Assessment of Postoperative Opioid Prescriptions Before and After Implementation of a Mandatory Prescription Drug Monitoring Program

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.

Uncertainty estimation and statistical comparative methodology for mammography x-ray energy spectra

Numerical models are an alternative to measurements of x-ray energy spectra when validated by comparative methods that assess the similarity of experimental and calculated spectra. In this work, we compared x-ray energy spectra using several methodologies and determined the methodology with highest statistical power among them. Experiments and Monte Carlo (MC) simulations were used to generate a set of 65 experimental and simulated x-ray mammography spectra pairs typically used in mammography applications. They were generated using Tungsten and Molybdenum targets and Molybdenum and Rhodium filters. The x-ray beams were transmitted through breast tissue equivalent material (bTEM) plates with different glandularities and thicknesses, and the transmitted beam was detected using solid-state x-ray spectrometry with a Cadmium Telluride (CdTe) diode. The MC simulations used the PENELOPE code. Additional uncertainties, beyond that from counting, were propagated using the MC method. Quantitative comparative methods based on the [Formula: see text] statistics, the first and second half-value layers, the mean energy, the effective energy, and the non-parametric u-test were applied and their specificity (true negative rate) was assessed. The polyenergetic normalized glandular dose (DgNp) to a 6 cm breast of 50/50 glandularity was derived from the spectra. In this work, the [Formula: see text] statistics attained the highest score; therefore, it is the most indicated metric for the x-ray energy spectra comparative evaluations. The contribution of the additional uncertainties was important, being responsible for up to 98% of the spectra total uncertainty and shifting the mean of the evaluated [Formula: see text] to 1.2(1), compatible with its expected value. The use of non-parametric test is discouraged by our results, since it failed to distinguish spectra pairs that resulted in up to 72% discrepant DgNp.

Evaluation of mean conversion coefficients from air-kerma to H *(10) using secondary and transmitted x-ray spectra in the diagnostic radiology energy range

Ambient dose equivalent H ^*(10) is an operational quantity recommended by the IAEA to establish dose constraints in area monitoring for external radiation. The direct measurement of H ^*(10) is not common due to the complexity in the calibration procedures of radiation monitors involving the use of expanded and aligned radiation fields. Therefore, conversion coefficients are used to assess H ^*(10) from the physical quantity air-kerma. Conversion coefficients published by international commissions, ICRU and ICRP, present a correlation with the radiation beam quality. However, Brazilian regulation establishes 1.14 Sv Gy^-1 as unique conversion coefficient to convert air-kerma into H ^*(10), disregarding its beam quality dependence. The present study computed mean conversion coefficients from secondary and transmitted x-ray beams in order to improve the current assessment of H ^*(10). The weighting of conversion coefficients corresponding to monoenergetic beams with the spectrum energy distribution in terms of air-kerma was used to compute the mean conversion coefficients. In order to represent dedicated chest radiographic facilities, an anthropomorphic phantom was used as scatter object of the primary beam. Secondary x-ray spectra were measured in the diagnostic energy range at scattering angles of 30°, 60°, 90° 120° and 150° degrees. Barite mortar plates were used as attenuator of the secondary beam to produce the corresponding transmitted x-ray spectra. Results show that the mean conversion coefficients are about 43% higher than the recommended value accepted by Brazilian regulation. For secondary radiation measured at 100 kV the mean coefficient should be 1.46 Sv Gy^-1, which represent the higher value in the mean coefficient set corresponding to secondary beams. Moreover, for transmitted x-ray beams at 100 kV, the recommended mean conversion coefficient is 1.65 Sv Gy^-1 for all barite mortar plate thickness and all scattering angles. An example of application shows the discrepancy in the evaluation of secondary shielding barriers in a controlled area when the shielding goals is evaluated. The conclusion based on these results is that a unique coefficient may not be adequate for deriving the H ^*(10).

