Abstract
Objective
To measure the variability in discharge opioid prescription practices for children discharged from the emergency department (ED) with a long-bone fracture.
Design
A retrospective cohort study of pediatric ED visits in 2015.
Setting
Four pediatric EDs.
Subjects
Children aged four to 18 years with a long-bone fracture discharged from the ED.
Methods
A multisite registry of electronic health record data (PECARN Registry) was analyzed to determine the proportion of children receiving an opioid prescription on ED discharge. Multivariable logistic regression was performed to determine characteristics associated with receipt of an opioid prescription.
Results
There were 5,916 visits with long-bone fractures; 79% involved the upper extremity, and 27% required reduction. Overall, 15% of children were prescribed an opioid at discharge, with variation between the four EDs: A = 8.2% (95% confidence interval [CI] = 6.9–9.7%), B = 12.1% (95% CI = 10.5–14.0%), C = 16.9% (95% CI = 15.2–18.8%), D = 23.8% (95% CI = 21.7–26.1%). Oxycodone was the most frequently prescribed opioid. In the regression analysis, in addition to variation by ED site of care, age 12–18 years, white non-Hispanic, private insurance status, reduced fracture, and severe pain documented during the ED visit were associated with increased opioid prescribing.
Conclusions
For children with a long-bone fracture, discharge opioid prescription varied widely by ED site of care. In addition, black patients, Hispanic patients, and patients with government insurance were less likely to be prescribed opioids. This variability in opioid prescribing was not accounted for by patient- or injury-related factors that are associated with increased pain. Therefore, opioid prescribing may be modifiable, but evidence to support improved outcomes with specific treatment regimens is lacking.
Keywords: Pediatric, Pain, Opioid, Fracture
Introduction
Pain is the most common reason for seeking health care in the emergency department (ED) for both adults and children [1–4]. The current opioid abuse epidemic poses challenges for conscientious providers making analgesic prescription decisions for children discharged to home with acute pain. As little is known about children and opioid prescription abuse, fear of addiction and adverse events are often cited by both physicians and families as reasons that influence their prescription and use of opioid medication [5–10]. The Centers for Disease Control and Prevention (CDC) advises prescribing opioids at the lowest effective dose with the minimum quantity needed [11]. The American Academy of Pediatrics has stipulated that the appropriate recommendation of analgesia for use after discharge is an important health care objective [12–14]. Currently, there is no clear evidence demonstrating which analgesic is most clinically effective for the treatment of children with a long-bone fracture after discharge from the ED.
The ED discharge prescription patterns for children with fracture and injury pain have been evaluated previously in single-site studies [2,15–21]. The most recent was a retrospective evaluation of discharge analgesic prescription practices in Canadian EDs, which found that only 24% documented a discharge analgesic and, of these, 22% were opioids [15]. In that study, no subset of children had increased odds of receiving discharge analgesics when analyzed by injury type or use of an analgesic during the ED visit. A one-year retrospective review of discharge prescription practices at a single site in the US performed in 2013 found that 60% of children were prescribed an opioid at discharge and both older age and nonminority race/ethnicity were associated with differential prescription patterns [20–22]. Variation in at-home pain management advice suggests that further evidence is needed to guide health care providers’ discharge prescription of analgesics for injured children with fracture pain. A multicenter evaluation of prescription patterns has not been previously performed.
We performed this multi-institutional study to 1) describe the current opioid discharge prescription patterns for children with a long-bone fracture treated in the ED and 2) determine if ED site of care or patient characteristics is associated with differences in opioid discharge prescription. We hypothesized that opioid discharge prescription practice patterns would be variable across ED site of care and that children with lower extremity fractures or fractures reduced in the ED would be more likely to receive opioid prescriptions on discharge.
Methods
Study Design
We performed a retrospective cohort study using the Pediatric Emergency Care Applied Research Network (PECARN) Registry from January 1, 2015, to December 31, 2015. This study was approved by the institutional review boards of all study sites and the data coordinating center.
