Optimizing Postoperative Opioid Prescribing Through Quality-Based Reimbursement

Howard, Ryan; Hallway, Alexander; Santos‐Parker, Jessica R.; Vu, Joceline V.; Waljee, Jennifer F.; Brummett, Chad M.; Englesbe, Michael J.

doi:10.1001/jamanetworkopen.2019.11619

Cited by 25 publications

(18 citation statements)

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“…The adherence to these guidelines can be motivated by incentives from payers, including possibly by employing cost-sharing. [44][45][46] There are several limitations inherent in this study. First, our analysis focuses on prescription fills, which may not reflect actual opioid use.…”

Section: Discussionmentioning

confidence: 99%

Association between insurance cost-sharing subsidy and postoperative opioid prescription refills among Medicare patients

Kirsch

Montgomery

Hu³

et al. 2020

Surgery

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Background: Models of health care coverage with varying degrees of patient cost-sharing have been shown to influence health care behaviors for chronic conditions including medication adherence. The effect of insurance cost-sharing subsidies on the probability of postoperative opioid refill, however, is unclear.Methods: This retrospective cohort study examined 100% Medicare claims data among patients (N = 21,781) ages 65 and older undergoing orthopedic procedures in Michigan between January 2013 and September 2016. Patients were classified based on the presence of low-income subsidy and on prior opioid exposure using Medicare Part D prescription files of drug events. We investigated the association of these factors with the probability of both initial and second postoperative opioid fill within 90 days from the date of discharge. Results:In this cohort, 84.6% of patients filled an initial opioid prescription, and 66.4% refilled an opioid prescription. Patients with a full low-income subsidy had greater odds of refill within the postoperative 90 days compared with those patients without a low-income subsidy (odds ratio 1.38, 95% confidence interval 1.18-1.60). Among opioid naïve patients with a full low-income subsidy, the adjusted refill rate was 61.3% (95% confidence interval 58.0-64.7%

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Section: Discussionmentioning

confidence: 99%

Association between insurance cost-sharing subsidy and postoperative opioid prescription refills among Medicare patients

Kirsch

Montgomery

Hu³

et al. 2020

Surgery

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“…Identifying concerns about financial losses also allowed us to couple these strategies with P4P incentives, which have similarly been used to motivate adoption of evidence-based opioid prescribing practices after surgery. 35 However, a future state that links P4P to actual preoperative optimization success and not simply referral rate may even further maximize the effect of this intervention.…”

Section: Discussionmentioning

confidence: 99%

“…Similar financial strategies have been deployed at the statewide level to improve postoperative opioid prescribing. 35…”

Section: Identifying Evidence-based Implementation Strategiesmentioning

confidence: 99%

Development and Implementation of Preoperative Optimization for High-Risk Patients With Abdominal Wall Hernia

et al. 2021

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IMPORTANCE Real-world surgical practice often lags behind the best scientific evidence. For example, although optimizing comorbidities such as smoking and morbid obesity before ventral and incisional hernia repair improves outcomes, as many as 25% of these patients have a high-risk characteristic at the time of surgery. Implementation strategies may effectively increase use of evidence-based practice.OBJECTIVE To describe current trends in preoperative optimization among patients undergoing ventral hernia repair, identify barriers to optimization, develop interventions to address these barriers, and then pilot these interventions. DESIGN, SETTING, AND PARTICIPANTSThis quality improvement study used a retrospective medical record review to identify hospital-level trends in preoperative optimization among patients undergoing ventral and incisional hernia repair. Semistructured interviews with 21 practicing surgeons were conducted to elicit barriers to optimizing high-risk patients before surgery. Next, a task force of experts was convened to develop pragmatic interventions to increase surgeon use of preoperative optimization. Finally, these interventions were piloted at 2 sites to assess acceptability and feasibility. This study was performed from January 1, 2014, to December 31, 2019. MAIN OUTCOMES AND MEASURESThe main outcome was rate of referrals for preoperative patient optimization at the 2 pilot sites. RESULTS Among 23 000 patients undergoing ventral hernia repair, the mean (SD) age was 53.9 (14.3) years, and 12 315 (53.5%) were men. Of these, 8786 patients (38.2%) had at least 1 high-risk characteristic at the time of surgery, including 7683 with 1, 1079 with 2, and 24 with 3. At the hospital level, the mean proportion of patients with at least 1 of 3 high-risk characteristics at the time of surgery was 38.2% (95% CI, 38.1%-38.3%). This proportion varied widely from 21.5% (95% CI, 17.6%-25.5%) to 52.8% (95% CI, 43.9%-61.8%) across hospitals. Interviews with surgeons identified 3 major barriers to improving this practice: lost financial opportunity by not offering a patient an operation, lack of surgeon awareness of available resources for optimization, and organizational barriers. A task force therefore developed 3 interventions: a financial incentive to optimize high-risk patients, an educational intervention to make surgeons aware of available optimization resources, and on-site facilitation. These strategies were piloted at 2 sites where preoperative risk optimization referrals increased 860%. CONCLUSIONS AND RELEVANCEThis study demonstrates a stepwise process of identifying a practice gap, eliciting barriers that contribute to this gap, using expert consensus and local resources to develop strategies to address these barriers, and piloting these strategies. This implementation (continued) Key Points Question Is a stepwise implementation intervention associated with increased use of preoperative optimization by surgeons for patients with abdominal wall hernia? Findings In this quality improvement study in...

