Implementation of a Quality Improvement Initiative to Decrease Opioid Prescribing After Cesarean Delivery

Prabhu, Malavika; Dubois, Heloise; James, Kaitlyn; Leffert, Lisa; Riley, Laura E.; Bateman, Brian T.; Henderson, Marie

doi:10.1097/aog.0000000000002789

Cited by 46 publications

(54 citation statements)

References 7 publications

(13 reference statements)

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“…16,26 Opioid-sparing pain protocols for cesarean delivery have been shown to successfully decrease opioid prescribing while maintaining patient comfort. 27,28 These protocols include 3 main components: patient preparation (when cesarean delivery is scheduled), perioperative measures, and multimodal postoperative therapy. Preparation can help patients set expectations and develop coping techniques prior to surgery.…”

Section: Discussionmentioning

confidence: 99%

Rates of New Persistent Opioid Use After Vaginal or Cesarean Birth Among US Women

et al. 2019

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IMPORTANCE Research has shown an association between opioid prescribing after major or minor procedures and new persistent opioid use. However, the association of opioid prescribing with persistent use among women after vaginal delivery or cesarean delivery is less clear. OBJECTIVE To assess the association between opioid prescribing administered for vaginal or cesarean delivery and rates of new persistent opioid use among women. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used national insurance claims data for 988 036 women from a single private payer from January 1, 2008, to December 31, 2016. Participants included reproductive age, opioid-naive women with 1 year of continuous enrollment before and after delivery. For participants with multiple births, only the first birth was included. EXPOSURES Peripartum opioid prescription (1 week before delivery to 3 days after discharge) captured by pharmacy claims, including prescription timing and size in oral morphine equivalents. Multivariable adjusted odds ratios were estimated using regression models. MAIN OUTCOMES AND MEASURES Rates of new persistent opioid use, defined as pharmacy claims for 1 or more opioid prescription 4 to 90 days after discharge and 1 or more prescription 91 to 365 days after discharge among women who filled peripartum opioid prescriptions. RESULTS In total, 308 226 deliveries were included: 195 013 (63.3%) vaginal deliveries and 113 213 (36.7%) cesarean deliveries. Participant mean (SD) age was 31.3 (5.3) years, and 70 567 (51.0%) were white patients. Peripartum opioid prescriptions were filled by 27.0% of women with vaginal deliveries and 75.7% of women with cesarean deliveries. Among them, 1.7% of those with vaginal deliveries and 2.2% with cesarean deliveries had new persistent opioid use. By contrast, among women not receiving a peripartum opioid prescription, 0.

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Section: Discussionmentioning

confidence: 99%

Rates of New Persistent Opioid Use After Vaginal or Cesarean Birth Among US Women

et al. 2019

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“…Given these findings, there is a need to develop and test approaches to better align the amount of opioid medication that is prescribed with what women require. Strategies that have demonstrated promise in this regard include the use of shared decision-making (in which women select the quantity of opioids they want to be prescribed up to a defined limit) 48,49 and individualized prescriptions based on inpatient opioid use. 50 Given the risks and adverse side-effect profile of opioids, some have questioned whether oral opioids should be prescribed routinely for all women after cesarean delivery.…”

Section: Pain Management After Cesarean Delivery Among Opioid-naïve Wmentioning

confidence: 99%

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

Ecker

Abuhamad

Hill

et al. 2019

American Journal of Obstetrics and Gynecology

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111

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“…18 Prabhu and colleagues note that among 624 women who underwent cesarean section, 95% were prescribed opioids upon discharge. 16 Within our own institution, Badreldin and colleagues noted that 86.7% of women who underwent a cesarean section received a prescription for an opioid prior to discharge. 19 However, the latter two studies did not elucidate whether or not these prescriptions were filled through querying a PMP.…”

Section: Discussionmentioning

confidence: 98%

“…Insofar, as outpatient prescriptions have been declining over time, these data suggest the accuracy of the PMP is dynamic and, perhaps, improving with increased pharmacy utilization. 16 To the best of our knowledge, this study is the first of its kind to assess the reliability of identifying postpartum women in a statewide PMP who are at high risk of opioid utilization after discharge. ACOG has specifically emphasized opioid stewardship in regards to postpartum prescribing, and recommends referencing the state PMP prior to prescribing opioids for any patient.…”

Section: Discussionmentioning

confidence: 99%

“…However, given previous data suggesting frequencies of filling a prescription opioid post-cesarean delivery between 83 and 95% among women prescribed opioids, our finding that the frequency was less than what is reported in the literature suggests the possibility of an issue in the PMP. 16,18,19 Furthermore, the small timeframe in which our study performed was during the early initiation of an PMP in our state may have affected the quality of data obtained from the database. This finding may represent issues with the implementation of the PMP, though our data suggest that detection may improve over time.…”

Section: Limitationsmentioning

confidence: 99%

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How Reliable Is a Statewide Prescription Monitoring Program for Identifying Post-Cesarean Opioid Use?

Premkumar

Speedy

2020

AJP Rep

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Objective This study was aimed to estimate the percentage of women taking opioids post-cesarean who could be detected in a state prescription monitoring program (PMP) and characteristics of those not able to be detected. Study Design This observational cohort study included all women with an Illinois address who delivered via cesarean section and used opioids within 24 hours prior to discharge at a tertiary care hospital between August 21, 2017 and March 1, 2018. The Illinois PMP was queried for presence of an opioid prescription filled within the first 3 months postpartum. Sociodemographic and clinical factors associated with an undetectable PMP record were evaluated in bivariable and multivariable logistic regression analyses. Results A total of 517 women underwent a cesarean delivery during the study period, of whom 344 (66.5%) met inclusion criteria. Of these women, 169 (49%) did not have a detectable PMP record of filling any outpatient postpartum prescription opioid. On bivariable and multivariable logistic regression analysis, year of delivery (2018 vs. 2017) was significantly associated with a higher incidence of detectable postpartum prescription opioid record in the PMP with increasing relative risk of detectable records in the second year of analyses (n = 110/244 [45%] in 2017 vs. n = 59/100 [59%] in 2018, adjusted risk ratio [aRR] = 1.32, 95% confidence interval [CI]: 1.06–1.64, p = 0.013). No other sociodemographic or clinical characteristics was significantly associated. Conclusion Nearly half of women who underwent a cesarean section and who were administered opioids 24 hours prior to discharge did not have a detectable postpartum opioid prescription in the PMP. While identification of prescription filling improved with time, many of women were not detectable in the PMP system. These data call into question the accuracy of PMPs in identifying prescription opioid filling patterns in the postpartum setting.

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Implementation of a Quality Improvement Initiative to Decrease Opioid Prescribing After Cesarean Delivery

Abstract: Implementation of a multiphase quality improvement protocol to decrease opioid prescribing, combined with iterative review of discharge data, resulted in a significant decrease in the number of opioid tablets prescribed after cesarean delivery.

Cited by 46 publications

References 7 publications

Rates of New Persistent Opioid Use After Vaginal or Cesarean Birth Among US Women

Rates of New Persistent Opioid Use After Vaginal or Cesarean Birth Among US Women

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

How Reliable Is a Statewide Prescription Monitoring Program for Identifying Post-Cesarean Opioid Use?

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