Study Setting and Population
The PECARN Registry is a de-identified electronic health record (EHR) registry of all encounters at participating EDs [23]. Through automated extraction, transformation, and de-identification processes, the PECARN Registry captures ED visit data from each site’s EHR and submits them monthly to the Data Coordinating Center at the University of Utah, Salt Lake City, Utah, in a uniform format. The ED sites of care included for this study were Children’s Hospital of Colorado, Denver, Colorado; Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Children’s National Medical Center, Washington, DC; and Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio. The ED sites of care are labeled A through D in the Results section and tables to preserve the confidentiality of sites.
Study Protocol
Children aged four to 18 years were included in the study if they were diagnosed with an acute isolated long-bone fracture, including clavicle, humerus, radius, ulna, femur, tibia, or fibula, as identified by an ICD-9 code (810.**, 812.**, 813.**, 820.**, 821.**, 823.**, 733.93/6/7), ICD-10 code (M84.311-M84.339 and M84.351-M84.353 and M84.361-M84.369 ***.***A only, S42.0**A/B, S42.2**A/B, S42.3**A/B, S42.4**A/B, S49.0**A, S49.1**A, S52.***A/B/C, S59.***A, S72.***A/B/C, S79.0**A, S79.1**A, S82.1**A/B/C, S82.2**A/B/C, S82.3**A/B/C, S82.4**A/B/C, S82.8**A/B/C, S89.0**A, S89.1**A, S89.2**A), or via natural language processing (NLP) of the written radiologist’s report of a radiograph performed during the ED visit [24]. Only children discharged home from the ED were included. If no pain score was recorded in the ED, the child was excluded.
Study Measures
Outcome Variable: Opioid Discharge Prescription
The primary outcome was any opioid prescription at ED discharge. Opioid discharge prescriptions included oral oxycodone and/or oxycodone and acetaminophen, hydrocodone and/or hydrocodone and acetaminophen, and codeine and/or codeine and acetaminophen. These medications accounted for 99.08% of all oral discharged opioid prescriptions from these four ED sites.
Predictors
To determine if ED site of care, patient-related characteristics, or injury-related characteristics were associated with difference in opioid discharge prescription, we a priori selected predictor variables that have been shown to be associated with analgesic prescription patterns. The four ED sites of care are labeled Site A through Site D. Patient characteristics included age, sex, race/ethnicity, and insurance payer. Age was determined by date of birth on the date of visit and was categorized into four to seven years, eight to 11years, and 12–18 years. Sex was dichotomized as female or male. Race/ethnicity categories were grouped into white non-Hispanic, black non-Hispanic, Hispanic, and other (including Asian/Pacific Islander, American Indian/Alaskan Native, or other). Insurance payer was grouped into four categories: private insurance, government (Medicaid including SCHIP and Medicare), self-pay, and other. Injury-related characteristics included fracture location, fracture reduction, and pain severity. Fracture location was dichotomized as upper extremity vs lower extremity according to ICD-9 or ICD-10 codes. For NLP-identified fractures (N = 1359), imaging reports were independently reviewed by two investigators (ALD, ERA) to classify upper vs lower extremity fracture. If both an upper and lower extremity fracture were identified, the location was categorized as a lower extremity fracture, with the assumption that the lower extremity fracture would be more painful. A fracture was categorized as a reduced fracture if ketamine was administered during the ED visit. Ketamine was the medication routinely used for procedural sedations at each of the four EDs during the study period. Severity of pain was categorized as none = 0, mild = 1–3, moderate = 4–6, and severe = 7–10 [25]. Pain score was dichotomized into none/mild/moderate and severe.
A priori, it was hypothesized that receiving an opioid in the ED would be highly correlated with discharge opioid prescription, the outcome of interest. The proportion of children receiving an opioid in the ED was measured. Opioids in the ED included all oral opioids previously outlined and intranasal/intravenous fentanyl, as well as intravenous morphine and hydromorphone. None of the sites of care had institutional practices that guided opioid administration in the ED or opioid prescription at discharge at the time of this study.
