The impact of opioid prescribing reduction interventions on prescribing patterns across orthopedic subspecialties
DOI:
https://doi.org/10.5055/jom.2021.0626Keywords:
opioid, narcotic, morphine, over prescribing, quality improvementAbstract
Objective: To date, the majority of studies have focused on the adverse effect of opioid overutilization on outcomes, risk factors for overutilization and dependence, and the development of procedure-specific guidelines. We present the results of a multiphased approach to reducing opioid prescribing.
Design: A retrospective pre-post study of opioid prescriptions across 386,393 patient encounters was conducted. The preintervention cohort included patient encounters from November 2016 to March 2017, and the post-intervention cohort included encounters from April 2017 to October 2019.
Setting: Single-institution orthopedic practice.
Patients, participants: 386,393 patient encounters.
Intervention: Multiple prescribing reduction interventions were implemented from April 2017 to July 2018.
Main outcome measure: Average morphine milligram equivalent (MME) per patient encounter.
Results: Implementation of the interventions resulted in an average reduction of 15.2 MME per encounter (54.5 percent) compared to the preimplementation cohort (pre: avg. MME = 27.9, SD 113.6; post: avg. MME = 12.7, SD 66.1; p < 0.001). The number of pills per opioid prescription was reduced by 13.4 (29.5 percent) (pre: avg. pill count = 45.5, S.D. 25.1; post: avg. pill count = 32.1, SD 21.1; p < 0.001), and the percent of patients receiving opioids was reduced from 8.3 percent to 5.8 percent (p < 0.001). Prescribing compliance was evaluated for 7,664 surgical encounters, with 98.2 percent of prescriptions meeting stated guidelines; 5.5 percent of these encounters required second prescriptions.
Conclusions: The use of a multiphase approach effectively reduced the opioid prescribing patterns of a large orthopedic practice and was successful across subspecialties. This approach provides a template that other institutions may use to reduce opioid overprescribing in orthopedic practices.
References
Manchikanti L, Helm S 2nd, Fellows B, et al.: Opioid epidemic in the United States. Pain Physician. 2012; 15(3 Suppl): Es9-38.
Kumar K, Gulotta LV, Dines JS, et al.: Unused opioid pills after outpatient shoulder surgeries given current perioperative prescribing habits. Am J Sports Med. 2017; 45(3): 636-641.
Gostin LO, Hodge JG Jr, Noe SA.: Reframing the opioid epidemic as a national emergency. JAMA. 2017; 318(16): 1539-1540.
Martin L, Laderman M: A Systems Approach is the Only Way to Address the Opioid Crisis. Health Affairs Blog.
National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Health Sciences Policy, Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington, DC: National Academies Press, 2017.
Rodgers J, Cunningham K, Fitzgerald K, et al.: Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am. 2012; 37(4): 645-650.
Hernandez NM, Parry JA, Taunton MJ: Patients at risk: Large opioid prescriptions after total knee arthroplasty. J Arthroplasty. 2017; 32(8): 2395-2398.
Morris BJ, Mir HR: The opioid epidemic: Impact on orthopaedic surgery. J Am Acad Orthop Surg. 2015; 23(5): 267-271.
Meisenberg BR, Grover J, Campbell C, et al.: Assessment of opioid prescribing practices before and after implementation of a health system intervention to reduce opioid overprescribing. JAMA Network Open. 2018; 1(5): e182908.
Health MDo. CRISP PDMP Registration. Available at https://crisphealth.org/services/prescription-drug-monitoring-programpdmp/pdmp-registration/. Accessed 2019.
Pugely AJ, Bedard NA, Kalakoti P, et al.: Opioid use following cervical spine surgery: Trends and factors associated with long-term use. Spine J. 2018; 18(11): 1974-1981.
Gil JA, Gunaseelan V, DeFroda SF, et al.: Risk of prolonged opioid use among opioid-naive patients after common shoulder arthroscopy procedures. Am J Sports Med. 2019; 47(5): 1043-1050.
Bedard NA, Pugely AJ, Dowdle SB, et al.: Opioid use following total hip arthroplasty: Trends and risk factors for prolonged use. J Arthroplasty. 2017; 32(12): 3675-3679.
Schoenfeld AJ, Nwosu K, Jiang W, et al.: Risk factors for prolonged opioid use following spine surgery, and the association with surgical intensity, among opioid-naive patients. J Bone Joint Surg Am. 2017; 99(15): 1247-1252.
Mohamadi A, Chan JJ, Lian J, et al.: Risk factors and pooled rate of prolonged opioid use following trauma or surgery: A systematic review and meta-(regression) analysis. J Bone Joint Surg Am. 2018; 100(15): 1332-1340.
Kidner CL, Mayer TG, Gatchel RJ: Higher opioid doses predict poorer functional outcome in patients with chronic disabling occupational musculoskeletal disorders. J Bone Joint Surg Am. 2009; 91(4): 919-927.
Holman JE, Stoddard GJ, Higgins TF: Rates of prescription opiate use before and after injury in patients with orthopaedic trauma and the risk factors for prolonged opiate use. J Bone Joint Surg Am. 2013; 95(12): 1075-1080.
Smith SR, Bido J, Collins JE, et al.: Impact of preoperative opioid use on total knee arthroplasty outcomes. J Bone Joint Surg Am. 2017; 99(10): 803-808.
Weick J, Bawa H, Dirschl DR, et al.: Preoperative opioid use is associated with higher readmission and revision rates in total knee and total hip arthroplasty. J Bone Joint Surg Am. 2018; 100(14): 1171-1176.
Lee D, Armaghani S, Archer KR, et al.: Preoperative opioid use as a predictor of adverse postoperative self-reported outcomes in patients undergoing spine surgery. J Bone Joint Surg Am. 2014; 96(11): e89.
