Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor.
Michigan Opioid Prescribing Engagement Network, University of Michigan Medical School, Ann Arbor.
JAMA Netw Open. 2023 Jan 3;6(1):e2249378. doi: 10.1001/jamanetworkopen.2022.49378.
Advanced practice clinicians (APCs), defined as nurse practitioners and physician assistants, are increasingly being incorporated into surgical teams. Despite this inclusion, there are no recent national data on the role of these clinicians in surgical opioid prescribing or the dosing of such prescriptions.
To calculate the proportion of surgical opioid prescriptions written by APCs and to compare the total and daily dosages of these prescriptions with those written by surgeons.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used the Optum's De-Identified Clinformatics Data Mart, which contains deidentified claims from patients with private insurance and Medicare Advantage plans across the US. Adults and children who underwent 1 of 31 inpatient and outpatient surgical procedures from January 1, 2017, through November 30, 2019, were identified. The analysis was limited to procedures with 1 or more perioperative opioid prescriptions, defined as an opioid prescription dispensed within 3 days of the index date of surgery. Data were analyzed from April 1, 2021, to July 31, 2022.
Prescriber specialty.
The outcome was the proportion of perioperative opioid prescriptions and refill prescriptions written by APCs. Linear regression was used to compare the total dosage of perioperative opioid prescriptions written by APCs vs surgeons measured in morphine milligram equivalents (MMEs). Models were adjusted for demographic characteristics, comorbidities, opioid-naive status, year of index date, hospitalization or observation status, surgical complications, and surgeon specialty. Analyses were conducted at the procedure level, and patients with multiple procedures were included.
Analyses included 628 197 procedures for 581 387 patients (358 541 females [57.1%]; mean [SD] age, 56 [18] years). Overall, APCs wrote 119 266 (19.0%) of the 628 197 perioperative opioid prescriptions and 59 679 (25.1%) of the 237 740 refill prescriptions. Perioperative opioid prescriptions written by APCs had higher total dosages compared with those written by surgeons (adjusted difference, 40.0 MMEs; 95% CI, 31.3-48.7 MMEs). This difference persisted in a subgroup analysis limited to opioid-naïve patients (adjusted difference, 15.7 MMEs; 95% CI, 13.9-17.5 MMEs).
In this cross-sectional analysis, one-fifth of perioperative opioid prescriptions and one-quarter of refill prescriptions were written by APCs. While surgeons wrote most perioperative opioid prescriptions that were intended for perioperative analgesia, higher total dosages from APCs suggest that opioid stewardship initiatives that support the role of APCs may be warranted.
高级执业医师（APC），定义为护士从业者和医师助理，正越来越多地被纳入手术团队。尽管如此，目前仍缺乏关于这些临床医生在手术阿片类药物处方或此类处方剂量方面作用的最新全国数据。
计算 APC 开具的手术阿片类药物处方的比例，并比较这些处方的总剂量和日剂量与外科医生开具的处方。
设计、地点和参与者：这项横断面研究使用了 Optum 的 De-Identified Clinformatics Data Mart，其中包含来自美国私人保险和 Medicare Advantage 计划患者的匿名索赔数据。2017 年 1 月 1 日至 2019 年 11 月 30 日期间接受 31 种住院和门诊手术之一的成年人和儿童被确定为研究对象。分析仅限于具有 1 种或多种围手术期阿片类药物处方的手术，定义为在手术索引日期的 3 天内开出的阿片类药物处方。数据分析于 2021 年 4 月 1 日至 2022 年 7 月 31 日进行。
处方医师的专业。
结果是 APC 开具的围手术期阿片类药物处方和补充处方的比例。线性回归用于比较 APC 开具的围手术期阿片类药物处方的总剂量与外科医生开具的以吗啡毫克当量（MME）衡量的总剂量。模型调整了人口统计学特征、合并症、阿片类药物初治状态、索引日期年份、住院或观察状态、手术并发症和外科医生专业。分析在手术层面进行，且每位患者有多个手术。
分析纳入了 628197 例手术，涉及 581387 名患者（358541 名女性[57.1%]；平均[标准差]年龄，56[18]岁）。总体而言，APC 开具了 119266（19.0%）例 628197 例围手术期阿片类药物处方和 59679（25.1%）例 237740 例补充处方。APC 开具的围手术期阿片类药物处方的总剂量高于外科医生开具的处方（调整差异，40.0 MME；95%置信区间，31.3-48.7 MME）。在仅限于阿片类药物初治患者的亚组分析中，这一差异仍然存在（调整差异，15.7 MME；95%置信区间，13.9-17.5 MME）。
在这项横断面分析中，五分之一的围手术期阿片类药物处方和四分之一的补充处方是由 APC 开具的。尽管外科医生开具了大多数用于围手术期镇痛的围手术期阿片类药物处方，但 APC 开具的处方总剂量较高表明，支持 APC 作用的阿片类药物管理计划可能是合理的。
