David Geffen School of Medicine, Department of Surgery, University of California, Los Angeles, Los Angeles.
Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, California.
JAMA Health Forum. 2021 Oct 1;2(10):e212924. doi: 10.1001/jamahealthforum.2021.2924. eCollection 2021 Oct.
Legislation mandating consultation with a prescription drug monitoring program (PDMP) was implemented in California on October 2, 2018. This mandate requires PDMP consultation before prescribing a controlled substance and integrates electronic health record (EHR)-based alerts; prescribers are exempt from the mandate if they prescribe no more than a 5-day postoperative opioid supply. Although previous studies have examined the consequences of mandated PDMP consultation, few have specifically analyzed changes in postoperative opioid prescribing after mandate implementation.
To examine whether the implementation of mandatory PDMP consultation with concurrent EHR-based alerts was associated with changes in postoperative opioid quantities prescribed at discharge.
This cross-sectional study performed an interrupted time series analysis of opioid prescribing patterns within a large health care system (Sutter Health) in northern California between January 1, 2015, and February 1, 2020. A total of 93 760 adult patients who received an opioid prescription at discharge after undergoing general, obstetric and gynecologic (obstetric/gynecologic), or orthopedic surgery were included.
Mandatory PDMP consultation before opioid prescribing, with concurrent integration of an EHR alert. Prescribers are exempt from this mandate if prescribing no more than a 5-day opioid supply postoperatively.
The primary outcome was the total quantity of opioid medications (morphine milligram equivalents [MMEs] and number of opioid tablets) prescribed at discharge before and after implementation of the PDMP mandate, with separate analyses by surgical specialty (general, obstetric/gynecologic, and orthopedic) and most common surgical procedure within each specialty (laparoscopic cholecystectomy, cesarean delivery, and knee arthroscopy). The secondary outcome was the proportion of prescriptions with a duration of longer than 5 days.
Of 93 760 patients (mean [SD] age, 46.7 [17.6] years; 67.9% female) who received an opioid prescription at discharge, 65 911 received prescriptions before PDMP mandate implementation, and 27 849 received prescriptions after implementation. Most patients received general or obstetric/gynecologic surgery (48.6% and 30.1%, respectively), did not have diabetes (90.3%), and had never smoked (66.0%). Before the PDMP mandate was implemented, a decreasing pattern in opioid prescribing quantities was already occurring. During the quarter of implementation, total MMEs prescribed at discharge further decreased for all 3 surgical specialties (eg, medians for general surgery: β = -10.00 [95% CI, -19.52 to -0.48]; obstetric/gynecologic surgery: β = -18.65 [95% CI, -22.00 to -15.30]; and orthopedic surgery: β = -30.59 [95% CI, -40.19 to -21.00]) after adjusting for the preimplementation prescribing pattern. The total number of tablets prescribed also decreased across specialties (eg, medians for general surgery: β = -3.02 [95% CI, -3.47 to -2.57]; obstetric/gynecologic surgery: β = -4.86 [95% CI, -5.38 to -4.34]; and orthopedic surgery: β = -4.06 [95% CI, -5.07 to -3.04]) compared with the quarters before implementation. These reductions were not consistent across the most common surgical procedures. For cesarean delivery, the median number of tablets prescribed decreased during the quarter of implementation (β = -10.00; 95% CI, -10.10 to -9.90), but median MMEs did not (β = 0; 95% CI, -9.97 to 9.97), whereas decreases were observed in both median MMEs and number of tablets prescribed (MMEs: β = -33.33 [95% CI, -38.48 to -28.19]; tablets: β = -10.00 [95% CI, -11.17 to -8.82]) for laparoscopic cholecystectomy. For knee arthroscopy, no decreases were found in either median MMEs or number of tablets prescribed (MMEs: β = 10.00 [95% CI, -22.33 to 42.33; tablets: β = 0.83; 95% CI, -3.39 to 5.05). The proportion of prescriptions written for longer than 5 days also decreased significantly during the quarter of implementation across all 3 surgical specialties.