Data Analysis
We used standard measures to describe our study population and calculate rates of opioid ED administration and opioid ED discharge prescription. We tested for difference in distribution of patient- and fracture-related characteristics between ED populations using chi-square tests. Odds ratios were used to assess the association between ED site of care, patient- and injury-related characteristics, and opioid discharge prescription. Multivariable logistic regression was used to determine the independent association between each predictor variable and opioid discharge prescription. For multivariable modeling, we included all predictor variables except receiving an opioid in the ED. For all variables in the model, we investigated collinearity using variance inflation factors and condition indices [26]. No serious collinearity was detected. Data were analyzed using SAS software, version 9.4 (SAS Institute Inc., Cary, NC, USA).
Results
The sites had >340,000 ED visits during the study period, and 5,916 visits with a long-bone fracture met all inclusion criteria (Figure 1). Table 1 provides patient demographic and fracture characteristics at each of the four ED sites and overall. The number of visits at each site was evenly distributed; any significant differences in patient or fracture characteristics are shown in Table 1. Overall, 32.9% of children received an opioid during their ED visit, with significant variation between ED sites: A = 32.8%, B = 35.5%, C = 36.8%, and D = 26.3%.
Figure 1.
Flow diagram of study cohort.
Table 1.
Patient and injury characteristics at each of the sites
| A | B | C | D | Overall | |
|---|---|---|---|---|---|
| ED visits in 2015 | 93,638 | 86,276 | 91,354 | 71,068 | 342,336 |
| Cohort, No. | 1,462 | 1,344 | 1,640 | 1,470 | 5,916 |
| Age, No. (%) | |||||
| 4–7 y | 493 (33.7) | 556 (41.4) | 501 (30.5) | 458 (31.2) | 2,008 (33.9) |
| 8–11 y | 488 (33.4) | 426 (31.7) | 565 (34.5) | 472 (32.1) | 1,951 (33.0) |
| 12–18 y | 481 (32.9) | 362 (26.9) | 574 (35.0) | 540 (36.7) | 1,957 (33.1) |
| Gender, No. (%) | |||||
| Female | 532 (36.4) | 512 (38.1) | 634 (38.7) | 552 (37.6) | 2,230 (37.7) |
| Male | 930 (63.6) | 832 (61.9) | 1,006 (61.3) | 918 (62.4) | 3,686 (62.3) |
| Race/ethnicity, No. (%) | |||||
| NH white | 723 (49.5) | 208 (15.5) | 1,009 (61.5) | 440 (29.9) | 2,380 (40.2) |
| NH black | 492 (33.7) | 627 (46.7) | 454 (27.7) | 169 (11.5) | 1,742 (29.4) |
| Hispanic | 84 (5.7) | 261 (19.4) | 54 (3.3) | 679 (46.2) | 1,078 (18.2) |
| Other | 163 (11.1) | 248 (18.5) | 123 (7.5) | 182 (12.4) | 716 (12.1) |
| Primary payer, No. (%) | |||||
| Private insurance | 746 (51.0) | 288 (21.4) | 841 (51.3) | 403 (27.4) | 2,278 (38.5) |
| Government | 666 (45.6) | 691 (51.4) | 715 (43.6) | 956 (65.0) | 3,028 (51.2) |
| Self-pay | 43 (2.9) | 55 (4.1) | 75 (4.6) | 84 (5.7) | 257 (4.3) |
| Other/none | 7 (0.5) | 310 (23.1) | 9 (0.5) | 27 (1.8) | 353 (6.0) |
| Fracture site, No. (%) | |||||
| Upper extremity fracture only | 1,188 (81.3) | 1,048 (78.0) | 1,301 (79.3) | 1,124 (76.5) | 4,661 (78.8) |
| Lower extremity fracture or both | 274 (18.7) | 296 (22.0) | 339 (20.7) | 346 (23.5) | 1,255 (21.2) |
| Fracture reduction, No. (%) | |||||
| Fracture not reduced | 1,031 (70.5) | 986 (73.4) | 1,110 (67.7) | 1,220 (83.0) | 4,347 (73.5) |
| Fracture reduced | 431 (29.5) | 358 (26.6) | 530 (32.3) | 250 (17.0) | 1,569 (26.5) |
| Highest pain score, No. (%) | |||||
| None/mild/moderate | 928 (63.5) | 756 (56.3) | 1,096 (66.8) | 787 (53.5) | 3,567 (60.3) |
| Severe | 534 (36.5) | 588 (43.8) | 544 (33.2) | 683 (46.5) | 2,349 (39.7) |
Chi-square tests of homogeneity among ED sites of care resulted in P < 0.001 for all characteristics except lower extremity fracture (P = 0.01) and gender (P = 0.61).
