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Kirkegaard A, Friedman EM, Edgington S, Kennedy D. Increased Care Provision and Caregiver Wellbeing: Moderation by Changes in Social Network Care Provision. J Gerontol B Psychol Sci Soc Sci 2024; 79:gbae015. [PMID: 38364364 PMCID: PMC10997277 DOI: 10.1093/geronb/gbae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Indexed: 02/18/2024] Open
Abstract
OBJECTIVES Previous research links increased care provision to worse wellbeing among family and friend caregivers, both before and during the coronavirus disease 2019 (COVID-19) pandemic. We expand on this by incorporating data on caregivers' social networks and exploring the relationships between own and network changes in care during the pandemic and caregiver wellbeing. METHODS We use nationally representative data from 1,876 family and friend caregivers in the first wave of our Care Network Connections over Time study (fielded 12/17/2020-1/4/2021) who had provided care continuously since before the COVID-19 pandemic began. Caregivers were asked about the amount of care that they and each member of their social networks were providing at the time of the survey relative to before the pandemic. We use multivariate regression models to examine the associations between five caregiver wellbeing outcomes and changes in care, and explore the moderating role of networks' changes in care. RESULTS Among caregivers who had provided care since prior to the pandemic, most increased (42.0%) or maintained the same (40.8%) care. Their networks also typically increased (33.4%) or maintained (46.5%) care. Increasing one's own care provision was associated with higher levels of anxiety, depression, loneliness, and emotional difficulty than maintaining stable care. Among those who increased care, these levels were highest when the network also increased or decreased care. DISCUSSION Increased care provision was most strongly associated with poor caregiver wellbeing in contexts where caregivers' social networks also changed care provisions. Supports for caregivers undertaking additional care tasks should take into account caregivers' networks.
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Affiliation(s)
| | - Esther M Friedman
- Institute for Social Research, University of Michigan at Ann Arbor, Ann Arbor, Michigan, USA
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Zanocco K, Romanelli RJ, Meeker D, Mariano LT, Shenoy R, Wagner Z, Kirkegaard A, Mudiganti S, Martinez M, Watkins KE. Drivers of Variation in Opioid Prescribing after Common Surgical Procedures in a Large Multihospital Healthcare System. J Am Coll Surg 2024:00019464-990000000-00969. [PMID: 38690834 DOI: 10.1097/xcs.0000000000001095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
BACKGROUND Misuse of prescription opioids is a well-established contributor to the United States opioid epidemic. The primary objective of this study was to identify which level of care delivery (i.e. patient, prescriber, or hospital) produced the most unwarranted variation in opioid prescribing after common surgical procedures. STUDY DESIGN Electronic health record (EHR) data from a large multihospital healthcare system was used in conjunction with random-effect models to examine variation in opioid prescribing practices following similar inpatient and outpatient surgical procedures between October 2019 and September 2021. Unwarranted variation was conceptualized as variation resulting from prescriber behavior unsupported by evidence. Covariates identified as drivers of warranted variation included characteristics known to influence pain levels or patient safety. All other model variables, including prescriber specialty and patient race, ethnicity, and insurance status were characterized as potential drivers of unwarranted variation. RESULTS Among 25,188 procedures with an opioid prescription at hospital discharge, 53.5% exceeded guideline recommendations, corresponding to 13,228 patients receiving the equivalent of >140,000 excess 5mg oxycodone tablets following surgical procedures. Prescribing variation was primarily driven by prescriber-level factors, with approximately half of the total variation in morphine milligram equivalents (MMEs) prescribed observed at the prescriber level and not explained by any measured variables. Unwarranted covariates associated with higher prescribed opioid quantity included non-Hispanic black race, Medicare insurance, smoking history, later hospital discharge times, and prescription by a surgeon rather than a hospitalist or primary care provider. CONCLUSION Given the large proportion of unexplained variation observed at the provider level, targeting prescribers through education and training may be an effective strategy for reducing postoperative opioid prescribing.
