Abstract
Background:
The majority of opioid overdose admissions in pediatric patients are associated with prescription opioids. Post-operative prescriptions are an addressable source of opioids in the household. This study aims to assess for sustained reduction in opioid prescribing after implementation of provider-based education at nine centers.
Methods:
Opioid prescribing information was collected for pediatric patients undergoing umbilical hernia repair at nine centers between December 2018 and January 2019, one year after the start of an education intervention. This was compared to prescribing patterns in the immediate pre- and post-intervention periods at each of the nine centers.
Results:
In the current study period, 29/127 (22.8%) patients received opioid prescriptions (median 8 doses) following surgery. There were no medication refills, emergency department returns or readmissions related to the procedure. There was sustained reduction in opioid prescribing compared to pre-intervention (22.8% vs 75.8% of patients, p<0.001, Fig. (1). Five centers showed statistically significant improvement and the other four demonstrated decreased prescribing, though not statistically significant.
Conclusions:
Our multicenter study demonstrates sustained reduction in opioid prescribing after pediatric umbilical hernia repair after a provider-based educational intervention. Similar low-fidelity provider education interventions may be beneficial to improve opioid stewardship for a wider variety of pediatric surgical procedures.
Levels of evidence:
(treatment study)-level 3.
Keywords: Education, Opioid, Pediatric surgery, Umbilical herniorrhaphy
1. Introduction
Between 2006 and 2017, deaths related to prescription opioids increased by an annual average of 2% [1]. The rate of deaths involving synthetic opioids (fentanyl, fentanyl analogs, and tramadol) increased by 45% between 2016 and 2017, from 6.2 to 9.0 per 100,000 [2]. In 2017, prescription opioid medications claimed the lives of approximately 17,000 people in the United States [1]. Overall, opioids accounted for almost 68% of drug overdose deaths. Opioid related poisonings resulted in nearly 200,000 emergency department visits in the United States in 2016, a rate of 62 visits per 100,000 population. Young adults continue to remain at high risk, with 5.5% reporting misuse of prescription pain medications within the past year [1].
This epidemic is affecting both adult and pediatric patients. The rate of opioid overdoses in pediatric patients tripled between 2000 and 2012, during which 84% of pediatric opioid overdose admissions were owing to prescription opioids [3]. Furthermore, it has also been shown that pediatric surgical patients have a higher risk of persistent opioid use compared with non-surgical controls [4]. This emphasizes the importance of opioid stewardship among physicians and surgeons who serve as a potential gateway to opioid addiction. Unfortunately, the amount of prescription opioids that pediatric providers currently supply to patients and the community is unnecessarily high. A recent study in 2018 found that for 7 of 9 procedures analyzed, pediatric patients consumed less than half of the prescribed opioids after discharge and 64% kept the remaining prescription opioids in their home [5]. An analysis of the National Survey on Drug Use and Health (NSDUH) from 2015 to 2016 found that among those misusing opioids, 55.7% obtained them from friends or relatives. This type of diversion was also the most common source for adolescents (33.5%) and young adults (41.4%) [6]. Another recent study found that among US high school seniors surveyed, the most common source of non-medical use prescription drugs including opioids that are “given free from friends” (53.7%), “bought from a friend” (38.0%), or “from their own prior prescription” (29.5%) [7].
There is currently significant variation in opioid prescribing and limited guidelines to assist pediatric surgeons in their choice of dosage or duration of therapy after various operations [8,9]. In pediatric urology, for instance, 48% of providers reported always prescribing opioids to patients undergoing routine procedures such as orchiopexy, hydrocele repair, and circumcision, while 14% reported never prescribing opioids for these cases. Furthermore, only 16% of the providers felt that patients take the majority of opioids prescribed [10]. Overprescribing and prescriber variation are targets to safely address the oversupply of prescription opioids in the community. In pediatric urologic surgery, a reduction in prescribed opioids by 50% did not lead to a significant increase in post-operative pain [11]. Similar reductions may be achievable for other common pediatric surgical procedures without negative consequences to the patient.
