Patient-Centered Default Opioid Orders—A Path Forward for Postoperative Opioid Stewardship

Delgado, M. Kit

doi:10.1001/jamanetworkopen.2022.19712

Cited by 3 publications

(6 citation statements)

References 7 publications

(18 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…[41][42][43] This intervention is effective because clinicians tend to stick with the status quo since opting out requires more effort, and in the absence of strong preference, the default is accepted as an implicit recommendation. 44,45 Further work could characterize the effects of default opioid dosages on equity in prescribing.…”

Section: Discussionmentioning

confidence: 99%

“…First, studies have demonstrated that implementation of guideline‐concordant dosage amounts through default orders increases prescriptions for the default dosage 41–43 . This intervention is effective because clinicians tend to stick with the status quo since opting out requires more effort, and in the absence of strong preference, the default is accepted as an implicit recommendation 44,45 . Further work could characterize the effects of default opioid dosages on equity in prescribing.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions

Crowley

Sun

Yan

et al. 2023

Academic Emergency Medicine

Self Cite

View full text Add to dashboard Cite

Objectives Racial and ethnic minorities receive opioid prescriptions at lower rates and dosages than White patients. Though opioid stewardship interventions can improve or exacerbate these disparities, there is little evidence about these effects. We conducted a secondary analysis of a cluster‐randomized controlled trial conducted among 438 clinicians from 21 emergency departments and 27 urgent care clinics. Our objective was to determine whether randomly allocated opioid stewardship clinician feedback interventions that were designed to reduce opioid prescriptions had unintended effects on disparities in prescribing by patient race and ethnicity. Methods The primary outcome was likelihood of receiving a low‐pill prescription (low ≤10 pills, medium 11–19 pills, high ≥20 pills). Generalized mixed‐effects models were used to determine patient characteristics associated with low‐pill prescriptions during the baseline period. These models were then used to determine whether receipt of a low‐pill prescription varied by patient race or ethnicity during the intervention period between usual care and three opioid stewardship interventions: (1) individual audit feedback, (2) peer comparison feedback, and (3) combined (individual audit + peer comparison) feedback. Results Compared with White patients, Black patients were more likely to receive a low‐pill prescription during the baseline (adjusted odds ratio [OR] 1.18, 95% confidence interval [CI] 1.06–1.31, p = 0.002) and intervention (adjusted OR 1.43, 95% CI 1.07–1.91, p = 0.015). While combined feedback was associated with an overall increase in low‐pill prescriptions as intended (adjusted OR 1.89, 95% CI 1.28–2.78, p = 0.001), there were no significant differences in treatment effects of any of the interventions by patient race and ethnicity. Conclusions Combined individual audit and peer comparison feedback was associated with fewer opioid pills per prescription equally by patient race and ethnicity. However, the intervention did not significantly close the baseline disparity in prescribing by race.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions

Crowley

Sun

Yan

et al. 2023

Academic Emergency Medicine

Self Cite

View full text Add to dashboard Cite

show abstract

“…13 This approach has several advantages, including low implementation costs and the preservation of clinician autonomy, the latter of which may increase clinician support. 14,15 In our 2022 study, 14 we collected data on opioid consumption from adolescents and young adults aged 12 to 25 years undergoing tonsillectomy on the pediatric otolaryngology service at Michigan Medicine and lowered the default number of opioid doses in the EHR system from 30 doses to 12 doses, a level that would meet the needs of most patients. Compared with a control group, the proportion of opioid prescriptions with 12 doses increased by 45.3 percentage points and the number of opioid doses prescribed decreased by 29.2%.…”

Section: Introductionmentioning

confidence: 99%

“…A promising approach to achieve this goal may be to implement evidence-based default settings for the number of doses in opioid prescriptions written through electronic health record (EHR) systems, the primary means by which controlled substances are prescribed in the US . This approach has several advantages, including low implementation costs and the preservation of clinician autonomy, the latter of which may increase clinician support …”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Surgeons’ Perspectives on Changing the Default Number of Doses for Opioid Prescriptions in Electronic Health Record Systems