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Affiliation(s)
- Kyle Zanocco
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Daniella Meeker
- Biomedical Informatics and Data Science, Yale University, New Haven, CT
| | - Louis T Mariano
- Economics, Sociology & Statistics, RAND Corporation, Arlington, VA
| | - Rivfka Shenoy
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA
- National Clinician Scholars Program, University of California, Los Angeles, Los Angeles, CA
| | - Zachary Wagner
- Economics, Sociology & Statistics, RAND Corporation, Santa Monica CA
| | | | - Satish Mudiganti
- Division of Research, Development & Dissemination, Sutter Health, Center for Health Systems Research, Walnut Creek, CA
| | - Meghan Martinez
- Palo Alto Medical Foundation Research Institute, Sutter Health, Center for Health Systems Research, Palo Alto, CA
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Doctor JN, Meeker D, Fox CR, Persell SD, Wagner Z, Bouskill KE, Zanocco KA, Romanelli RJ, Brummett CM, Kirkegaard A, Watkins KE. A call for community-shared decisions. BMJ Evid Based Med 2024:bmjebm-2023-112641. [PMID: 38604618 DOI: 10.1136/bmjebm-2023-112641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 04/13/2024]
Affiliation(s)
- Jason N Doctor
- University of Southern California Sol Price School of Public Policy, Los Angeles, California, USA
| | | | - Craig R Fox
- University of California Los Angeles Anderson School of Management, Los Angeles, California, USA
| | - Stephen D Persell
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | | | - Kyle A Zanocco
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Chad M Brummett
- University of Michigan Medical School, Ann Arbor, Michigan, USA
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Martinez M, Kirkegaard A, Bouskill K, Yan XS, Wagner Z, Watkins KE. Surgeons' views of peer comparison and guideline-based feedback on postsurgery opioid prescriptions: a qualitative investigation. BMJ Open Qual 2024; 13:e002750. [PMID: 38580444 PMCID: PMC11002351 DOI: 10.1136/bmjoq-2024-002750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/17/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Excess opioid prescribing after surgery can lead to prolonged opioid use and diversion. We interviewed surgeons who were part of a three-group cluster-randomised controlled trial aimed at reducing prescribed opioid quantities after surgery via two versions of a monthly emailed behavioural 'nudge' (messages encouraging but not mandating compliance with social norms and clinical guidelines around prescribing) at the end of the implementation year in order to understand surgeons' reasoning for changing or continuing their prescribing behaviour as a result of the intervention and the context for their rationale. METHODS The study took place at a large healthcare system in northern California with surgeons from three surgical specialties-orthopaedics, obstetrics/gynaecology and general surgery. Following the intervention period, we conducted semistructured interviews with 36 surgeons who had participated in the trial, ensuring representation across trial arm, specialty and changes in prescribing quantities over the year. Interviews focused on reactions to the nudges, impacts of the nudges on prescribing behaviours and other factors impacting prescribing. Three study team members coded and analysed the transcribed interviews. RESULTS Nudges were equally effective in reducing postsurgical opioid prescribing across surgical specialties and between intervention arms. Surgeons were generally receptive to the nudge intervention, noting that it reduced the size of their discharge opioid prescriptions by improving their awareness and intentionality around prescribing. Most were unaware that clinical guidelines around opioid prescribing existed. Some had reservations regarding the accuracy and context of information provided in the nudges, the prescription quantities encouraged by the nudges and feelings of being watched or admonished. A few described discussing the nudges with colleagues. Respondents emphasised that the prescribing behaviours are informed by individual clinical experience and patient-related and procedure-related factors. CONCLUSIONS Surgeons were open to learning about their prescribing behaviour through comparisons to guidelines or peer behaviour and incorporating this feedback as one of several factors that guide discharge opioid prescribing. Increasing awareness of clinical guidelines around opioid prescribing is important for curbing postsurgical opioid overprescribing. TRIAL REGISTRATION NUMBER NCT05070338.