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“…14 Although a handful of pilot efforts in the US have implemented "opioid-sparing recovery," these efforts typically target only a few procedures, and it is unclear if this strategy could be replicated on a larger scale. [15][16][17] Despite increasing awareness of the risks associated with opioids in the postoperative period, uncertainty around the feasibility of minimizing opioids after surgery has slowed efforts to mitigate these risks. Better understanding patient outcomes when surgeons do not prescribe any opioids after surgery may bolster efforts to further minimize their role postoperatively and may serve as an important complement to increasingly comprehensive patient education and multimodal analgesia regimens.…”

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confidence: 99%

The Association of Postoperative Opioid Prescriptions with Patient Outcomes

Howard

Brown

Lai³

et al. 2021

Annals of Surgery

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To compare outcomes after surgery between patients who were not prescribed opioids and patients who were prescribed opioids. Summary of Background Data: Postoperative opioid prescriptions carry significant risks. Understanding outcomes among patients who receive no opioids after surgery may inform efforts to reduce these risks. Methods: We performed a retrospective study of adult patients who underwent surgery between January 1, 2019 and October 31, 2019. The primary outcome was the composite incidence of an emergency department visit, readmission, or reoperation within 30 days of surgery. Secondary outcomes were postoperative pain, satisfaction, quality of life, and regret collected via postoperative survey. A multilevel, mixed-effects logistic regression was performed to evaluate differences between groups. Results: In a cohort of 22,345 patients, mean age (standard deviation) was 52.1 (16.5) years and 13,269 (59.4%) patients were female. About 3175 (14.2%) patients were not prescribed opioids, of whom 422 (13.3%) met the composite adverse event endpoint compared to 2255 (11.8%) of patients not prescribed opioids (P = 0.015). Patients not prescribed opioids had a similar probability of adverse events {11.7% [95% confidence interval (CI) 10.2%−13.2%] vs 11.9% (95% CI 10.6%-13.3%]}. Among 12,872 survey respondents, patients who were not prescribed an opioid had a similar rate of high satisfaction [81.7% (95% CI 77.3%-86.1%) vs 81.7% (95% CI 77.7%-85.7%)] and no regret [(93.0% (95% CI 90.8%-95.2%) vs 92.6% (95% CI 90.4%-94.7%)].Conclusions: Patients who were not prescribed opioids after surgery had similar clinical and patient-reported outcomes as patients who were prescribed opioids. This suggests that minimizing opioids as part of routine postoperative care is unlikely to adversely affect patients.

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Optimizing Postoperative Opioid Prescribing Through Quality-Based Reimbursement

Abstract: This quality improvement study examines the use of a novel reimbursement incentive for surgeons to counsel patients on an opioid-sparing pathway for postoperative pain management.

Cited by 25 publications

References 4 publications

Association between insurance cost-sharing subsidy and postoperative opioid prescription refills among Medicare patients

Association between insurance cost-sharing subsidy and postoperative opioid prescription refills among Medicare patients

Development and Implementation of Preoperative Optimization for High-Risk Patients With Abdominal Wall Hernia

The Association of Postoperative Opioid Prescriptions with Patient Outcomes

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