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Impact of an Electronic Health Record Pain Medication Prescribing Tool on Opioid Prescriptions for Postoperative Pain in Hand, Orthopedic, Plastic, and Spine Surgery Across a Health Care System

Published:September 29, 2022DOI:https://doi.org/10.1016/j.jhsa.2022.08.009

      Purpose

      We hypothesized that a pain management prescribing tool embedded in the electronic health record system of a multihospital health care system would decrease prescription opioids for postoperative pain by hand, orthopedic, plastic, and spine surgeons.

      Methods

      A prescribing tool for postoperative pain was designed for hand, orthopedic, plastic, and spine surgeons and implemented into electronic discharge order sets in a 10-hospital health care system. Stakeholders were educated on tool use in person and/or by email on 2 occasions. A dashboard was created to monitor opioid pill quantities and morphine milligram equivalents (MMEs) prescribed. Overall compliance with the suggested opioid amounts was assessed for 20 months after tool implementation. A subgroup of 6 hand surgeons, one of whom was instrumental in designing the tool, were evaluated for MMEs prescribed, opioid refills, patient emergency room visits, and patient readmissions within 30 days after discharge. Comparisons in this subgroup were made from 12 months before to 15 months after tool implementation.

      Results

      The mean system-wide compliance with the suggested opioid pill quantities and MMEs prescribed in all 4 specialties improved by less than 5%. In the subgroup of hand surgeons, 5 of whom championed tool use, prescribed MMEs decreased by 10% during each of the 4 quarters before launching the tool and contracted an additional 26% in the first quarter after tool implementation. Opioid refills held steady at 5%, and there were no emergency room visits or readmissions within 30 days after discharge in this patient subgroup.

      Conclusions

      The prescribing tool had a negligible impact on system-wide compliance with suggested prescription opioid pill quantities and MMEs. In a small group of surgeons who championed the use of the tool, there was a significant and sustained decline in MMEs prescribed without adversely impacting patient refills, emergency room visits, or readmissions.

      Clinical relevance

      An electronic prescribing tool to assist surgeons in lowering opioid prescription pill quantities and MMEs may have a negligible impact on prescribing behavior in a multihospital health care system.

      Key words

      JHS Podcast

      November 1, 2022

      JHS Podcast Episode 80

      Dr. Graham interviews Dr. David Kalainov regarding his paper “Impact of an Electronic Health Record Pain Medication Prescribing Tool on Opioid Prescriptions for Postoperative Pain in Hand, Orthopedic, Plastic, and Spine Surgery Across a Health Care System”, which appears in the November 2022 issue of the Joiurnal of Hand Surgery.

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      November 1, 2022

      Perspectives - November 2022

      Listen to Dr. Jeffrey Stepan discuss the article “Impact of an Electronic Health Record Pain Medication Prescribing Tool on Opioid Prescriptions for Postoperative Pain in Hand, Orthopedic, Plastic, and Spine Surgery Across a Health Care System”, which appears in the November 2022 issue of the Journal of Hand Surgery.