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Affiliation(s)
- Meghan Martinez
- Palo Alto Medical Foundation Research Institute and Center for Health Systems Research, Sutter Health, Palo Alto, California, USA
| | | | | | - Xiaowei Sherry Yan
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | | | - Katherine E Watkins
- Behavioral and Policy Sciences, RAND Corporation, Santa Monica, California, USA
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Kennedy DP, Friedman EM, Kirkegaard A, Edgington S, Shih R. Perceived loss of support to community caregivers during the COVID-19 pandemic in the United States. J Community Psychol 2024; 52:475-497. [PMID: 38329412 DOI: 10.1002/jcop.23107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 02/09/2024]
Abstract
Coronavirus disease (COVID-19) had a negative impact on the health and well-being of community caregivers. Few studies examine the pandemic's negative impact on the availability of social networks of caregivers. This article uses data collected during COVID-19 before vaccination to examine caregivers' reports of perceived lost and reduced network support. We assessed the personal networks of a nationally representative sample of 2214 community caregivers in the United States. We analyzed associations between caregiving factors and caregivers' perceptions of lost and reduced network support. Changes in care recipient living circumstances during COVID-19, longer-term caregiving, care recipient hearing/vision/mobility problems, caregiver travel/socializing restrictions, caregiver race/ethnicity, caregiver income, caregiver age, network connectivity, family relationships, and network members' age were associated with perceived lost/reduced support during the pandemic. Findings provide insights for the development of social network interventions to support caregivers and help them cultivate support networks resilient to public health crises.
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Affiliation(s)
- David P Kennedy
- Department of Behavioral and Policy Sciences, RAND Corporation, Santa Monica, California, USA
| | - Esther M Friedman
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Allison Kirkegaard
- Department of Behavioral and Policy Sciences, RAND Corporation, Santa Monica, California, USA
| | - Sarah Edgington
- Research Programming Group, RAND Corporation, Santa Monica, California, USA
| | - Regina Shih
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Friedman EM, Kirkegaard A, Kennedy D, Edgington S, Shih RA. Change in Caregiving to Older Adults During the COVID-19 Pandemic: Differences by Dementia Status. J Appl Gerontol 2023; 42:2277-2282. [PMID: 37683281 PMCID: PMC10840888 DOI: 10.1177/07334648231197514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023] Open
Abstract
We use a nationally representative study of 3451 adults who provided assistance to a relative or friend age 50 or older immediately prior to the Coronavirus Disease 2019 (COVID-19) pandemic to explore changes to care provisions, use of services, and support networks. While we see turnover in assistance during a retrospectively assessed 12-month time period, respondents exited or adopted caregiving roles primarily for reasons unrelated to the pandemic. About two thirds of caregivers' social networks remained unchanged and, of those that did change, only half lost network members without gaining others. Changes in care settings and use of support services were uncommon. Caregivers to persons with dementia may have been more adversely affected than other caregivers as they were more likely to experience loss of social ties, potentially performing more care activities without the full support system they had in place prior to the pandemic.