Key initiatives for reducing opioid prescribing must include provider education. We previously reported short term results for a nine center study, in which a brief thirty to sixty minute presentation to providers was associated with a significant decrease in opioid prescribing after pediatric umbilical hernia repair [12]. In the present study, we aim to determine if the decrease in opioid prescriptions after an educational intervention persists in the long-term.
2. Materials and methods
2.1. Intervention
Between January and August of 2018, a thirty to sixty minute slide presentation was given at nine children's medical centers across the United States, representing 74 pediatric surgeons. The presentation was targeted to pediatric surgeons, advanced practice providers, residents, and fellows. Key items presented included: (1) data demonstrating the significance of the opioid epidemic, (2) the current large variation in opioid prescribing practices, (3) the effectiveness of multimodal pain therapy at reducing opioid use, (4) recommendations that opioid prescribing should be tailored to individual patient needs, and (5) Evidence that strategies to reduce opioid prescribing has not previously been associated with increased emergency department visits, readmissions, or opioid refills.
2.2. Sample selection
At each of the nine institutions, a retrospective review of all patients <18 years old who underwent umbilical hernia repair was performed during a thirty day period between December 2018 and January 2019, which was 4 to 12 months after the educational intervention took place, depending on the site. To be included in the study, patients had to have undergone outpatient umbilical hernia repair at one of the institutions. Patients were excluded if they underwent additional operations in addition to umbilical hernia repair.
2.3. Data collection
After patients who met inclusion criteria were identified, the patients’ charts were retrospectively reviewed and basic demographic information was collected including age, sex, and weight. Details of the operation were also recorded, including the operating surgeon, size of the umbilical hernia, and whether the patient underwent umbilicoplasty. Patient discharge information was reviewed to determine whether patients were prescribed opioid medications, the number and strength (ME/kg/dose) of opioid doses prescribed, and whether non-opioid pain medications were prescribed. Lastly, the patients’ charts were reviewed to determine if they received any opioid medication refills, presented to the emergency department (ED), or were readmitted post-operatively.
2.4. Data analysis
Unadjusted patient demographic information was compared for pre-intervention and 1 year data using Pearson chi-square and Mann-Whitney tests. The primary outcomes examined were the proportion of patients prescribed opioids, the number and strength of doses prescribed to those who received opioids, and the percentage of patients that received non-opioid medications. Estimates for these outcomes were modeled using log transformation and generalized linear mixed models with age, sex, and umbilicoplasty as fixed effects and site as a random effect. Adjusted odds ratios were calculated using mixed effect logistic regression with age, sex, and umbilicoplasty as fixed effects and site as a random effect for whether patients received opioids in the pre-intervention and one year period. Models were evaluated for goodness of fit using R2 and Hosmer-Lemeshow Goodness of Fit statistic. In the cases of sites 2, 6, and 8, where either 0 or 100% of patients received opioids in one of the periods, a Pearson chi-squared test was used to evaluate for significance of difference in the percentage of patients that received opioids, All data analysis was performed using Stata/IC version 16.1 (StataCorps, College Station, TX) and RStudio version 1.3.107 (RStudio, PBC, Boston, MA). Institutional review board approval was obtained from each institution involved in the study.
3. Results
One year after the start of the initiative, 127 new patients were identified ranging from 8 to 40 patients per site with a median age of 6 years (range 0.14–15 years) and a median umbilical hernia size of 1.3 cm. There were 29 patients (22.8%) prescribed opioids with a median and adjusted mean of 8 and 8.17 doses respectively (0.18 adjusted mean morphine equivalents/kg/dose), ranging from 0% to 60% of patients being prescribed opioids at each center. No patients received a new opioid prescription or refill after discharge, and there were no ED returns or readmissions related to the procedure. To the best of our knowledge, there were also no additional post-operative outpatient visits related to pain. Three patients presented to the ED and one patient was admitted to the hospital during the study period, but these were unrelated to the procedure. (Table 1) There was no significant change to the cohort of pediatric surgeons working at the 9 centers over the one year period; however, the trainees rotating on the pediatric surgery service did vary.
