Evaluation of Quality Improvement Methods for Altering Opioid Prescribing Behavior in Hand Surgery

Abstract

Background: The opioid epidemic in the United States continues to be problematic as morbidity and mortality rates increase yearly. Orthopaedic surgeons are the third highest prescribing group among physicians. Studies show that orthopaedic surgeons tend to overprescribe opioids, but published data on patient opioid utilization, pain management satisfaction, and national clinical practice guidelines on opioid prescribing are scarce or lacking. Furthermore, little information is available on influences on physician prescribing behavior and whether changes in prescribing habits are lasting. Methods: Using recently published opioid utilization and prescribing guidelines for hand surgery, we created an opioid prescribing quality improvement program with the aim of reducing postoperative opioid prescribing without negatively impacting patient pain satisfaction. The main aspect of the program was the implementation and modification of an opioid prescribing order set, but the program also included surgeon education—executed in 2 intervention steps—about how their prescribing behavior compared with that of their peers. Three phases of data representing 3 months each were collected prior to, between, and after the interventions. Results: Two thousand and sixty-seven hand surgery cases were reviewed (629 in Phase 1, 655 in Phase 2, and 783 in Phase 3). The average number of morphine milligram equivalents (MMEs) was reduced from 142.0 in Phase 1 to 69.9 in Phase 2 (51% reduction) to 61.3 in Phase 3 (57% reduction compared with Phase 1). Significant reductions in MMEs occurred across the procedural categories as well as the hand surgeons. Patient pain satisfaction was similar before and after implementation of the first intervention (p = 0.96). Conclusions: Quality improvement methods were effective in altering prescribing behavior by physicians in the long term, and our approach may be effective if applied more widely. Similar studies on quality improvement methods and prescribing behavior, patient opioid utilization, and patient satisfaction with pain management are needed in other orthopaedic subspecialties. Clinical Relevance: Evidence-based guidelines, a quality improvement process, and unblinded information on prescribing behavior compared with that of peers may result in long-lasting reductions in surgeons’ opioid prescribing practices.

Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

“…Furthermore, it likely will improve outcomes after shoulder arthroplasty, as not only is prolonged opioid usage associated with poor outcomes after TSA, 6 , 22 , 24 , 31 higher utilization of opioids postoperatively is correlated with worse satisfaction with the surgery. 4 , 25 , 35 In this study, we identified the rate of and risk factors for prolonged opioid use following TSA in the opioid-naïve patient, as well as correlated the initial prescription number to the risk for prolonged postoperative opioid usage.…”

“… 16 Most people’s first exposure to opioids is via prescription medication, 32 with many patients receiving prescriptions with the number of opioids well in excess of the number they will ultimately need to take for adequate pain control. 25 Orthopedic surgeons are among the leading prescribers of opiate medications, 23 and therefore, orthopedists have a substantial opportunity for improved opioid stewardship. For many opiate-naïve patients, the need to undergo an orthopedic surgery may represent the initial gateway to prolonged opiate use.…”

A Work in Progress: National Opioid Prescription Reductions Across Orthopaedic Subspecialties in a Contemporary Medicare Sample of 5,026,911 Claims

“… 31 32 33 34 Although the development of consistent guidelines is challenged by wide variations in opioid consumption reported in the current literature, 35 , 36 the implementation of institution-specific prescription protocols has resulted in notable decrease in excessive prescription practices. 37 , 38 Therefore, continued research and development of these standardized protocols should be at the forefront of future efforts aimed at curbing the opioid epidemic.…”

A focus on the future of opioid prescribing: implementation of a virtual opioid and pain management module for medical students

“…The United States (U.S.) opioid epidemic is an ongoing public health crisis, fueled in part by inaccurate prescriber beliefs of low opioid harm and addiction risks [ 1 ]. Yet following recognition of opioid risks, 80% of the world’s entire opioid supply is still consumed annually in the U.S., which constitutes merely 5% of the global population [ 2 ]. In 2018, 46,802 overdose deaths (69.5% of all drug overdose deaths) in the U.S. were attributed to opioids, with prescription opioid overdoses comprising almost 32% of these deaths [ 3 ].…”