EMR quantity autopopulation removal on hospital discharge prescribing patterns: Implications for opioid stewardship

Abstract

What is Known and Objective: Prescription drug stewardship is critical. Autopopulation(AP) of medication quantities may influence prescriber behaviour. We investigate the impact of AP removal(APR) on opioid prescribing. Methods: Inpatient and emergency department(ED) discharges with opioid pain medications 2 years before and after APR were identified. Milligrams of morphine equivalents(MMEs) prescribed were recorded. Group comparisons were performed using Mann-Whitney U tests. Spearman's rho was used to analyse correlations between pain level and quantity of prescribed opioids. Mann-Kendall tests assessed trends in prescription patterns. Generalized estimating equations assessed trends in total quantity of prescribed MME. Results and Discussion: A total of 53 608 patient encounters were included for analysis. In surgical patients, there were no trends in the frequency of prescriptions below, at or above the AP quantity pre-APR. Post-APR, there was a decrease in the percentage of prescriptions written for the AP quantity(τ = −.493, P = .001) and an increase in prescriptions for <30 tablets(τ = .468,P = .001). In non-operative patients, the pre-APR period was associated with a lower percentage of prescriptions >30 tablets and a greater percentage of prescriptions for <30 tablets. Interestingly, APR reversed this trend in prescriptions for >30 tablets and resulted in an increase in larger prescriptions. Multivariate analysis of the total prescribed quantity of MME found no significant trend across months for inpatients prior to and after APR (0.997, P = .065 and 1.003, P = .142; respectively). The ED model found a monthly downward trend in amount of prescribed MME prior to and after APR (0.986, P < .001 and 0.990, P < .001; respectively). In the inpatient setting, pain was positively correlated to discharge MME (ρ = .028, P < .001); with those reporting the highest pain receiving the greatest amount of opioids both pre-and post-APR. Interestingly, in the ED, this finding was negatively correlated (ρ = −.086, P < .001); with those reporting the lowest pain receiving the greatest amount of opioids both pre-and post-APR. What is New and Conclusions: AP removal may have unintended consequences, such as increased prescriptions for greater quantities. To drive down prescription amounts, lower anchor values may be of more utility than APR. The poor correlation of pain values with prescribed medications warrants further investigation.

Evaluation of Interventions to Reduce Opioid Prescribing for Patients Discharged From the Emergency Department

“…Of these, 180 were kept for full-text review, and 63 unique studies were included in the review ( Figure 1 ). 12 , 27 , 28 , 29 , 30 , 31 , 32 , 35 , 36 , 37 , 39 , 40 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , …”

Opioid Stewardship: Moving Beyond the “Why” to the “How”

“…6 Alternatively, a pharmacist's review of the quantity of opioid provided upon discharge may identify opportunities to reduce opioid exposure, although this approach has not been successful in all settings. 7 A group of pharmacists in Minneapolis, Minnesota, have published a thorough description of the expectations for review of all opioid treatments by pharmacists within their institutions, 6 which can serve as a good starting point for Canadian pharmacists wishing to establish realistic expectations of engagement.…”

“…Once launched, such initiatives are doomed to fail unless processes are established for the ongoing measurement and evaluation of the impact of these efforts on opioid use. 7 Clinicians from Houston, Texas, recently published their recommendations, along with some commentary by other clinicians, for 19 quality indicators that would be useful in measuring the ongoing, sustained effects of opioid stewardship activities. 10 All Canadian institutional pharmacists are encouraged to move from discussion of potential benefits to implementation of actions to optimize the use of opioids for their patients.…”

Intendance des opioïdes : Passer du « pourquoi » au « comment »

“…6 Autrement, l'examen de la quantité d'opioïde fournie au moment du congé, mené par le pharmacien, pourrait permettre de déterminer les occasions de réduire l'exposition à cette substance, bien que la réussite de cette approche n'ait pas été démontrée dans tous les contextes. 7 Un groupe de pharmaciens de Minneapolis (Minnesota) a publié une description approfondie des attentes liées aux examens de tous les traitements opioïdes faits par les pharmaciens au sein de leur établissement. 6 Elle peut servir de point de départ fiable pour les pharmaciens canadiens souhaitant déterminer des attentes réalistes.…”

“…Une fois lancées, de telles initiatives ne réussissent que si des processus sont eux aussi définis pour pouvoir mesurer et évaluer en continu l'impact de ces efforts sur l'utilisation des opioïdes. 7 Des cliniciens de Houston au Texas ont récemment publié leurs recommandations accompagnées de commentaires d'autres cliniciens. Elles portaient sur 19 indicateurs de qualité qui pourraient être utiles pour mesurer les effets continus et soutenus des activités d'intendance des opioïdes.…”