Table 1.
Pediatric patient demographic and pain medication prescribing after umbilical hernia repair.
| Pre (n = 343) | Post (n = 346) | 1 Year (n = 127) | P Value* | |
|---|---|---|---|---|
| Number of patients per site, n (%) | <0.001 | |||
| Site 1 | 20 (5.8) | 18 (5.2) | 10 (7.9) | |
| Site 2 | 9 (2.6) | 21 (6.1) | 5 (3.9) | |
| Site 3 | 19 (5.5) | 10 (2.9) | 18 (14.2) | |
| Site 4 | 11 (3.2) | 26 (7.5) | 12 (9.4) | |
| Site 5 | 132 (38.5) | 115 (33.2) | 40 (31.5) | |
| Site 6 | 11 (3.2) | 27 (7.8) | 7 (5.5) | |
| Site 7 | 78 (22.7) | 52 (15.0) | 12 (9.4) | |
| Site 8 | 33 (9.6) | 28 (8.1) | 10 (7.9) | |
| Site 9 | 30 (8.7) | 49 (14.2) | 13 (10.2) | |
| Age (years), median (IQR) | 5 (3) | 5 (2.6) | 6 (3.2) | 0.19 |
| Sex, n (%) | 0.41 | |||
| Female | 169 (49.3) | 196 (56.6) | 68 (53.5) | |
| Male | 174 (50.7) | 150 (43.4) | 59 (46.5) | |
| Weight (kg), median (IQR) | 21.1 (9.7) | 20.5 (7.9) | 20.9 (9.5) | 0.95 |
| Hernia Size (CM), median (IQR) | 1.5 (1) | 1.5 (1) | 1.3 (1) | 0.17 |
| Umbilicoplasty, n (%) | 35 (10.2) | 44 (12.7) | 10 (7.9) | 0.46 |
| Prescribed Opioids, n (%) | 260 (75.8) | 156 (45.1) | 29 (22.8) | <0.001 |
| Number of doses, median (IQR)^ | 12 (9.7) | 10 (6.9) | 8 (9.0) | 0.39 |
| ME/kg/dose, median (IQR)^ | 0.13 (0.05) | 0.11 (0.08) | 0.17 (0.27) | 0.05 |
| Non-opioid pain meds, n (%) | 148 (43.1) | 189 (54.6) | 76 (59.8) | 0.03 |
| Refill, n (%) | 0 (0.0) | 1 (0.3) | 0 (0) | |
| Return to ED, n (%) | 12 (3.5) | 9 (2.6) | 3 (2.4) | 0.53 |
| Readmission, n (%) | 1 (0.3) | 0 (0.0) | 1 (0.8) | 0.46 |
P values calculated comparing pre to 1 year.
Among patients who were prescribed Opioids.
The cohort of 9 centers overall demonstrated a sustained and improved reduction in opioid prescribing compared to the immediate post-education period. (Fig. 1) Compared with pre-intervention, the percentage of patients prescribed opioids decreased from 75.8% to 22.8%, with an adjusted odds ratio of 0.07 (95% CI 0.04 – 0.12, p<0.001), (Table 2). The Hosmer-Lemeshow test for goodness of fit suggested the fit of the model in adjusting for age, gender, and site was acceptable (chi-squared statistic 8.05, p = 0.43). Compared to pre-intervention, 5 centers showed statistically significant improvement and the other 4 centers also demonstrated a trend towards reduced opioid prescribing, though it was not significantly different. In the patients who received opioids, there was a significant decrease in the mean number of doses prescribed from 12.23 to 8.19 after adjusting for age, gender and the random clustering effects of site (p<0.001). There was no significant difference in the strength of opioids prescribed (ME/kg/dose) at 1 year compared with pre-intervention dosages (0.18 ME/kg/dose versus 0.17, p = 0.25), also after adjusting for age, gender and the random clustering effects of site. The R squared statistic for the dose and strength models were 0.27 and 0.46 respectively, suggesting that a significant amount of variation in prescribing is attributed to factors not included in the current model.