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Romanelli RJ, Shenoy R, Martinez MC, Mudiganti S, Mariano LT, Zanocco KA, Wagner Z, Kirkegaard A, Watkins KE. Disparities in postoperative opioid prescribing by race and ethnicity: an electronic health records-based observational study from Northern California, 2015-2020. Arch Public Health 2023; 81:83. [PMID: 37149630 PMCID: PMC10163682 DOI: 10.1186/s13690-023-01095-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 04/21/2023] [Indexed: 05/08/2023] Open
Abstract
OBJECTIVES To examine racial and ethnic disparities in postoperative opioid prescribing. DATA SOURCES Electronic health records (EHR) data across 24 hospitals from a healthcare delivery system in Northern California from January 1, 2015 to February 2, 2020 (study period). STUDY DESIGN Cross-sectional, secondary data analyses were conducted to examine differences by race and ethnicity in opioid prescribing, measured as morphine milligram equivalents (MME), among patients who underwent select, but commonly performed, surgical procedures. Linear regression models included adjustment for factors that would likely influence prescribing decisions and race and ethnicity-specific propensity weights. Opioid prescribing, overall and by race and ethnicity, was also compared to postoperative opioid guidelines. DATA EXTRACTION Data were extracted from the EHR on adult patients undergoing a procedure during the study period, discharged to home with an opioid prescription. PRINCIPAL FINDINGS Among 61,564 patients, on adjusted regression analysis, non-Hispanic Black (NHB) patients received prescriptions with higher mean MME than non-Hispanic white (NHW) patients (+ 6.4% [95% confidence interval: 4.4%, 8.3%]), whereas Hispanic and non-Hispanic Asian patients received lower mean MME (-4.2% [-5.1%, -3.2%] and - 3.6% [-4.8%, -2.3%], respectively). Nevertheless, 72.8% of all patients received prescriptions above guidelines, ranging from 71.0 to 80.3% by race and ethnicity. Disparities in prescribing were eliminated among Hispanic and NHB patients versus NHW patients when prescriptions were written within guideline recommendations. CONCLUSIONS Racial and ethnic disparities in opioid prescribing exist in the postoperative setting, yet all groups received prescriptions above guideline recommendations. Policies encouraging guideline-based prescribing may reduce disparities and overall excess prescribing.
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Affiliation(s)
| | | | - Meghan C Martinez
- Sutter Health, Center for Health Services Research-Palo Alto and Walnut Creek, Los Angeles, CA, USA
| | - Satish Mudiganti
- Sutter Health, Center for Health Services Research-Palo Alto and Walnut Creek, Los Angeles, CA, USA
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Friedman E, Kirkegaard A, Kennedy D. CHANGES TO CARE PROVISIONS TO OLDER ADULTS DURING COVID-19: IMPLICATIONS FOR CAREGIVER WELL-BEING. Innov Aging 2022. [DOI: 10.1093/geroni/igac059.2480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Among the many consequences of the COVID-19 pandemic is its impact on caregiving for older adults. Pandemic-related physical distancing policies, avoidance of infection risk, and changing obligations at home and work has caused shifts in care that may not have occurred otherwise. We use nationally representative data on 2,363 caregivers to older family members and friends collected at the height of the pandemic to explore the extent to which family caregivers changed the amount and types of care they provided to a loved one with a disabling condition, and the impact of such changes on caregiver burden and wellbeing. About 41.5% of caregivers who continued to care for someone they helped prior to the pandemic, increased the amount of care provided, while only 7% reduced their intensity of help. Caregiving disruption in the amount of help – both increasing and decreasing care – was significantly associated with increased anxiety, depression, and loneliness of caregivers, but not with self-rated health. These findings persist even after controlling for a variety of sociodemographic, caregiving, and contextual characteristics, and the characteristics of support networks. This work points to an underexplored consequence of the pandemic: the impact on caregiving for older adults and caregiver burden. It will be important to explore the extent to which these effects persist as the pandemic runs its course.
