Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor.
Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor.
JAMA Netw Open. 2022 Jun 1;5(6):e2219701. doi: 10.1001/jamanetworkopen.2022.19701.
In prior studies, decreasing the default number of doses in opioid prescriptions written in electronic health record systems reduced opioid prescribing. However, these studies did not rigorously assess patient-reported outcomes, and few included pediatric patients.
To evaluate the association between decreasing the default number of doses in opioid prescriptions written in electronic health record systems and opioid prescribing and patient-reported outcomes among adolescents and young adults undergoing tonsillectomy.
DESIGN, SETTING, AND PARTICIPANTS: This nonrandomized clinical trial included adolescents and young adults aged 12 to 50 years undergoing tonsillectomy from October 1, 2019, through July 31, 2021, at a tertiary medical center. The treatment group comprised patients from a pediatric otolaryngology service (mostly aged 12-21 years) and the control group comprised patients from a general otolaryngology service (mostly aged 18-25 years).
Data on patient-reported opioid consumption and outcomes were collected via a survey on postoperative day 14. Based on opioid consumption among pediatric otolaryngology patients before the intervention, the default number of opioid doses was decreased from 30 to 12 in a tonsillectomy order set. This change occurred only for pediatric otolaryngology patients.
Proportion of patients with 12 doses in the discharge opioid prescription, number of doses in this prescription, and refills and pain-related visits within 2 weeks of surgery. In a secondary analysis of patients completing the postoperative survey, patient-reported opioid consumption, pain control, sleep disturbance, anxiety, and depression were assessed. Linear or log-linear difference-in-differences models were fitted, adjusting for patients' demographic characteristics and presence of a mental health or substance use disorder.
The study included 237 patients (147 female patients [62.0%]; mean [SD] age, 17.3 [3.6] years). Among 131 pediatric otolaryngology patients, 1 of 70 (1.4%) in the preintervention period and 27 of 61 (44.3%) in the postintervention period had 12 doses in the discharge opioid prescription (differential change, 45.5 percentage points; 95% CI, 32.2-58.8 percentage points). Among pediatric otolaryngology patients, the mean (SD) number of doses prescribed in the preintervention period was 22.3 (7.4) and in the postintervention period was 16.1 (6.5) (differential percentage change, -29.2%; 95% CI, -43.2% to -11.7%). The intervention was not associated with changes in refills or pain-related visits. The secondary analysis included 150 patients. The intervention was not associated with changes in patient-reported outcomes except for a 3.5-point (95% CI, 1.5-5.5 points) differential increase in a sleep disturbance score that ranged from 4 to 20, with higher scores indicating poorer sleep quality.
This nonrandomized clinical trial suggests that evidence-based default dosing settings may decrease perioperative opioid prescribing among adolescents and young adults undergoing tonsillectomy, without compromising analgesia.
ClinicalTrials.gov Identifier: NCT04066829.
在之前的研究中，减少电子病历系统中开具的阿片类药物处方的默认剂量数可减少阿片类药物的处方量。然而，这些研究没有严格评估患者报告的结果，且很少包括儿科患者。
评估减少电子病历系统中开具的阿片类药物处方的默认剂量数与青少年和年轻人接受扁桃体切除术时的阿片类药物处方量和患者报告的结果之间的关联。
设计、设置和参与者：这是一项非随机临床试验，纳入了 2019 年 10 月 1 日至 2021 年 7 月 31 日期间在一家三级医疗中心接受扁桃体切除术的 12 岁至 50 岁青少年和年轻人。治疗组包括来自儿科耳鼻喉科服务的患者（大多为 12-21 岁），对照组包括来自普通耳鼻喉科服务的患者（大多为 18-25 岁）。
通过术后第 14 天的调查收集患者报告的阿片类药物使用情况和结果的数据。根据干预前儿科耳鼻喉科患者的阿片类药物使用情况，将扁桃体切除术医嘱集中的阿片类药物剂量默认数量从 30 减至 12。这种变化仅适用于儿科耳鼻喉科患者。
出院阿片类药物处方中包含 12 剂的患者比例、该处方中的剂量数、术后 2 周内的补充处方和与疼痛相关的就诊。在对完成术后调查的患者进行的二次分析中，评估了患者报告的阿片类药物使用情况、疼痛控制、睡眠障碍、焦虑和抑郁情况。使用线性或对数线性差异-差异模型进行拟合，调整了患者的人口统计学特征以及是否存在精神健康或物质使用障碍。
研究纳入了 237 名患者（147 名女性患者[62.0%]；平均[标准差]年龄为 17.3[3.6]岁）。在 131 名儿科耳鼻喉科患者中，干预前有 70 名中的 1 名（1.4%）和干预后有 61 名中的 27 名（44.3%）在出院阿片类药物处方中包含 12 剂（差异变化为 45.5 个百分点；95%CI 为 32.2-58.8 个百分点）。在儿科耳鼻喉科患者中，干预前处方的平均（标准差）剂量数为 22.3（7.4），干预后为 16.1（6.5）（差异百分比变化为-29.2%；95%CI 为-43.2%至-11.7%）。干预与补充处方或与疼痛相关的就诊次数的变化无关。二次分析纳入了 150 名患者。除了睡眠障碍评分增加了 3.5 分（95%CI 为 1.5-5.5 分）外，干预与患者报告的结果变化无关，睡眠障碍评分范围为 4 至 20 分，得分越高表示睡眠质量越差。
这项非随机临床试验表明，基于证据的默认剂量设置可能会减少青少年和年轻人接受扁桃体切除术时的围手术期阿片类药物的处方量，而不会影响镇痛效果。
ClinicalTrials.gov 标识符：NCT04066829。