Fig. 1.
Percent of pediatric umbilical hernia repair patients prescribed opioids in pre- post- and 1 year after educational intervention.
Table 2.
Number of pediatric patients who underwent umbilical hernia repair that received opioids before and after intervention.
| Pre | Post | 1 Year | Percentage Decrease |
Adjusted Odds Ratio (95% CI) |
P Value | Ref. [2] | H-L GOF ChiSq(P Value) |
|
|---|---|---|---|---|---|---|---|---|
| Site 1 | 17/20 (85.0%) | 11/18 (61.1%) | 6/10 (60.0%) | 29.4% | 0.29 (0.02–2.64) | 0.29 | 0.14 | ** |
| Site 2* | 2/9 (22.2%) | 1/21 (4.8%) | 0/5 (0.0%) | 100.0% | 0 (Not estimable) | 0.25 | – | – |
| Site 3 | 9/19 (47.4%) | 0/10 (0.0%) | 1/18 (5.6%) | 88.3% | 0.06 (0.00–0.42) | 0.02 | 0.31 | ** |
| Site 4 | 6/11 (54.5% | 4/12 (33.3%) | 4/12 (33.3%) | 38.9% | 0.36 (0.05–2.27) | 0.29 | 0.21 | 8.52 (0.38) |
| Site 5 | 97/132 (73.5%) | 64/115 (55.7%) | 7/40 (17.5%) | 76.2% | 0.07 (0.03–0.17) | <0.001 | 0.24 | 7.22 (0.51) |
| Site 6* | 4/11 (36.4%) | 1/27 (3.7%) | 0/7 (0.0%) | 100.0% | 0 (Not estimable) | 0.07 | – | – |
| Site 7 | 77/78 (98.7%) | 37/52 (71.2%) | 5/12 (41.7%) | 57.8% | 0.01 (0.00–0.06) | <0.001 | 0.55 | 4.84 (0.77) |
| Site 8* | 33/33 (100.0%) | 19/28 (67.9%) | 4/10 (40.0%) | 60.0% | 0 (Not estimable) | <0.001 | – | – |
| Site 9 | 15/30 (50.0%) | 19/49 (38.8%) | 2/13 (15.4%) | 69.2% | 0.13 (0.02–0.66) | 0.03 | 0.14 | 12.63 (0.13) |
| Total | 260/343 (75.8%) | 156/346 (45.1%) | 29/127 (22.8%) | 69.9% | 0.07 (0.04–0.12) | <0.001 | 0.42 | 8.05 (0.43) |
Adjusted odds ratios not estimable owing to either zero or 100% of patients receiving opioids in one of groups.
Unable to calculate Hosmer-Lemeshow statistic using standard groupings of 10.
4. Discussion
Recent literature in general surgery suggests that provider education can significantly reduce opioid prescribing after various operations, without increasing pain-related emergency department visits [13]. In early data from our study that was previously published, we also found that similar reductions could be achieved for pediatric surgical patients undergoing umbilical hernia repair. A brief educational intervention to pediatric surgical providers was associated with a significant reduction from 75.8% to 44.5% of patients receiving opioid prescriptions. We also found statistically significant reductions for five of nine centers individually, with the remaining four also demonstrating decreased prescribing (though not statistically significant) [12]. It was unclear, however, if the effects of this intervention would persist.