ED = emergency department; NH = non-Hispanic.
Description of Opioid Prescription at Discharge from the ED
Overall, 15% of children were prescribed an opioid at discharge. A nearly threefold variation in opioid prescription was found between the ED site of care: A = 8.2% (95% confidence interval [CI] = 6.9–9.7%), B = 12.1% (95% CI = 10.5–14.0%), C = 16.9% (95% CI = 15.2–18.8%), D = 23.8% (95% CI = 21.7–26.1%). The most frequently prescribed opioid at discharge was oxycodone (either alone or with acetaminophen), accounting for 10.8% of children. Hydrocodone (either alone or with acetaminophen) was prescribed to 3.4%, and codeine (either alone or with acetaminophen) was prescribed to 1.4%. The proportion of each opioid (oxycodone/hydrocodone/codeine) prescribed varied significantly between the four sites (P < 0.0001): Site A (95%/2%/4%), Site B (64%/3%/36%), Site C (90%/4%/6%), and Site D (49%/51%/<1%).
No difference in opioid prescription at discharge was found for children with a lower extremity fracture compared with an upper extremity fracture (14.7% vs 15.6%, odds ratio [OR] = 0.94, 95% CI = 0.79–1.12). A higher proportion of children with a reduced fracture compared with a nonreduced fracture were prescribed an opioid at discharge (29.3% vs 10.4%, OR = 3.57, 95% CI = 3.09–4.13). Differential opioid prescription practices at each ED site of care were consistent for children with reduced fractures and severe pain (Figure 2).
Figure 2.
Proportion of children prescribed an opioid comparing fracture site and reduction status at each of the four ED sites.
Association Between Predictors and Opioid Prescription at Discharge from the ED
In univariable analysis, an increased likelihood of opioid prescription was associated with the ED site of care and the following patient and injury characteristics: increasing patient age, male sex, white non-Hispanic race/ethnicity, private insurance, reduced fracture, and severe pain in the ED (Table 2).
Table 2.
The association between ED site of care, patient- and injury-related characteristics, and opioid prescription at ED discharge
| Received Opioids at ED Discharge, No. (%) | OR (95% CI) | aOR (95% CI) | |
|---|---|---|---|
| Site | |||
| A | 120 (8.2) | Reference | |
| B | 163 (12.1) | 1.54 (1.20–1.98) | 1.99 (1.50–2.65) |
| C | 277 (16.9) | 2.27 (1.81–2.85) | 2.20 (1.73–2.79) |
| D | 350 (23.8) | 3.49 (2.80–4.36) | 5.40 (4.19–6.96) |
| Age, y | |||
| 4–7 | 242 (12.1) | Reference | |
| 8–11 | 278 (14.2) | 1.21 (1.01–1.46) | 1.07 (0.88–1.31) |
| 12–18 | 390 (19.9) | 1.82 (1.53–2.16) | 1.74 (1.42–2.12) |
| Gender | |||
| Female | 316 (14.2) | Reference | |
| Male | 594 (16.1) | 1.16 (1.00–1.35) | 1.04 (0.88–1.22) |
| Race/ethnicity | |||
| White NH | 465 (19.5) | Reference | |
| Black NH | 180 (10.3) | 0.47 (0.39–0.57) | 0.63 (0.50–0.79) |
| Hispanic | 156 (14.5) | 0.70 (0.57–0.85) | 0.59 (0.46–0.76) |
| Other | 109 (15.2) | 0.74 (0.59–0.93) | 0.84 (0.65–1.09) |
| Primary payer | |||
| Private Insurance | 443 (19.4) | Reference | |
| Government | 374 (12.4) | 0.58 (0.50–0.68) | 0.68 (0.57–0.82) |
| Self-pay | 42 (16.3) | 0.81 (0.57–1.14) | 0.82 (0.56–1.20) |
| Other | 51 (14.4) | 0.70 (0.51–0.96) | 0.88 (0.61–1.27) |
| Fracture site | |||
| Upper extremity fracture only | 725 (15.6) | Reference | |
| Lower extremity fracture | 185 (14.7) | 0.94 (0.79–1.12) | 1.16 (0.95–1.41) |
| Fracture reduction | |||
| Fracture not reduced | 451 (10.4) | Reference | |
| Fracture reduced | 459 (29.3) | 3.57 (3.09–4.13) | 4.23 (3.57–5.00) |
| Highest pain score | |||
| Mild/moderate (<7) | 395 (11.1) | Reference | |
| Severe (≥7) | 515 (21.9) | 2.25 (1.95–2.60) | 2.06 (1.75–2.41) |
aOR = adjusted odds ratio; CI = confidence interval; ED = emergency department; NH = non-Hispanic; OR = odds ratio.