In this cross-sectional study, the implementation of mandatory PDMP consultation with a concurrent EHR-based alert was associated with an immediate decrease in opioid prescribing across the 3 surgical specialties. These findings might be explained by prescribers' attempts to meet the mandate exemption and bypass PDMP consultation rather than the PDMP consultation itself. Although policies coupled with EHR alerts may be associated with changes in postoperative opioid prescribing behavior, they need to be well designed to optimize evidence-based opioid prescribing.
2018 年 10 月 2 日，加利福尼亚州实施了一项立法，要求在开具受控物质处方前咨询处方药物监测计划（PDMP）。该规定要求，如果开的是术后不超过 5 天用量的阿片类药物，则医生可以豁免该规定。尽管之前的研究已经研究了强制性 PDMP 咨询的后果，但很少有研究专门分析该规定实施后术后阿片类药物处方的变化。
研究强制性 PDMP 咨询与基于电子健康记录（EHR）的警报同时实施是否与出院时开具的术后阿片类药物数量的变化有关。
设计、设置和参与者：本研究是一项在加利福尼亚州北部的 Sutter Health 大型医疗保健系统中进行的回顾性研究，时间范围为 2015 年 1 月 1 日至 2020 年 2 月 1 日，共纳入 93760 名在接受普通、产科和妇科（产科/妇科）或骨科手术后出院时开具阿片类药物处方的成年患者。
在开具阿片类药物处方前进行强制性 PDMP 咨询，同时整合基于 EHR 的警报。如果医生开具的术后阿片类药物处方不超过 5 天，则可豁免该规定。
主要结果是在实施 PDMP 规定前后，通过普通、产科/妇科和骨科手术的最常见手术分别分析，按手术专业（普通、产科/妇科和骨科）和最常见手术（腹腔镜胆囊切除术、剖宫产和膝关节镜检查），出院时开具的阿片类药物的总数量（吗啡毫克当量[MME]和阿片类药物片数）。次要结果是处方持续时间超过 5 天的比例。
在 93760 名（平均[SD]年龄 46.7[17.6]岁；67.9%为女性）出院时开具阿片类药物处方的患者中，65911 名患者在 PDMP 规定实施前开具了处方，27849 名患者在实施后开具了处方。大多数患者接受了普通或产科/妇科手术（分别为 48.6%和 30.1%），没有糖尿病（90.3%），从不吸烟（66.0%）。在 PDMP 规定实施之前，阿片类药物的处方数量已经呈现出下降趋势。在实施的季度中，所有 3 个手术专业的出院时开具的 MME 总量进一步下降（例如，普通外科：β=−10.00[95%CI，−19.52 至−0.48]；产科/妇科手术：β=−18.65[95%CI，−22.00 至−15.30]；骨科手术：β=−30.59[95%CI，−40.19 至−21.00]），这是在调整实施前的处方模式之后。各专科的总片数也有所下降（例如，普通外科：β=−3.02[95%CI，−3.47 至−2.57]；产科/妇科手术：β=−4.86[95%CI，−5.38 至−4.34]；骨科手术：β=−4.06[95%CI，−5.07 至−3.04]）与实施前的几个季度相比。这些减少在最常见的手术过程中并不一致。对于剖宫产，实施季度的处方片数中位数减少（β=−10.00；95%CI，−10.10 至−9.90），但 MME 中位数没有减少（β=0；95%CI，−9.97 至 9.97），而腹腔镜胆囊切除术的 MME 和片数中位数均有所减少（MME：β=−33.33[95%CI，−38.48 至−28.19]；片剂：β=−10.00[95%CI，−11.17 至−8.82]）。对于膝关节镜检查，MME 和片剂的中位数均未减少（MME：β=10.00[95%CI，−22.33 至 42.33]；片剂：β=0.83；95%CI，−3.39 至 5.05）。开 5 天以上的处方比例也在实施季度内显著下降，在所有 3 个手术专业中都有下降。
在这项横断面研究中，强制性 PDMP 咨询与基于 EHR 的警报同时实施与 3 个外科专业的阿片类药物处方量立即减少有关。这些发现可能是由于医生试图满足豁免规定并绕过 PDMP 咨询，而不是 PDMP 咨询本身。尽管结合 EHR 警报的政策可能与术后阿片类药物处方行为的变化有关，但它们需要精心设计，以优化基于证据的阿片类药物处方。
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