In the present study, therefore, we aimed to determine whether opioid prescribing levels would remain low in the long term after the educational intervention. When adjusting for age, gender, umbilicoplasty, and site, we found that there was a clinically and statistically significant decrease in the percentage of patients who were prescribed opioids from 75.8% to 22.8%. The intervention was effective at all nine sites in reducing opioid prescribing, though this was only significant for 5 of 9 site. (Table 2) The lack of statistical significance at these sites is likely because of too few patients who underwent umbilical hernia repair at those sites during our study period. In patients who received opioids, there was also a statistically significant decrease in the mean number of doses they received after adjusting for age, gender, umbilicoplasty, and site (12.23 vs. 8.19 doses, p <0.001). (Tables 3 and 4). This also fits with our hypothesis that an educational intervention on opioid stewardship can lead to a persistent decrease in opioid prescribing. There was no statistically significant increase in the strength of doses prescribed at the 1 year period when adjusting for age, gender, umbilicoplasty, and site (0.17 vs 0.18 ME/kg/dose, p = 0.25). Given that strength of opioid dosing is relatively standardized and weight based currently, this lack of difference is to be expected and the overall emphasis of the intervention was on reducing or eliminating the number of doses prescribed. These results also fit with the changes seen in our initial post-intervention study when the number of doses prescribed decreased from 14.3 to 10.43 (p<0.001), but the strength of doses was unchanged. Overall the results of our study are encouraging and suggest that increased education of providers regarding prescribing opioids may persistently reduce the supply of narcotics available for diversion. However, given the inevitable turnover of surgeon's, trainees, and advanced practice providers, opioid education such as this should be given on an annual basis to ensure persistent improvements in opioid prescribing. Ultimately, multiple centers were able to reduce their opioid prescriptions to zero or nearly zero after the intervention, without an increase in readmissions, ER visits, or post-discharge opioid prescriptions. This indicates that non-opioid pain management for pediatric umbilical hernia repair patients is an achievable standard of care.
Table 3.
Number of opioid doses prescribed to pediatric patients who received opioids before intervention and at 1 year after intervention.
| PreAdjusted Mean(95% CI) | 1 YearAdjusted Mean(95% CI) | Adjusted Ratio(95% CI) | P Value | Ref. [2] | |
|---|---|---|---|---|---|
| Site 1 | 19.35 (12.71–29.45) | 10.05 (6.85–14.75) | 0.52 (0.35–0.76) | 0.004 | 0.70 |
| Site 2 * | 12 * | NA | NA | – | – |
| Site 3 | 10.68 (6.89–16.54) | 25.09 (15.11–41.66) | 2.35 (1.42–3.90) | 0.02 | 0.76 |
| Site 4 | 2.23 (0.77–6.44) | 1.71 (0.95–3.05) | 0.76 (0.43–1.37) | 0.4 | 0.75 |
| Site 5 | 20.90 (14.92–29.28) | 9.74 (6.60–14.37) | 0.47 (0.32–0.69) | <0.001 | 0.70 |
| Site 6 * | 9.25 * | NA | NA | – | – |
| Site 7 | 13.06 (10.52–16.21) | 15.42 (11.45–20.75) | 1.18 (0.88–1.59) | 0.28 | 0.75 |
| Site 8 | 8.89 (5.36–14.73) | 5.90 (2.97–11.72) | 0.66 (0.33–1.32) | 0.25 | 0.70 |
| Site 9 | 12.89 (7.32–22.71) | 10.43 (4.85–22.44) | 0.81 (0.38–1.74) | 0.58 | 0.75 |
| Overall | 12.23 (9.61–15.36) | 8.19 (6.83–9.83) | 0.67 (0.56–0.80) | <0.001 | 0.27 |
Adjusted means not estimable owing to either zero or 100% of patients receiving opioids in one of groups, here the mean was used instead.
Table 4.
