Abstract
This quality improvement study involves comparison of opioid prescription data before and after implementation of an opioid stewardship program in a safety-net medical system.
Overprescription of postoperative opioids can lead to persistent opioid use, and unused pills can be diverted for illicit purposes.1,2 Current pain management guidelines (eg, Michigan Opioid Prescribing Engagement Network) favor a reduction in prescribed opioid pills as well as a decoupling of combination opioid drugs (eg, hydrocodone-acetaminophen) to maximize acetaminophen dosing.3 The Los Angeles County Department of Health Services (LAC-DHS), a safety-net health system, was concerned that reducing the number of opioid pills prescribed would result in more frequent returns to the emergency department (ED) given that patients in this system may have more limited access to follow-up and that replacing hydrocodone-acetaminophen with a more potent opioid (ie, oxycodone) would result in higher overall opioid use. We hypothesized that implementation of an opioid stewardship program would be associated with reduced opioid prescribing without increasing ED return visits across the safety-net hospital system.
Methods
Operations in the LAC-DHS are performed at 4 public hospitals and 2 outpatient surgery centers. Opioid stewardship interventions implemented across the health system from 2019 to 2021 included (1) promoting and optimizing use of nonopioids (eg, acetaminophen and nonsteroidal anti-inflammatory medications), (2) discouraging combination drugs to maximize acetaminophen dosing, (3) removing formulary restrictions on oxycodone, (4) updating pain management order sets in the electronic medical record (EMR), and (5) auditing adherence with feedback to surgical leadership. This quality improvement project was deemed by the John F. Wolf Human Subject Committee to be exempt from review and patient consent. This study followed the SQUIRE reporting guideline. The study included a baseline period from October 3, 2018, to December 31, 2018, with a corresponding postintervention period from October 3, 2021, to December 31, 2021. During these periods, use of the EMR was mandatory for all discharge prescriptions.
Data from all operative cases were abstracted from the EMR. Procedures performed by services unlikely to require postoperative opioids were excluded. In addition, patients with length of stay greater than 7 days were excluded to avoid cases that had a complicated postoperative course. Morphine milligram equivalents (MME) were estimated using MME calculators based on opioid amount and potency. Perioperative MME was calculated by adding all intraoperative and postoperative MME doses prior to discharge.4 Adherence with prescribing less than or equal to the number of opioid pills recommended by Michigan Opioid Prescribing Engagement Network5 for 27 specific procedures was audited. Outcomes were compared using Fisher exact test or Wilcoxon test with significance set at 2-sided P < .05. All analyses were conducted using JMP statistical software package version 16 (SAS Institute Inc).
Results
Results for the 6047 baseline cases and 5786 postintervention cases are summarized in the Table. Median perioperative opioids significantly decreased. At the time of discharge, hydrocodone-acetaminophen prescriptions decreased significantly (51% to 17%), whereas prescriptions for acetaminophen (15% to 53%), ibuprofen (20% to 30%), and oxycodone (7% to 44%) increased (P < .001). Despite a shift toward outpatient surgery and reduced median length of stay, the median number of opioid pills prescribed decreased from 10 (IQR, 0-20) to 8 (IQR, 0-12) (P < .001) with no significant change in median MME. Adherence prescribing less than or equal to the recommended number of opioid pills for audited procedures increased from 52% to 84% (P < .001). Return to ED within less than 30 days decreased from 11% to 8.7%.
Table. Summary of Characteristics and Results for Baseline Cases and Postintervention Cases.
| Variable | No. (%) | P value | |
|---|---|---|---|
| Baseline | Postintervention | ||
| Demographic characteristics | |||
| No. of operative cases performed | 6047 | 5786 | NA |
| No. of hospitals/outpatient surgery centers | 4/2 | 4/2 | NA |
| No. of surgeons/specialties | 405/27 | 416/30 | NA |
| Results | |||
| Perioperative morphine milligram equivalents administered, median (IQR) | 45 (20-84) | 40 (20-69) | <.001 |
| Outpatient surgery | 2951 (49) | 3138 (54) | <.001 |
| Length of stay, median (IQR), d | 0.43 (0.1-2.0) | 0.19 (0.08-1.9) | <.001 |
| Prescribed oxycodone at discharge | 435 (7) | 2554 (44) | <.001 |
| Prescribed acetaminophen at discharge | 930 (15) | 3046 (53) | <.001 |
| Prescribed ibuprofen at discharge | 1223 (20) | 1729 (30) | <.001 |
| Prescribed hydrocodone-acetaminophen at discharge | 3104 (51) | 973 (17) | <.001 |
| No. of opioid pills prescribed, median (IQR) | 10 (0-20) | 8 (0-12) | <.003 |
| Morphine milligram equivalents prescribed, median (IQR) | 50 (0-100) | 50 (0-90) | .10 |
| Prescribed ≤ recommended pills/procedures audited | 950/1826 (52) | 1459/1743 (84) | <.001 |
| Return to emergency department ≤30 d | 679 (11) | 506 (8.7) | <.001 |
Abbreviation: NA, not applicable.
Discussion
A health systemwide opioid stewardship program was associated with a reduction in opioids without increasing return visits to the ED. Limitations included the lack of data on postdischarge opioid refills. Findings of our study suggest that opioid stewardship initiatives favoring nonopioids and oxycodone over combination drugs are feasible and can have wide-scale utility across a safety-net health system.
References
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- 3.Michigan Opioid Prescribing Engagement Network (OPEN) . February 25, 2020. Accessed January 15, 2022. https://michigan-open.org/
- 4.Centers for Disease Control and Prevention . CDC opioid guideline mobile app. July 5, 2022. Accessed November 10, 2022. https://www.cdc.gov/opioids/providers/prescribing/app.html
- 5.Michigan Opioid Prescribing Engagement Network (OPEN) Prescribing Recommendations updated on February 25, 2020. Accessed January 15, 2022. https://michigan-open.org/prescribing-recommendations/