University of Wisconsin School of Medicine and Public Health, BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin.
University of California San Francisco, Zuckerberg San Francisco General.
West J Emerg Med. 2018 Mar;19(2):392-397. doi: 10.5811/westjem.2017.10.33798. Epub 2018 Feb 12.
Opioid prescribing patterns have come under increasing scrutiny with the recent rise in opioid prescriptions, opioid misuse and abuse, and opioid-related adverse events. To date, there have been limited studies on the effect of default tablet quantities as part of emergency department (ED) electronic order entry. Our goal was to evaluate opioid prescribing patterns before and after the removal of a default quantity of 20 tablets from ED electronic order entry.
We performed a retrospective observational study at a single academic, urban ED with 58,000 annual visits. We identified all adult patients (18 years or older) seen in the ED and discharged home with prescriptions for tablet forms of hydrocodone and oxycodone (including mixed formulations with acetaminophen). We compared the quantity of tablets prescribed per opioid prescription 12 months before and 10 months after the electronic order-entry prescription default quantity of 20 tablets was removed and replaced with no default quantity. No specific messaging was given to providers, to avoid influencing prescribing patterns. We used two-sample Wilcoxon rank-sum test, two-sample test of proportions, and Pearson's chi-squared tests where appropriate for statistical analysis.
A total of 4,104 adult patients received discharge prescriptions for opioids in the pre-intervention period (151.6 prescriptions per 1,000 discharged adult patients), and 2,464 post-intervention (106.69 prescriptions per 1,000 discharged adult patients). The median quantity of opioid tablets prescribed decreased from 20 (interquartile ration [IQR] 10-20) to 15 (IQR 10-20) (p<0.0001) after removal of the default quantity. While the most frequent quantity of tablets received in both groups was 20 tablets, the proportion of patients who received prescriptions on discharge that contained 20 tablets decreased from 0.5 (95% confidence interval [CI] [0.48-0.52]) to 0.23 (95% CI [0.21-0.24]) (p<0.001) after default quantity removal.
Although the median number of tablets differed significantly before and after the intervention, the clinical significance of this is unclear. An observed wider distribution of the quantity of tablets prescribed after removal of the default quantity of 20 may reflect more appropriate prescribing patterns (i.e., less severe indications receiving fewer tabs and more severe indications receiving more). A default value of 20 tablets for opioid prescriptions may be an example of the electronic medical record's ability to reduce practice variability in medication orders actually counteracting optimal patient care.
随着阿片类药物处方的增加、阿片类药物滥用和误用以及阿片类药物相关不良事件的增加，阿片类药物的处方模式受到了越来越多的关注。迄今为止，关于作为急诊（ED）电子医嘱输入一部分的默认片剂数量的影响，研究有限。我们的目标是评估从 ED 电子医嘱输入中删除默认 20 片片剂数量前后的阿片类药物处方模式。
我们在一家拥有 58000 名年就诊量的单所学术性城市急诊进行了回顾性观察性研究。我们确定了在 ED 就诊并出院回家时开有氢可酮和羟考酮（包括与对乙酰氨基酚混合制剂）片剂形式处方的所有成年患者（18 岁或以上）。我们比较了在去除默认的 20 片片剂数量并替换为无默认数量之前和之后的阿片类药物处方中每个阿片类药物处方规定的片剂数量。未向提供者提供任何特定的信息，以避免影响处方模式。我们使用了双样本 Wilcoxon 秩和检验、双样本比例检验和 Pearson's chi-squared 检验，根据需要进行统计分析。
共有 4104 名成年患者在干预前获得了出院阿片类药物处方（每 1000 名出院成年患者中有 151.6 份处方），2464 名患者在干预后获得了出院阿片类药物处方（每 1000 名出院成年患者中有 106.69 份处方）。规定的阿片类药物片剂数量中位数从 20 片（四分位间距[IQR] 10-20）降至 15 片（IQR 10-20）（p<0.0001）。虽然两组中最常见的片剂数量均为 20 片，但在默认数量去除后，接受 20 片出院处方的患者比例从 0.5（95%置信区间[CI] [0.48-0.52]）降至 0.23（95% CI [0.21-0.24]）（p<0.001）。
尽管干预前后的中位数存在显著差异，但这在临床上的意义尚不清楚。在去除默认的 20 片片剂数量后观察到的规定片剂数量分布更广泛，可能反映出更合适的处方模式（即，较轻的指征接受的片剂数量较少，较重的指征接受的片剂数量较多）。阿片类药物处方的默认 20 片片剂值可能是电子病历减少药物医嘱实践变异性的一个例子，实际上与最佳患者护理背道而驰。