Multivariable analysis indicated significant associations between opioid discharge prescription and ED site of care, with children at site D having more than five times the likelihood of having an opioid prescribed (Table 2). Significant associations were also found for opioid discharge prescription and patient age, race/ethnicity, primary payer, fracture reduction, and severe pain in the ED (Table 2). Children aged 12–18 years, children who were white non-Hispanic, those with private insurance, those with a reduced fracture, and those with severe pain in the ED were more likely to receive an opioid prescription at discharge.
Discussion
For children with a long-bone fracture, opioid prescription at discharge varied widely by ED site of care. Site of care differences were not accounted for by patient- or injury-related factors and therefore may be modifiable, though evidence to support improved outcomes with specific treatment regimens is lacking. The rate of opioid prescription for children at discharge from the ED in our study was 15%, compared with prior studies that reported rates between 0.3% and 60% [2,15–17,20]. Opioid prescription patterns were variable between the ED sites of care in this study, which is also consistent with the variable patterns found in the published pediatric literature [2,15–17,20], Overall, the percentage of children with a discharge opioid prescription from our study sites was low compared with a national study of opioid prescribing for adults at ED discharge, where 48.7% of those with fractures received an opioid prescription [27].
Consistent with our hypothesis, the proportion of children prescribed an opioid was higher for fracture characteristics expected to be more painful, including reduced fractures and children reporting severe pain during the ED visit. However, lower extremity fractures have previously been considered more painful injuries but were not associated with increased opioid prescription at discharge. In addition, we identified children with the following attributes who were less likely to be prescribed an opioid for whom discharge prescription was likely not related to experiencing less pain: ED site of care, patient age, and patient racial and insurance characteristics. These findings support the theory that opioid prescribing decisions for children at discharge may consider more than the severity of pain expected to be experienced. Therefore, variability in opioid prescribing cannot be fully explained by variation in pain and requires further investigation. Variability in opioid prescribing is unlikely to be reduced unless there is 1) an understanding of decision-making by prescribers to recommend an opioid and 2) further elucidation of those patient factors unrelated to severity, including age, race, and payer type, that were associated with a decreased likelihood of an opioid discharge prescription. These will aid in the development of sound evidence to support best practice.
The variability in opioid prescription based on ED site of care is not completely explained by patient or fracture characteristics and severity of pain but instead may represent local opioid prescribing culture. This is supported by the finding that receiving an opioid in the ED was consistent with discharge opioid prescription at three of the four sites of care. However, site D had the lowest proportion receiving opioids at the ED and the highest opioid prescription rate at discharge. This inconsistency does not support a culture of opioid prescription. Instead, institutional practice patterns or local workflows in the ED that result in this variation may be amenable to operational changes with evidence to support best practice. Regional differences in opioid prescription have been previously described [28,29]. A study of Medicaid drug utilization data found a 23-fold difference in opioid prescription rates between states and suggested that this variation may be related to prescriber habits, state policies, and efforts to curb prescription drug diversion and abuse and prescription drug marketing by manufacturers [30]. Future studies evaluating the effect of local culture and policies on opioid prescription practice, and ultimately patient outcomes, should be pursued.