et al. 2023

View full text Add to dashboard Cite

ImportanceAn intervention in 2021 at a tertiary medical center found that the implementation of evidence-based default dosing settings for opioid prescriptions written in electronic health record systems was associated with reduced opioid prescribing to adolescents and young adults aged 12 to 25 years undergoing tonsillectomy. It is unclear whether surgeons were aware of this intervention, whether they thought the intervention was acceptable, or whether they believed similar interventions were feasible to implement in other surgical populations and institutions.ObjectiveTo assess surgeons’ experiences and perspectives regarding an intervention that changed the default number of doses for opioid prescriptions to an evidence-based level.Design, Setting, and ParticipantsThis qualitative study was conducted at a tertiary medical center during October 2021, 1 year after implementation of the intervention, in which the default number of doses for opioid prescriptions written through an electronic health record system to adolescents and young adults undergoing tonsillectomy was lowered to an evidence-based level. Semistructured interviews were conducted with otolaryngology attending and resident physicians who had cared for the adolescents and young adults undergoing tonsillectomy after implementation of the intervention. Factors that play a role in opioid prescribing decisions after surgery and participants’ awareness of and views on the intervention were assessed. The interviews were coded inductively and a thematic analysis was performed. Analyses were conducted from March to December 2022.ExposureChange in the default dosing settings for opioid prescriptions written in an electronic health record system to adolescents and young adults undergoing tonsillectomy.Main Outcomes and MeasuresSurgeons’ experiences and perspectives regarding the intervention.ResultsThe 16 otolaryngologists interviewed included 11 residents (68.8%), 5 attending physicians (31.2%), and 8 women (50.0%). No participant reported noticing the change in the default settings, including those who wrote opioid prescriptions with the new default number of opioid doses. From the interviews, 4 themes regarding surgeons' perceptions and experiences of the intervention emerged: (1) opioid prescribing decisions are influenced by patient, procedure, physician, and health system factors; (2) defaults may substantially influence prescribing behavior; (3) support for the default dosing setting intervention depended on whether it was evidence-based and had unintended consequences; and (4) changing the default dosing settings is potentially feasible in other surgical populations and institutions.Conclusions and RelevanceThese findings suggest that interventions to change the default dosing settings for opioid prescriptions may be feasible to implement in a variety of surgical populations, particularly if the new settings are evidence-based and if unintended consequences are carefully monitored.

show abstract

A Resident-Driven Quality Initiative for Reducing Opioid Prescribing in Patients Undergoing Elective General Surgery Procedures, With Long-Term Follow-Up

Lamm,

Lundgren,

Christopher

et al. 2023

Patient Safety

View full text Add to dashboard Cite

Background The opioid epidemic has been declared a public health emergency in the United States—and major news outlets have labeled operating rooms as “unintended gateways.” In response to this emergency, our academic institution sought to decrease our contribution to the potential diversion pool—the opioids surgeons prescribe to patients which go unused. Methods Patients undergoing common surgical procedures between August 2017 and March 2018 were identified. Patients were contacted by phone and consented, and opioid use data was collected. The potential diversion pool was calculated as pills prescribed minus pills consumed for each patient and procedure, and subgroup analysis was performed to correlate the number of opioid pills taken within 24 hours before hospital discharge to the number taken after discharge. Results Surveys were completed for 357 patients. Overall, 6,831 of the 12,061 tablets prescribed were unused (57%). Patients who took 7 or more doses of oral opioids in the last 24 hours before discharge had significantly fewer (30%) pills remaining compared to patients who took 0–6 doses (68% remaining). Ninety-nine of 111 patients (89%) who took 0 tablets 24 hours prior to discharge left with an opioid prescription, creating a diversion pool of 2,419 pills remaining out of 3,353 prescribed (72%). Based on a 95% confidence interval of procedural opioid consumption, prescribing guidelines were created within a toolkit designed to set preoperative expectations, promote use of nonopioid analgesics, and provide opioid disposal information. We have continued to track our data, with low opioid prescribing patterns. Conclusion Surgical departments can develop opioid reduction toolkits aimed at reducing the potential diversion pool of opioids in our communities. Such toolkits have a sustained positive impact.

show abstract

Patient-Centered Default Opioid Orders—A Path Forward for Postoperative Opioid Stewardship

Cited by 3 publications

References 7 publications

Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions

Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions

Surgeons’ Perspectives on Changing the Default Number of Doses for Opioid Prescriptions in Electronic Health Record Systems

A Resident-Driven Quality Initiative for Reducing Opioid Prescribing in Patients Undergoing Elective General Surgery Procedures, With Long-Term Follow-Up

Contact Info

Product

Resources

About