Peahl Alex F, Low Lisa Kane, Langen Elizabeth S, Moniz Michelle H, Aaron Bryan, Hu Hsou Mei, Waljee Jennifer, Townsel Courtney
Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA.
School of Nursing, University of Michigan, Ann Arbor, Michigan, USA.
Birth. 2024 Sep;51(3):541-558. doi: 10.1111/birt.12809. Epub 2023 Dec 30.
We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics.
We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner- and hospital-level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient.
Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient-level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8-1066.7) and third-/fourth-degree perineal laceration (aOR 25.7, 95% CI 17.4-37.9). Receiving care from a certified nurse-midwife (aOR 0.63, 95% CI 0.48-0.82) or family medicine physician (aOR 0.60, 95%CI 0.39-0.91) was associated with lower prescribing rates. Hospital-level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61-15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15-0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%).
Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner- and hospital-level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms.
我们描述了全州质量协作组织中产后阿片类药物处方的差异，并评估了因从业者和医院特征导致的差异比例。
我们评估了2020年1月至2021年6月间未生育、足月、单胎、头位分娩的产后处方数据，这些数据包含在由密歇根蓝十字蓝盾公司资助的全州产科质量协作组织的临床登记中。数据使用描述性统计进行总结。混合效应逻辑回归和线性模型对患者特征进行了调整，并评估了接受产后阿片类药物处方和处方量的从业者和医院层面的预测因素。使用组内相关系数评估从业者和医院特征的相对贡献。
在68家医院分娩的40589名患者中，3.0%（872/29412）在阴道分娩后接受了阿片类药物处方，87.8%（9812/11177）在剖宫产术后接受了阿片类药物处方，各医院之间差异很大。在调整后的模型中，接受处方的最强患者层面预测因素是剖宫产（调整后比值比899.1，95%置信区间752.8 - 1066.7）和三度/四度会阴裂伤（调整后比值比25.7，95%置信区间17.4 - 37.9）。由认证助产士（调整后比值比0.63，95%置信区间0.48 - 0.82）或家庭医学医生（调整后比值比0.60，95%置信区间0.39 - 0.91）提供护理与较低的处方率相关。医院层面的预测因素包括在年分娩量<500例的医院接受护理（调整后比值比4.07，95%置信区间1.61 - 15.0）。积极的安全文化与较低的处方率相关（调整后比值比0.37，95%置信区间0.15 - 0.88）。产后处方的很大一部分差异可归因于从业者和医院（处方接受情况：从业者占25.1%，医院占12.1%；处方量：从业者占5.4%，医院占52.2%）。
产后阿片类药物处方差异很大，主要由从业者和医院层面的因素驱动。针对从业者和医院层面的阿片类药物管理措施可能对减少阿片类药物处方危害有效。