This study identified patient characteristics that were associated with a lower likelihood of opioid prescription. A better understanding of why these patients are not prescribed an opioid may provide important insights. The youngest children were less likely to have an opioid prescribed, which is consistent with prior pediatric studies [21,31,32]. Fear of opioid use in younger children or the misconception that young children do not experience pain in the same way might explain these differences. Black and Hispanic patients were also less likely to receive an opioid at discharge. This racial disparity in care is consistent with previous literature on provision of analgesia for fracture pain and abdominal pain in the ED setting [20,33–35]. A recent study examining opioid prescribing differences in the outpatient setting found higher rates of opioid prescribing to white and Native American children compared with all other races/ethnicities [36]. However, other prior studies of long-bone fracture have found no evidence of differences in opioid prescribing based on race/ethnicity [28,37–40]. These inconsistent conclusions suggest that further investigations of racial/ethnic disparities in opioid prescribing in the ED are needed. Possible reasons for these differences include racial bias in pain assessment and treatment recommendations, language or cultural barriers that may impact interpretation of symptoms or limit communication, and false beliefs about biological differences between people of different races and ethnicities. This study also identified a significantly lower rate of opioid prescription for patients with government insurance. This variable is often considered a marker for lower socioeconomic status, and the association found may be a result of implicit bias. It may also potentially be a function of lower health literacy and self-advocacy, where this patient population feels less empowered to request an opioid prescription. Overall, differential prescription of opioids based on patient characteristics is particularly concerning because our analysis controlled for pain severity. It is not clear whether patients with a lower likelihood of opioid prescription are receiving inadequate treatment or if others are overtreated, as the opioid prescription needs of these patients are unknown. Studies to evaluate the optimal post-ED discharge pain control for patients with long-bone fractures are needed to determine evidence-based practices in order to ensure good pain management and patient outcomes.
Limitations
This study has several limitations. First, it includes patients evaluated at tertiary care pediatric EDs, which may limit the generalizability of the findings in other settings. Second, we could only measure prescriptions provided and not recommendations for over-the-counter analgesics. As we did not capture verbal communication between patients/parents and the medical provider, it is possible that observed differences are related to patient/parent preferences rather than provider preferences. Identification of long-bone fractures was determined by diagnosis codes and radiology results, and there is the possibility of misclassification. However, it is unlikely that there are systematic differences in the cohort that would affect the results of this study. This study did not collect data on the providers who wrote the prescriptions, so individual practice variability could not be assessed. We evaluated the presence of an opioid prescription on ED discharge; however, determination of adequacy of dose or use of medications after discharge is beyond the scope of this work.
Conclusions
In summary, 15% of children with a long-bone fracture received an opioid discharge prescription. Opioid discharge prescription patterns varied widely by ED site of care. This variability in opioid prescribing was not accounted for by patient- or injury-related factors that are associated with increased pain, including age, race, and insurance status. Therefore, opioid prescribing may be modifiable, but evidence to support improved outcomes with specific treatment regimens is lacking.
Funding sources: This project work was supported by Agency for Healthcare Research and Quality (AHRQ) grant R01HS020270 and National Institutes of Health (NIH) grant R01HD091302. The PECARN infrastructure was supported by the Health Resources and Services Administration (HRSA), the Maternal and Child Health Bureau (MCHB), and the Emergency Medical Services for Children (EMSC) Network Development Demonstration Program under cooperative agreements U03MC00008, U03MC00001, U03MC00003, U03MC00006, U03MC00007, U03MC22684, and U03MC22685.
Conflicts of interest: The authors have no conflicts of interest relevant to this article to disclose.
Prior presentation: Pediatric Academic Society Meeting 2017.
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