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Kirkegaard A, Wagner Z, Mariano LT, Martinez MC, Yan XS, Romanelli RJ, Watkins KE. Evaluating the effectiveness of email-based nudges to reduce postoperative opioid prescribing: study protocol of a randomised controlled trial. BMJ Open 2022; 12:e061980. [PMID: 36123066 PMCID: PMC9486294 DOI: 10.1136/bmjopen-2022-061980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Surgical patients are commonly prescribed more opioids at discharge than needed to manage their postoperative pain. These excess opioids increase the risks of new persistent opioid use, opioid-induced ventilatory impairment and opioid diversion. This study tests the effectiveness of two behavioural nudges, one based on peer behaviour and one based on best practice guidelines, in reducing excessive postoperative opioid prescriptions. METHODS AND ANALYSIS The study will be conducted at 19 hospitals within a large healthcare delivery system in northern California, USA. Three surgical specialties (general surgery, orthopaedic surgery and obstetric/gynaecological surgery) at each hospital will be randomised either to a control group or to one of two active intervention arms. One intervention is grounded in the theory of injunctive norms, and provides feedback to surgeons on their postoperative opioid prescribing relative to prescribing guidelines endorsed by their institution. The other intervention draws from the theory of descriptive norms, and provides feedback similar to the first intervention but using peers' behaviour rather than guidelines as the benchmark for the surgeon's prescribing behaviour. The interventions will be delivered by a monthly email. Both interventions will be active for twelve months. The effects of each intervention relative to the control group and to each other will be tested using a four-level hierarchical model adjusted for multiple hypothesis testing. ETHICS AND DISSEMINATION Using behavioural nudges rather than rigid policy changes allows us to target excessive prescribing without preventing clinicians from using their clinical judgement to address patient pain. All study activities have been approved by the RAND Human Subjects Protection Committee (ID 2018-0988). Findings will be disseminated through conference presentations, peer-reviewed publications and social media accounts. TRIAL REGISTRATION NUMBER NCT05070338.
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Affiliation(s)
| | | | | | - Meghan C Martinez
- Center for Health Systems Research (West), Palo Alto, California, USA
| | - Xiaowei Sherry Yan
- Center for Health Systems Research (East), Walnut Creek, California, USA
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Shenoy R, Wagner Z, Kirkegaard A, Romanelli RJ, Mudiganti S, Mariano L, Martinez M, Zanocco K, Watkins KE. Assessment of Postoperative Opioid Prescriptions Before and After Implementation of a Mandatory Prescription Drug Monitoring Program. JAMA Health Forum 2021; 2:e212924. [PMID: 35977161 PMCID: PMC8725834 DOI: 10.1001/jamahealthforum.2021.2924] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/04/2021] [Indexed: 11/21/2022] Open
Abstract
Importance Legislation mandating consultation with a prescription drug monitoring program (PDMP) was implemented in California on October 2, 2018. This mandate requires PDMP consultation before prescribing a controlled substance and integrates electronic health record (EHR)-based alerts; prescribers are exempt from the mandate if they prescribe no more than a 5-day postoperative opioid supply. Although previous studies have examined the consequences of mandated PDMP consultation, few have specifically analyzed changes in postoperative opioid prescribing after mandate implementation. Objective To examine whether the implementation of mandatory PDMP consultation with concurrent EHR-based alerts was associated with changes in postoperative opioid quantities prescribed at discharge. Design Setting and Participants This cross-sectional study performed an interrupted time series analysis of opioid prescribing patterns within a large health care system (Sutter Health) in northern California between January 1, 2015, and February 1, 2020. A total of 93 760 adult patients who received an opioid prescription at discharge after undergoing general, obstetric and gynecologic (obstetric/gynecologic), or orthopedic surgery were included. Exposures Mandatory PDMP consultation before opioid prescribing, with concurrent integration of an EHR alert. Prescribers are exempt from this mandate if prescribing no more than a 5-day opioid supply postoperatively. Main Outcomes and Measures The primary outcome was the total quantity of opioid medications (morphine milligram equivalents [MMEs] and number of opioid tablets) prescribed