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      References

        • Theisen K.
        • Jacobs B.
        • Macleod L.
        • Davies B.
        The United States opioid epidemic: a review of the surgeon's contribution to it and health policy initiatives.
        BJU Int. 2018; 122: 754-759
        • Brummett C.M.
        • Waljee J.F.
        • Goesling J.
        • et al.
        New persistent opioid use after minor and major surgical procedures in US adults.
        JAMA Surg. 2017; 152e170504
        • Shei A.
        • Rice J.B.
        • Kirson N.Y.
        • et al.
        Sources of prescription opioids among diagnosed opioid abusers.
        Curr Med Res Opin. 2015; 31: 779-784
        • Khan N.F.
        • Bateman B.T.
        • Landon J.E.
        • Gagne J.J.
        Association of opioid overdose with opioid prescriptions to family members.
        JAMA Intern Med. 2019; 179: 1186-1192
        • Shah A.
        • Hayes C.J.
        • Martin B.C.
        Characteristics of initial prescription episodes and likelihood of long-term opioid use - United States, 2006–2015.
        MMWR Morb Mortal Wkly Rep. 2017; 66: 265-269
        • Johnson S.P.
        • Chung K.C.
        • Zhong L.
        • et al.
        Risk of prolonged opioid use among opioid-naïve patients following common hand surgery procedures.
        J Hand Surg Am. 2016; 41 (e3): 947-957
        • Gaddis A.
        • Dowlati E.
        • Apel P.J.
        • et al.
        Effect of prescription size on opioid use and patient satisfaction after minor hand surgery: a randomized clinical trial.
        Ann Surg. 2019; 270: 976-982
        • Frazee R.
        • Garmon E.
        • Isbell C.
        • Bird E.
        • Papaconstantinou H.
        Postoperative opioid prescription reduction strategy in a regional healthcare system.
        J Am Coll Surg. 2020; 230: 631-635
        • Chiu A.S.
        • Jean R.A.
        • Hoag J.R.
        • Freedman-Weiss M.
        • Healy J.M.
        • Pei K.Y.
        Association of lowering default pill counts in electronic medical record systems with postoperative opioid prescribing.
        JAMA Surg. 2018; 153: 1012-1019
        • Meisenberg B.R.
        • Grover J.
        • Campbell C.
        • Korpon D.
        Assessment of opioid prescribing practices before and after implementation of a health system intervention to reduce opioid overprescribing.
        JAMA Netw Open. 2018; 1e182908
        • Weiner S.G.
        • Price C.N.
        • Atalay A.J.
        • et al.
        A health system-wide initiative to decrease opioid-related morbidity and mortality.
        Jt Comm J Qual Patient Saf. 2019; 45: 3-13
        • Slovis B.H.
        • Riggio J.M.
        • Girondo M.
        • et al.
        Reduction in hospital system opioid prescribing for acute pain through default prescription preference settings: pre–post study.
        J Med Internet Res. 2021; 23e24360
        • Losby J.L.
        • Hyatt J.D.
        • Kanter M.H.
        • Baldwin G.
        • Matsuoka D.
        Safer and more appropriate opioid prescribing: a large healthcare system’s comprehensive approach.
        J Eval Clin Pract. 2017; 23: 1173-1179
        • Gaspar M.P.
        • Pflug E.M.
        • Adams A.J.
        • et al.
        Self-reported postoperative opioid-prescribing practices following commonly performed orthopaedic hand and wrist surgical procedures: a nationwide survey comparing attending surgeons and trainees.
        J Bone Joint Surg Am. 2018; 100: e127
        • Raneses E.
        • Secrist E.S.
        • Freedman K.B.
        • Sohn D.H.
        • Fleeter T.B.
        • Aland C.M.
        Opioid prescribing practices of orthopaedic surgeons: results of a national survey.
        J Am Acad Orthop Surg. 2019; 27: e166-e172
        • Sabatino M.J.
        • Kunkel S.T.
        • Ramkumar D.B.
        • Keeney B.J.
        • Jevsevar D.S.
        Excess opioid medication and variation in prescribing patterns following common orthopaedic procedures.
        J Bone Joint Surg Am. 2018; 100: 180-188
        • Dwyer C.L.
        • Soong M.
        • Hunter A.
        • Dashe J.
        • Tolo E.
        • Kasparyan N.G.
        Prospective evaluation of an opioid reduction protocol in hand surgery.
        J Hand Surg Am. 2018; 43: 516-522.e1
        • Earp B.E.
        • Silver J.A.
        • Mora A.N.
        • Blazar P.E.
        Implementing a postoperative opioid-prescribing protocol significantly reduces the total morphine milligram equivalents prescribed.
