From the Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA (Zanocco, Shenoy).
Health and Wellbeing, RAND Europe, Cambridge, UK (Romanelli).
J Am Coll Surg. 2024 Sep 1;239(3):242-252. doi: 10.1097/XCS.0000000000001095. Epub 2024 May 1.
Misuse of prescription opioids is a well-established contributor to the US opioid epidemic. The primary objective of this study was to identify which level of care delivery (ie patient, prescriber, or hospital) produced the most unwarranted variation in opioid prescribing after common surgical procedures.
Electronic health record data from a large multihospital healthcare system were used in conjunction with random-effect models to examine variation in opioid prescribing practices after similar inpatient and outpatient surgical procedures between October 2019 and September 2021. Unwarranted variation was conceptualized as variation resulting from prescriber behavior unsupported by evidence. Covariates identified as drivers of warranted variation included characteristics known to influence pain levels or patient safety. All other model variables, including prescriber specialty and patient race, ethnicity, and insurance status were characterized as potential drivers of unwarranted variation.
Among 25,188 procedures with an opioid prescription at hospital discharge, 53.5% exceeded guideline recommendations, corresponding to 13,228 patients receiving the equivalent of >140,000 excess 5 mg oxycodone tablets after surgical procedures. Prescribing variation was primarily driven by prescriber-level factors, with approximately half of the total variation in morphine milligram equivalents prescribed observed at the prescriber level and not explained by any measured variables. Unwarranted covariates associated with higher prescribed opioid quantity included non-Hispanic Black race, Medicare insurance, smoking history, later hospital discharge times, and prescription by a surgeon rather than a hospitalist or primary care provider.
Given the large proportion of unexplained variation observed at the provider level, targeting prescribers through education and training may be an effective strategy for reducing postoperative opioid prescribing.
处方类阿片药物的滥用是美国阿片类药物泛滥的一个公认的主要原因。本研究的主要目的是确定在常见的手术之后，在哪个医疗服务提供层面（即患者、医生或医院）的处方类阿片药物的开具存在最多无依据的差异。
利用大型多医院医疗保健系统的电子健康记录数据，并结合随机效应模型，研究了 2019 年 10 月至 2021 年 9 月期间，相似的住院和门诊手术之后，医生开具阿片类药物处方的做法存在的差异。无依据的差异被定义为医生的行为没有得到证据支持而导致的差异。被确定为有依据的差异驱动因素的变量包括已知会影响疼痛水平或患者安全的特征。所有其他模型变量，包括医生的专业和患者的种族、族裔和保险状况，被描述为无依据差异的潜在驱动因素。
在 25188 例出院时开具了阿片类药物处方的手术中，有 53.5%的处方超过了指南的建议，这相当于在手术后有 13228 名患者接受了相当于超过 140000 片过量的 5 毫克羟考酮片。处方差异主要由医生层面的因素驱动，在开具的吗啡毫克当量处方中，约有一半的差异可以在医生层面观察到，并且无法用任何测量的变量来解释。与开具的阿片类药物处方数量较高相关的无依据的协变量包括非西班牙裔黑人种族、医疗保险、吸烟史、较晚的出院时间，以及由外科医生而不是医院医生或初级保健医生开具的处方。
鉴于在医生层面观察到的无法解释的差异比例较大，通过教育和培训来针对医生可能是减少术后阿片类药物处方开具的有效策略。