at discharge before and after implementation of the PDMP mandate, with separate analyses by surgical specialty (general, obstetric/gynecologic, and orthopedic) and most common surgical procedure within each specialty (laparoscopic cholecystectomy, cesarean delivery, and knee arthroscopy). The secondary outcome was the proportion of prescriptions with a duration of longer than 5 days. Results Of 93 760 patients (mean [SD] age, 46.7 [17.6] years; 67.9% female) who received an opioid prescription at discharge, 65 911 received prescriptions before PDMP mandate implementation, and 27 849 received prescriptions after implementation. Most patients received general or obstetric/gynecologic surgery (48.6% and 30.1%, respectively), did not have diabetes (90.3%), and had never smoked (66.0%). Before the PDMP mandate was implemented, a decreasing pattern in opioid prescribing quantities was already occurring. During the quarter of implementation, total MMEs prescribed at discharge further decreased for all 3 surgical specialties (eg, medians for general surgery: β = -10.00 [95% CI, -19.52 to -0.48]; obstetric/gynecologic surgery: β = -18.65 [95% CI, -22.00 to -15.30]; and orthopedic surgery: β = -30.59 [95% CI, -40.19 to -21.00]) after adjusting for the preimplementation prescribing pattern. The total number of tablets prescribed also decreased across specialties (eg, medians for general surgery: β = -3.02 [95% CI, -3.47 to -2.57]; obstetric/gynecologic surgery: β = -4.86 [95% CI, -5.38 to -4.34]; and orthopedic surgery: β = -4.06 [95% CI, -5.07 to -3.04]) compared with the quarters before implementation. These reductions were not consistent across the most common surgical procedures. For cesarean delivery, the median number of tablets prescribed decreased during the quarter of implementation (β = -10.00; 95% CI, -10.10 to -9.90), but median MMEs did not (β = 0; 95% CI, -9.97 to 9.97), whereas decreases were observed in both median MMEs and number of tablets prescribed (MMEs: β = -33.33 [95% CI, -38.48 to -28.19]; tablets: β = -10.00 [95% CI, -11.17 to -8.82]) for laparoscopic cholecystectomy. For knee arthroscopy, no decreases were found in either median MMEs or number of tablets prescribed (MMEs: β = 10.00 [95% CI, -22.33 to 42.33; tablets: β = 0.83; 95% CI, -3.39 to 5.05). The proportion of prescriptions written for longer than 5 days also decreased significantly during the quarter of implementation across all 3 surgical specialties. Conclusions and Relevance In this cross-sectional study, the implementation of mandatory PDMP consultation with a concurrent EHR-based alert was associated with an immediate decrease in opioid prescribing across the 3 surgical specialties. These findings might be explained by prescribers' attempts to meet the mandate exemption and bypass PDMP consultation rather than the PDMP consultation itself. Although policies coupled with EHR alerts may be associated with changes in postoperative opioid prescribing behavior, they need to be well designed to optimize evidence-based opioid prescribing.
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Affiliation(s)
- Rivfka Shenoy
- David Geffen School of Medicine, Department of Surgery, University of California, Los Angeles, Los Angeles,Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, California,National Clinician Scholars Program, University of California, Los Angeles, Los Angeles
| | | | | | - Robert J. Romanelli
- Center for Health Systems Research, Division of Research, Development and Dissemination, Sutter Health, Walnut Creek, California
| | - Satish Mudiganti
- Center for Health Systems Research, Division of Research, Development and Dissemination, Sutter Health, Walnut Creek, California
| | | | - Meghan Martinez
- Center for Health Systems Research, Palo Alto Medical Foundation Research Institute, Sutter Health, Palo Alto, California
| | - Kyle Zanocco
- David Geffen School of Medicine, Department of Surgery, University of California, Los Angeles, Los Angeles
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Kleif J, Kirkegaard A, Vilandt J, Gögenur I. Randomized clinical trial of preoperative dexamethasone on postoperative nausea and vomiting after laparoscopy for suspected appendicitis. Br J Surg 2017; 104:384-392. [PMID: 28072446 DOI: 10.1002/bjs.10418] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/08/2016] [Accepted: 09/30/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Few studies have investigated the effects of preoperative dexamethasone in acute surgical patients. This study examined the effects of 8 mg dexamethasone administered intravenously 30 min before surgery for suspected acute appendicitis. METHODS A multicentre, parallel-group, double-blind, placebo-controlled study was conducted at two university