Evaluation of conversion coefficients relating air-kerma to H*(10) using primary and transmitted x-ray spectra in the diagnostic radiology energy range

According to the International Commission on Radiation Units and Measurements (ICRU), the relationship between effective dose and incident air-kerma is complex and depends on the attenuation of x-rays in the body. Therefore, it is not practical to use this quantity for shielding design purposes. This correlation is adopted in practical situations by using conversion coefficients calculated using validated mathematical models by the ICRU. The ambient dose equivalent, H*(10), is a quantity adopted by the IAEA for monitoring external exposure. Dose constraint levels are established in terms of H*(10), while the radiation levels in radiometric surveys are calculated by means of the measurements of air-kerma with ion chambers. The resulting measurements are converted into ambient dose equivalents by conversion factors. In the present work, an experimental study of the relationship between the air-kerma and the operational quantity ambient dose equivalent was conducted using different experimental scenarios. This study was done by measuring the primary x-ray spectra and x-ray spectra transmitted through materials used in dedicated chest radiographic facilities, using a CdTe detector. The air-kerma to ambient dose equivalent conversion coefficients were calculated from these measured spectra. The resulting values of the quantity ambient dose equivalent using these conversion coefficients are more realistic than those available in the literature, because they consider the real energy distribution of primary and transmitted x-ray beams. The maximum difference between the obtained conversion coefficients and the constant value recommended in national and international radiation protection standards is 53.4%. The conclusion based on these results is that a constant coefficient may not be adequate for deriving the ambient dose equivalent.

Endovenous laser therapy of the incompetent great saphenous vein

PURPOSE

The aim of this study was the development of a new, even less invasive technique, for the treatment of varicose veins of the lower limbs than traditional surgery (ligation with stripping of the saphenous vein).

MATERIALS AND METHODS

The new interventional radiological procedure uses the 810- to 980-nm endovascular laser fibre proposed by Min et al. Our technique involves the superselective catheterisation of the great saphenous vein under fluoroscopy with contralateral venous access achieved by performing iliac crossover. Retrograde and anterograde phlebographies are performed with a needle cannula positioned in the dorsum of the foot. This enables accurate venous mapping during the procedure of laser photothermolysis. We treated 52 patients between June 2003 and June 2004, with a percentage of recanalisation of 7.5% at 1 year.

RESULTS AND CONCLUSIONS

The contralateral approach allows greater control over the entire procedure, with a reduction in potential risks in relation to the saphenofemoral junction given that, unlike in the technique proposed by Min et al. the tip of the laser is directed at all times towards the saphenous vein and never towards the femoral vein. This more radical procedure offers a significant reduction in the possibility of relapse of varicose disease of the saphenofemoral junction.

Recombinant human angiostatin (rhAngiostatin) in combination with paclitaxel and carboplatin in patients with advanced non-small-cell lung cancer: a phase II study from Indiana University

BACKGROUND

Recombinant human angiostatin (rhAngiostatin) functions as a potent inhibitor of angiogenesis. This study combined rhAngiostatin with a standard chemotherapy regimen in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Eligible patients had chemotherapy-naïve stage IIIB (with pleural effusion) or IV NSCLC, performance status (PS) 0 or 1, no history of bleeding, brain metastasis or requirements for anti-coagulation. Patients received carboplatin (AUC 5) intravenously and paclitaxel (175 mg/m2) intravenously day 1 + subcutaneous rhAngiostatin at either 15 mg or 60 mg twice daily. Cycles were repeated every 3 weeks, for up to six cycles. Patients without progression after completing at least four cycles were continued on maintenance rhAngiostatin until disease progression.

RESULTS

Patient characteristics (n = 24) were: 16 males, median age 66 years (range 45-78), 54% PS 1, 83.3% stage IV and 62.5% adenocarcinoma. Grade 3/4 toxicities included: fatigue 47.8%, neutropenia 39.1%, dyspnea 39.1%, vascular 26.1% and infection 17.4%. The overall response rate was 39.1%, 39.1% stable disease and 21.7% progressive disease. Median time to progression was 144 days, and 1-year survival was 45.8%.

CONCLUSIONS

rhAngiostatin in combination with paclitaxel and carboplatin is feasible and results in a high disease control rate in patients with advanced NSCLC.