        J Bone Joint Surg Am. 2018; 100: 1698-1703
        • Jamieson M.D.
        • Everhart J.S.
        • Lin J.S.
        • Jain S.A.
        • Awan H.M.
        • Goyal K.S.
        Reduction of opioid use after upper-extremity surgery through a predictive pain calculator and comprehensive pain plan.
        J Hand Surg Am. 2019; 44: 1050-1059.e4
        • Lovecchio F.
        • Stepan J.G.
        • Premkumar A.
        • et al.
        An institutional intervention to modify opioid prescribing practices after lumbar spine surgery.
        J Neurosurg Spine. 2019; 30: 483-490
        • Stepan J.G.
        • Lovecchio F.C.
        • Premkumar A.
        • et al.
        Development of an institutional opioid prescriber education program and opioid-prescribing guidelines: impact on prescribing practices.
        J Bone Joint Surg Am. 2019; 101: 5-13
        • Stepan J.G.
        • Sacks H.A.
        • Lovecchio F.C.
        • et al.
        Opioid prescriber education and guidelines for ambulatory upper-extremity surgery: evaluation of an institutional protocol.
        J Hand Surg Am. 2019; 44: 129-136
        • Gauger E.M.
        • Gauger E.J.
        • Desai M.J.
        • Lee D.H.
        Opioid use after upper extremity surgery.
        J Hand Surg Am. 2018; 43: 470-479
        • Kim N.
        • Matzon J.L.
        • 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: e89
        • Gupta A.
        • Kumar K.
        • Roberts M.M.
        • et al.
        Pain management after outpatient foot and ankle surgery.
        Foot Ankle Int. 2018; 39: 149-154
        • Hart A.M.
        • Broecker J.S.
        • Kao L.
        • Losken A.
        Opioid use following outpatient breast surgery: are physicians part of the problem?.
        Plast Reconstr Surg. 2018; 142: 611-620
        • Lovecchio F.
        • Derman P.
        • Stepan J.
        • et al.
        Support for safer opioid prescribing practices: a catalog of published use after orthopaedic surgery.
        J Bone Joint Surg Am. 2017; 99: 1945-1955
        • Peters B.
        • Izadpanah A.
        • Islur A.
        Analgesic consumption following outpatient carpal tunnel release.
        J Hand Surg Am. 2018; 43: 189.e1-189.e5
        • Bhashyam A.R.
        • Basilico M.
        • Weaver M.J.
        • Harris M.B.
        • Heng M.
        Using historical variation in opioid prescribing immediately after fracture surgery to guide maximum initial prescriptions.
        J Orthop Trauma. 2019; 33: e131-e136
        • Wagner A.K.
        • Soumerai S.B.
        • Zhang F.
        • Ross-Degnan D.
        Segmented regression analysis of interrupted time series studies in medication use research.
        J Clin Pharm Ther. 2002; 27: 299-309
        • Kunstler B.E.
        • Lennox A.
        • Bragge P.
        Changing prescribing behaviours with educational outreach: an overview of evidence and practice.
        BMC Med Educ. 2019; 19: 311
        • Schommer J.
        • Allen S.
        • Scholz N.
        • Reams M.
        • Bohn D.
        Evaluation of quality improvement methods for altering opioid prescribing behavior in hand surgery.
        J Bone Joint Surg Am. 2020; 102: 804-810
        • Pflug E.M.
        • Huang S.
        • Haquebord J.H.
        • Hutzler L.
        • Paksima N.
        Opioid prescribing patterns among orthopedic hand surgeons after implementation of a divisional protocol.
        J Healthc Qual. 2022; 44: e31-e37
        • Sutherland T.N.
        • Wunsch H.
        • Pinto R.
        • et al.
        Association of the 2016 US Centers for Disease Control and Prevention opioid prescribing guideline with changes in opioid dispensing after surgery.
        JAMA Netw Open. 2021; 4e2111826
        • Goldstick J.E.
        • Guy G.P.
        • Losby J.L.
        • Baldwin G.
        • Myers M.
        • Bohnert A.S.B.
        Changes in initial opioid prescribing practices after the 2016 release of the CDC guideline for prescribing opioids for chronic pain.
        JAMA Netw Open. 2021; 4e2116860
        • Wiese H.J.C.
        • Piercey R.R.
        • Clark C.D.
        Changing prescribing behavior in the United States: moving upstream in opioid prescription education.
        Clin Pharmacol Ther. 2018; 103: 982-989
        • Reid D.B.C.
        • Shah K.N.
        • Shapiro B.H.
        • Ruddell J.H.
        • Akelman E.
        • Daniels A.H.
        Mandatory prescription limits and opioid utilization following orthpaedic surgery.
        J Bone Joint Surg Am. 2019; 101: e43