Discharge Opioid Prescribing Patterns in an Academic Orthopaedic Setting: Level of Training and Subspecialty Patterns

Abstract

Introduction:Despite increased research on opioids in the orthopaedic literature, little is known of the prescribing practices of orthopaedic providers based on their level of training. The purpose of this study was to describe the discharge opioid prescribing patterns of orthopaedic providers, stratifying by level of training and orthopaedic subspecialty, within a single medical system.Methods:A retrospective review of orthopaedic surgical encounters was performed over a 1-year period for adults who received a discharge opioid prescription. Patient demographics and prescriber characteristics were collected, including the provider's level of training (attending, fellow, resident, physician assistant [PA], and nurse practitioner [NP]) and surgical subspecialty. Junior residents were postgraduate year 1 to 3, whereas senior residents/fellows were postgraduate year 4 to 6. Discharge opioids were converted to milligram morphine equivalents (MMEs). Overprescribing was defined as a prescribing more than a seven-day supply or >45 MMEs per day. Multivariable linear regression analysis determined the factors associated with discharge MMEs, whereas logistic regression determined the factors associated with overprescribing opioids.Results:Of the 3,786 patients reviewed, 1,500 met the criteria for inclusion in the study. The greatest proportion of opioid prescriptions was written by junior residents (33.9%), followed by NPs (30.1%), PAs (24.1%), senior residents/fellows (10.6%), and attendings (1.2%). Compared with junior residents, senior residents prescribed −59.4 MMEs, NPs prescribed +104 MMEs, and attendings prescribed +168 MMEs (P < 0.05), whereas PAs prescribed similar amounts (P > 0.05). Orthopaedic subspecialty was also predictive of discharge MMEs (P < 0.05). Senior residents and attendings were more likely to prescribe more than seven days of opioids (P < 0.05), whereas NPs and PAs were more likely to prescribe >45 MMEs per day (P < 0.05).Discussion:This study demonstrates significant variability in opioid prescribing practices according to provider level of training and subspecialty. National guidelines for opioid prescribing practices and educational programs may help reduce such variability.Level of Evidence:Level III, retrospective cohort study

Factors Associated With Total Discharge Opioid Prescription Morphine Milligram Equivalent Amounts Following Primary Anterior Cervical Spine Surgery

“…The authors also identified associations between provider type and opioid prescription volumes after surgery, 9 with midlevel providers prescribing markedly higher discharge opioid volumes as compared with residents. 19 Studies have also found associations between preoperative opioid use and increased postoperative opioid quantity and duration of use after spine surgery. 18,20–22…”

Team Approach: Use of Opioids in Orthopaedic Practice

“…It is also important to emphasize that discharging from the hospital or the first postoperative visit is not always performed by orthopaedic surgeons but rather by advanced practice providers or trainees, which may affect the prescription of opioids to patients. As a matter of fact, Fang et al 63 examined opioid prescribing patterns at discharge within an academic orthopaedic setting and determined that prescriptions differed both by subspecialty and by the level of training of the providers. Specifically, attending surgeons prescribed the greatest number of milligram morphine equivalents (MMEs) for discharge, followed by nurse practitioners, junior residents, PAs, and senior residents.…”

One size does not fit all: advanced practice provider considerations for the antimicrobial steward

“…One study of a multi-disciplinary orthopedic surgery teams at an academic medical center found that NPs and PAs were responsible for a similar amount of discharge opioid prescriptions as post-graduate years 1–3 residents; however, no studies have been published comparing inpatient antimicrobial prescriptions between APPs and other prescribers. 22 …”

“…One study of a multi-disciplinary orthopedic surgery teams at an academic medical center found that NPs and PAs were responsible for a similar amount of discharge opioid prescriptions as post-graduate years 1-3 residents; however, no studies have been published comparing inpatient antimicrobial prescriptions between APPs and other prescribers. 22 There are differences between APPs practicing in ambulatory settings, where there might be a higher level of autonomy, versus APPs working in inpatient settings. APPs on inpatient care teams may work as the primary hospitalist or as part of care teams that include attendings, fellows, and physician trainees.…”