Moucha CS, Weiser MC, Levin EJ: Current strategies in anesthesia and analgesia for total knee arthroplasty. JAAOS. 2016; 24(2): 60-73.
Kurd MF, Kreitz T, Schroeder G, et al.: The role of multimodal analgesia in spine surgery. JAAOS. 2017; 25(4): 260-268.
Parvizi J, Miller AG, Gandhi K: Multimodal pain management after total joint arthroplasty. J Bone Joint Surg Am. 2011; 93(11): 1075-1084.
Kang H, Ha YC, Kim JY, et al.: Effectiveness of multimodal pain management after bipolar hemiarthroplasty for hip fracture: A randomized, controlled study. J Bone Joint Surg Am. 2013; 95(4): 291-296.
Kim N, Matzon JL, Abboudi J, et al.: A prospective evaluation of opioid utilization after upper-extremity surgical procedures: Identifying consumption patterns and determining prescribing guidelines. J Bone Joint Surg Am. 2016; 98(20): e89.
Overton HN, Hanna MN, Bruhn WE, et al.: Opioid-prescribing guidelines for common surgical procedures: An expert panel consensus. J Am Coll Surg. 2018; 227(4): 411-418.
Raneses E, Secrist ES, Freedman KB, et al.: Opioid prescribing practices of orthopaedic surgeons: Results of a national survey. JAAOS. 2019; 27(4): e166-e172.
Wojahn RD, Bogunovic L, Brophy RH, et al.: Opioid consumption after knee arthroscopy. J Bone Joint Surg Am. 2018; 100(19): 1629-1636.
Reid DBC, Shah KN, Shapiro BH, et al.: Mandatory prescription limits and opioid utilization following orthopaedic surgery. J Bone Joint Surg Am. 2019; 101(10): e43.
Dwyer CL, Soong M, Hunter A, et al.: Prospective evaluation of an opioid reduction protocol in hand surgery. J Hand Surg Am. 2018; 43(6): 516-522.e511.
Eley N, Sikora M, Wright AK, et al.: Implementation of an opioid reduction protocol for simple outpatient neurosurgical procedures: A single-center experience. Spine. 2018; 45(6): 397-404.
Donabedian A: The quality of care: How can it be assessed? JAMA. 1988; 260(12): 1743-1748.
Denton E, Conron M: Improving outcomes in lung cancer: The value of the multidisciplinary health care team. J Multidiscip Healthc. 2016; 9: 137-144.
Bydder S, Nowak A, Marion K, et al.: The impact of case discussion at a multidisciplinary team meeting on the treatment and survival of patients with inoperable non-small cell lung cancer. Intern Med J. 2009; 39(12): 838-841.
Porter ME: What is value in health care? N Engl J Med. 2010; 363(26): 2477-2481.
Sackett DL: Evidence-based medicine. Semin Perinatol. 1997; 21(1): 3-5.
Sackett DL, Rosenberg WM, Gray JM, et al.: Evidence based medicine: What it is and what it isn't. BMJ. 1996; 312: 71.
Rosenberg W, Donald A: Evidence based medicine: An approach to clinical problem-solving. BMJ. 1995; 310(6987): 1122-1126.
Adams RJ: Improving health outcomes with better patient understanding and education. Risk Manag Healthc Policy. 2010; 3: 61.
Jarvis J, Skinner T, Carey M, et al.: How can structured self-management patient education improve outcomes in people with type 2 diabetes? Diabetes, Obesi Metab. 2010; 12(1): 12-19.
Greene J, Hibbard JH: Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes. J Gen Intern Med. 2012; 27(5): 520-526.
Greene J, Hibbard JH, Sacks R, et al.: When patient activation levels change, health outcomes and costs change, too. Health Aff (Millwood). 2015; 34(3): 431-437.
VanLare JM, Blum JD, Conway PH: Linking performance with payment: Implementing the physician value-based payment modifier. JAMA. 2012; 308(20): 2089-2090.
Chen C, Ackerly DC: Beyond ACOs and bundled payments: Medicare's shift toward accountability in fee-for-service. JAMA. 2014; 311(7): 673-674.
Bozic KJ: Improving value in healthcare. Clin Orthop Relat Res. 2013; 471(2): 368-370.
Ryan AM, Burgess JF Jr, Pesko MF, et al.: The early effects of Medicare's mandatory hospital pay-for-performance program. Health Serv Res. 2015; 50(1): 81-97.
Song Z, Ji Y, Safran DG, et al.: Health care spending, utilization, and quality 8 years into global payment. N Engl J Med. 2019; 381(3): 252-263.
Cassel CK, Jain SH: Assessing individual physician performance: Does measurement suppress motivation? JAMA. 2012; 307(24): 2595-2596.
Cho I, Bates DW: Behavioral economics interventions in clinical decision support systems. Yearb Med Inform. 2018; 27(1): 114-121.
Lin C, Lin CM, Lin B, et al.: A decision support system for improving doctors’ prescribing behavior. Expert Syst Appl. 2009; 36(4): 7975-7984.
Bright TJ, Wong A, Dhurjati R, et al.: Effect of clinical decision-support systems: A systematic review. Ann Intern Med. 2012; 157(1): 29-43.
Soffin EM, Waldman SA, Stack RJ, et al.: An evidence-based approach to the prescription opioid epidemic in orthopedic surgery. Anesth Analg. 2017; 125(5): 1704-1713.
Stepan JG, Lovecchio FC, Premkumar A, et al.: Development of an institutional opioid prescriber education program and opioid-prescribing guidelines: Impact on prescribing practices. JBJS. 2019; 101(1): 5-13.
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