Evaluating the effectiveness of email-based nudges to reduce postoperative opioid prescribing: study protocol of a randomised controlled trial

Abstract

IntroductionSurgical 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 analysisThe 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 disseminationUsing 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 numberNCT05070338.

Surgeons’ views of peer comparison and guideline-based feedback on postsurgery opioid prescriptions: a qualitative investigation

“…2022. 16 Nineteen Sutter Health hospitals and their associated surgeons from 3 surgical specialties (general, obstetric/gynecologic and orthopaedic) were included in the study, which was a three-arm cluster-randomised controlled trial of two behavioural nudges compared with usual postsurgical care (control). One nudge compared opioid prescribing behaviour relative to guidelines endorsed by Sutter Health (guideline arm), while the other provided feedback on prescribing behaviour relative to peers in the same specialty (peer comparison arm).…”

Peer Comparison or Guideline-Based Feedback and Postsurgery Opioid Prescriptions

“…We conducted 3 prespecified analyses. 22 In each, we estimated intervention effects using the surgeon's treatment assignment, regardless of whether the surgeon received an email during the study period. The first set of analyses modeled effects on primary and secondary outcomes at the level of the surgical specialty using a hierarchical linear model (HLM) 29 with random effects for the surgeon and specialty within hospital and controlling for the baseline levels of the outcome (averaged by surgeon in the 24 months prior to the intervention).…”

“…This was a 3-arm cluster-randomized clinical trial conducted October 19, 2021, to October 18, 2022, in 3 surgical specialties (general, orthopedic, and obstetrics/gynecology) at 19 hospitals within Sutter Health, a large health care system in northern California. Details of the intervention and analysis plan were prespecified in a published protocol and are also available in Supplement 1 . Activities were approved by the institutional review boards at Sutter Health and the RAND Corporation and monitored by an independent data safety and monitoring board.…”

“…We conducted 3 prespecified analyses . In each, we estimated intervention effects using the surgeon’s treatment assignment, regardless of whether the surgeon received an email during the study period.…”

“…The study was powered to detect a difference of 12 percentage points between each study arm and the control group. Baseline outcome measures were more strongly correlated with the outcome than the original conservative estimate, yielding additional power . All statistical analyses are described in more detail in the eAppendix in Supplement 2.…”