ME/Kg/Dose of opioids prescribed to pediatric patients who received opioids before intervention and at 1 year after intervention.
| PreAdjusted Mean(95% CI) | 1 YearAdjusted Mean(95% CI) | Adjusted Ratio(95% CI) | P Value | R[2] | |
|---|---|---|---|---|---|
| Site 1 | 0.16 (0.14–0.19) | 0.14 (0.12–0.16) | 0.85 (0.75–0.98) | 0.04 | 0.57 |
| Site 2 * | 0.13 * | NA** | NA | – | – |
| Site 3 | 0.19 (0.10–0.35) | 0.18 (0.09–0.38) | 0.97 (0.46–2.03) | 0.93 | 0.36 |
| Site 4 | 0.13 (0.07–0.27) | 0.17 (0.12–0.25) | 1.29 (0.87–1.90) | 0.25 | 0.62 |
| Site 5 | 0.15 (0.13–0.18) | 0.12 (0.10–0.15) | 0.80 (0.65–0.98) | 0.04 | 0.57 |
| Site 6 * | 0.13 * | NA** | NA | – | – |
| Site 7 | 0.15 (0.13–0.17) | 0.18 (0.14–0.22) | 1.21 (0.97–1.51) | 0.10 | 0.62 |
| Site 8 | 0.12 (0.10–0.15) | 0.18 (0.14–0.24) | 1.47 (1.12–1.94) | 0.01 | 0.57 |
| Site 9 | 0.48 (0.34–0.67) | 0.75 (0.47–1.18) | 1.57 (0.99–2.48) | 0.08 | 0.62 |
| Overall | 0.17 (0.14–0.22) | 0.18 (0.16–0.20) | 1.07 (0.95–1.19) | 0.25 | 0.46 |
Adjusted means not estimable owing to either zero or 100% of patients receiving opioids in one of groups, here the mean was used instead.
No patients received opioids in these groups.
There are several key limitations of this study. First, though we capture readmissions, emergency department visits, and opioid prescribing by the pediatric surgeons and their team, we are unable to account for patients that may have been seen by and received opioids from their PCP or another provider in the post-operative period. In addition, this was not a randomized controlled trial and many initiatives are currently taking place nationwide to address the opioid epidemic that may have also contributed to decreased prescribing patterns. There is increased information about the risks of opioids from public and other sources. In addition, certain states have instituted legislation limiting opioid prescription. Therefore, our data may overstate the effects of our intervention on opioid prescribing. Similarly, some sites saw more significant and continued reductions in opioid prescribing compared with others. This could be owing to other interventions to address opioid prescribing at individual sites. After our educational intervention, two sites implemented recurrent education on opioid prescribing. Site 8 presented annual opioid education to incoming interns and site 5 gave quarterly talks on opioid reduction. Site 5 also implemented standardized order bundles for post-operative pain management. These interventions may also have contributed to the persistent and further reduction in opioid prescribing seen at these sites. There was also variation in the length of time from the initial intervention between sites. Depending on the site, our follow-up period occurred between 4 and 12 months after the initial intervention. This may also account for the variation seen in opioid prescribing practices at follow-up.
This study focuses on a single population, pediatric patients undergoing umbilical hernia repair, and caution should be taken when generalizing the findings to other patient populations or procedures. Our population of patients that received opioids was also very small at several of our sites in the post-intervention period. This limited the ability of our models to adjust for the number and strength of doses prescribed to those that received opioids and may therefore impact our results for these. Further studies should focus on other patient populations and procedures, as well as determining whether reduced prescribing by physicians leads to fewer nation-wide opioid overdoses and deaths. Future studies should also assess surgeon specific variables that lead to increased opioid prescribing. This would allow more targeted future education interventions.
5. Conclusions
Our multicenter study demonstrates sustained and reduced opioid prescribing after pediatric umbilical hernia repair one year after a provider-based educational intervention. Though prescription patterns between sites remain variable, these results suggest continued improvements may be expected. Similar low-fidelity provider education interventions may be beneficial to improve opioid stewardship for a wider variety of children's surgical procedures.
Acknowledgments
This work was supported in part by the University of Chicago Bucksbaum Institute for Clinical Excellence
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Footnotes
Declaration of Competing Interest
None.
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