions written in electronic health record systems reduced opioid prescribing. However, these studies did not rigorously assess patient-reported outcomes, and few included pediatric patients. OBJECTIVE To evaluate the association between decreasing the default number of doses in opioid prescriptions written in electronic health record systems and opioid prescribing and patient-reported outcomes among adolescents and young adults undergoing tonsillectomy. DESIGN, SETTING, AND PARTICIPANTS This nonrandomized clinical trial included adolescents and young adults aged 12 to 50 years undergoing tonsillectomy from October 1, 2019, through July 31, 2021, at a tertiary medical center. The treatment group comprised patients from a pediatric otolaryngology service (mostly aged 12-21 years) and the control group comprised patients from a general otolaryngology service (mostly aged 18-25 years). INTERVENTIONS Data on patient-reported opioid consumption and outcomes were collected via a survey on postoperative day 14. Based on opioid consumption among pediatric otolaryngology patients before the intervention, the default number of opioid doses was decreased from 30 to 12 in a tonsillectomy order set. This change occurred only for pediatric otolaryngology patients. MAIN OUTCOMES AND MEASURES Proportion of patients with 12 doses in the discharge opioid prescription, number of doses in this prescription, and refills and pain-related visits within 2 weeks of surgery. In a secondary analysis of patients completing the postoperative survey, patient-reported opioid consumption, pain control, sleep disturbance, anxiety, and depression were assessed. Linear or log-linear difference-in-differences models were fitted, adjusting for patients' demographic characteristics and presence of a mental health or substance use disorder. RESULTS The study included 237 patients (147 female patients [62.0%]; mean [SD] age, 17.3 [3.6] years). Among 131 pediatric otolaryngology patients, 1 of 70 (1.4%) in the preintervention period and 27 of 61 (44.3%) in the postintervention period had 12 doses in the discharge opioid prescription (differential change, 45.5 percentage points; 95% CI, 32.2-58.8 percentage points). Among pediatric otolaryngology patients, the mean (SD) number of doses prescribed in the preintervention period was 22.3 (7.4) and in the postintervention period was 16.1 (6.5) (differential percentage change, -29.2%; 95% CI, -43.2% to -11.7%). The intervention was not associated with changes in refills or pain-related visits. The secondary analysis included 150 patients. The intervention was not associated with changes in patient-reported outcomes except for a 3.5-point (95% CI, 1.5-5.5 points) differential increase in a sleep disturbance score that ranged from 4 to 20, with higher scores indicating poorer sleep quality. CONCLUSIONS AND RELEVANCE This nonrandomized clinical trial suggests that evidence-based default dosing settings may decrease perioperative opioid prescribing among adolescents and young adults undergoing tonsillectomy, without compromising analgesia. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04066829.
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Affiliation(s)
- 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
| | - Marc C. Thorne
- Division of Pediatric Otolaryngology, Department of Otolaryngology, University of Michigan Medical School, Ann Arbor
| | - Sophia Ng
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor
| | - Mary Donahue
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor
| | - Chad M. Brummett
- Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
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