hospitals in Denmark. Adults undergoing laparoscopic surgery for suspected appendicitis were eligible for inclusion. Participants, healthcare staff and investigators were blinded until all data analysis had been done. The primary outcome was the incidence of postoperative nausea and vomiting (PONV) during the first postoperative day. Secondary outcomes were pain, fatigue, sleep, opioid consumption, use of antiemetics, quality of recovery and duration of convalescence. Analysis was done according to the intention-to-treat principle. RESULTS A total of 120 patients were enrolled; 57 patients in the dexamethasone group and 59 in the placebo group were eligible for primary analysis. In the dexamethasone group, 47 (95 per cent c.i. 35 to 60) per cent of patients experienced PONV compared with 63 (50 to 74) per cent) in the placebo group. The absolute risk reduction in PONV was 15 (-3 to 33) per cent in favour of the dexamethasone group (P = 0·098). Patients in the dexamethasone group had less pain at rest (difference in score on visual analogue scale (VAS) 9 (95 per cent c.i. 1 to 17) mm; P = 0·024), were less fatigued (difference in VAS score 7 (0 to 14) mm; P = 0·038), used fewer opioids (absolute risk reduction 17 (2 to 33) per cent; P = 0·033) and had better quality of recovery (difference in QoR-15 score 13 (4 to 22); P = 0·006) during the first postoperative day. There was no difference in postoperative complications (P = 0·595). CONCLUSION Preoperative dexamethasone did not reduce PONV by the target level of 50 per cent. Registration number: NCT02415335 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- J Kleif
- Departments of Surgery, Nordsjaellands Hospital, Copenhagen University Hospital, Hillerød, Denmark
| | - A Kirkegaard
- Køge Sygehus, Zealand University Hospital, Køge, Denmark
| | - J Vilandt
- Departments of Surgery, Nordsjaellands Hospital, Copenhagen University Hospital, Hillerød, Denmark
| | - I Gögenur
- Køge Sygehus, Zealand University Hospital, Køge, Denmark
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Christensen I, Geismar L, Kirkegaard A, Kirkegaard G. Additional studies on side effects of melperone in long-term therapy for 1-20 years in psychiatric patients. Arzneimittelforschung 1986; 36:855-60. [PMID: 2873821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The present study reporting on continuous melperone treatment of hitherto longest duration recorded in literature was conducted in order to reveal side effects of long-term melperone therapy. 50 patients, 24 females and 26 males, aged 37-102 (average: 81 years of age) were treated with melperone (Buronil, Bunil, Eunerpan) for 1 to 20 years. In most patients, daily dosage varied from 10 to 300 mg, total dosage ranging from 6510 mg to 1 662 225 mg, avr. 203 923 mg. Diagnoses were as follows: senile dementia (14), organic dementia (9), arterio-sclerotic dementia (8), schizophrenia (17) and nonspecific psychosis (2). The patients were examined for clinical side effects including abnormal ECGs and ophthalmological diseases. Biochemical laboratory tests comprised sedimentation rate, haemoglobin, leucocytes, creatinine, alanine-aminotransferase, gamma-glutamyl-transferase and bilirubin. The results were evaluated by a specialist in internal medicine and an ophthalmologist performed the examinations on the 20 patients who were able to cooperate. The conclusion was that no serious side effects were observed which could with any certainty be related to melperone therapy.
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Kirkegaard A. [Barbiturate poisoning cases in the poison control center in 1980]. Ugeskr Laeger 1984; 146:1374. [PMID: 6495416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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15
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Kirkegaard A, Jensen A. [Studies on side-effects in treatment of psychoses with clozapine (Leponex)]. Ugeskr Laeger 1977; 139:2800-5. [PMID: 595167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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16
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Kirkegaard G, Kirkegaard A. [Side effects of methylperone in long-term therapy up to 8 years]. Arzneimittelforschung 1974; 24:1115-7. [PMID: 4213783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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17
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St Urup GK, Hansen CJ, Kirkegaard A, Littauer J, Lunn V, Svendsen BB. [The evolution of forensic psychiatry in Denmark]. Ugeskr Laeger 1971; 133:1689-94. [PMID: 5110836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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18
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