Effect of a targeted quality improvement education on opioid prescribing

Introduction

The opioid epidemic has been and continues to be a major source of health, social and economic burden across the USA, claiming 75 673 lives in the year from May 2020 to April 2021 alone and accounting for 75.4% of all drug overdose deaths that year.1 2 The ‘first wave’ of the opioid epidemic began in the 1990s and correlated with an increase in opioid prescribing for non-cancer-related pain.3 4 Between 1999 and 2010, there was a steep climb in opioid overdoses and related deaths which was paralleled by increased opioid prescribing, which was responsible for the vast majority of opioid overdose deaths at this time.3 5 Despite decreasing rates of opioid prescribing since 2010, in 2015 the milligram morphine equivalents (MME) prescribed per patient was three times what it was in 2010, and in that same year more than half of the opioid overdoses occurred using prescription opioids.4 6 Opioid prescribing practices by physicians have been linked to the development of opioid use disorder, with one study showing that people receiving opioids for non-cancer-related pain for greater than 90 days, even at low doses, are at an increased risk of developing an opioid use disorder (OR=14.92).7 Additionally, multiple studies have shown that risk of opioid overdose progressively increases with increasing the maximum daily dose (MDD) of opioid prescribed.4 8 9

To decrease the prescriber’s role in the opioid epidemic, the Centers for Disease Control and Prevention (CDC) have established opioid treatment guidelines and other information for healthcare professionals. The CDC Guideline for Prescribing Opioids for Chronic Pain—USA, 2016 provides evidence-based recommendations on the safe and appropriate use of opioids for pain management outside of palliative care, end-of-life care and active cancer treatment.10 These guidelines focused on prescribing less than 50 MME per day. However, many physicians are poorly trained on opioid prescribing in medical school and residency, and therefore, may not be aware of these guidelines and/or not implement them well in practice.11 For example, students and residents may learn about patient satisfaction surveys and try to appease requests from patients for opioid pain medication rather than to educate patients about the hazards of opioid pain medications. In fact, it has been shown that teaching hospitals are more likely to inappropriately prescribe opioids than community hospitals, possibly as a result of lack of training.12 This may be because residents and fellows are arriving for a fleeting 1–7 years of training and may have missed opportunities to learn best practices on opioid prescribing, whereas community hospitals may have longer-term medical staff that adopt a culture of reducing opioid prescriptions more lastingly. One intervention intended to ameliorate this problem is the New York State Department of Health requirement for Mandatory Prescriber Education for all Prescribers licensed in New York to treat humans and who have a Drug Enforcement Administration (DEA) registration number to prescribe controlled substances.13 All licensed independent providers, including physicians, physician assistants, nurse practitioners and midwives, who prescribe controlled substances under a facility DEA registration number had to complete at least 3 hours of course work or training in pain management, palliative care and addiction. The purpose of this study was to evaluate the effect of individual institutional opioid prescriber training on prescriber adherence to CDC guidelines as they relate to number of opioid prescriptions and prescribed MDD.

Methods

Data were collected at an academic medical centre, including that from two hospitals and all affiliated outpatient practices. All prescriptions for opioid medications were collected from the electronic health record, Epic, from 1 July 2017 to 31 March 2020. Data were only included for electronic prescriptions written through Epic. Opioid medications included all formulations containing hydrocodone, oxycodone, morphine, fentanyl, tramadol, codeine, tapentadol, oxymorphone, hydromorphone, opium, meperidine, buprenorphine and methadone. Analysis was completed only on departments prescribing 5% or more of the institution’s opioid prescriptions, as determined by number of prescriptions per department from 1 July 2017 to 31 December 2018 to preserve validity of data and to capture data where there was the greatest room for improvement.

The medical centre implemented a mandatory opioid prescriber training as part of their standard annual provider education for all medical staff, which included physicians, both attendings and residents, physician assistants, nurse practitioners, and midwives, who were all required to attest having read it and pass a quiz by 30 September 2019. Data were analysed preintervention (prescriptions written between 1 July 2017 and 30 September 2019) and postintervention (prescriptions written between 1 October 2019 and 3 March 2020) to assess the effect of this intervention on opioid prescribing.

Analysis was based on MDD standardised in MME using conversion factors released by the CDC. The MDD was then compared with those suggested by the CDC.10 Based on these recommendations, a prescription was categorised as ‘compliant’ if it was written for an MDD for less than 50 MME and was otherwise categorised as ‘non-compliant’. Average rates of opioid prescribing were calculated by averaging the total number of opioid scripts written by a department before and after intervention by the number of days included in the interval.

MEdCalc V.19.4.1 was used for all statistical analyses. Proportion of prescriptions that were compliant with MDD recommendations were compared before and after intervention by χ² analysis of the difference of proportions. The rate of prescriptions written were also analysed by the difference of incidence rate before and after the intervention. A significant difference was defined as a p value <0.05.

Results

A total of 102 812 prescriptions were written preintervention and 17 572 prescriptions were written postintervention. The departments/divisions prescribing opioids most frequently preintervention include orthopaedic surgery (23.9%), haematology-oncology (10.0%), general medicine (8.0%), emergency medicine (7.8%), general surgery (7.7%), pain management (7.3%) and family medicine (5.0%) (see figure 1).

Request permission

Overall, across departments and divisions, there was a statistically significant decrease in the compliance with MDD before (71.3%) and after (67.3%) the intervention (4%, 95% CI 3.13% to 4.87% difference, p<0.001). General surgery showed the highest rates of compliance with MDD both before and after intervention. Haematology-oncology, however, had the lowest rates of compliance both before and after intervention. There was a statistically significant decrease in compliance with MDD after intervention in the departments of emergency medicine (22.2%, 95% CI 20.0% to 24.6% difference, p<0.001) and general medicine (10.3%, 95% CI 8.04% to 12.6% difference, p<0.001). There was a statistically significant increase in compliance with MDD after intervention in general surgery (6.7%, 95% CI 5.41% to 7.84% difference, p<0.001), haematology-oncology (3.3%, 95% CI 0.82% to 5.78% difference, p=0.01) and orthopaedics (4.5%, 95% CI 2.92% to 6.04% difference, p<0.01). Pain medicine and family medicine departments showed no statistically significant changes (see figure 2).

Request permission

Across all seven departments/divisions, opioid prescribing rates decreased from 88.5 scripts/day to 72.3 scripts/day after the intervention. Orthopaedics was the department with the highest opioid prescribing rates both before and after intervention (figure 1). Out of the departments/divisions included in this analysis, family medicine had the lowest opioid prescribing rate both before and after intervention. The general surgery (0.8%, 95% CI 0.26% to 1.26% rate difference, p=0.003), haematology oncology (2.7%, 95% CI 2.15% to 3.28% rate difference, p<0.01), orthopaedics (7.4%, 95% CI 6.57% to 8.26% rate difference, p<0.001), family medicine (2.6%, 95% CI 2.22% to 2.97% rate difference, p<0.001) and pain medicine (2.6%, 95% CI 2.07% to 3.04% rate difference, p<0.01) departments/divisions all saw statistically significant decreases in opioid prescribing rates after intervention. Meanwhile, no significant change in rates of opioid prescribing was seen in emergency medicine and general medicine after intervention.

Discussion

The results of this study were largely encouraging for the effectiveness of this institutional mandatory prescriber training. Overall opioid prescribing rates decreased by 18.3% and there were significant decreases in opioid prescribing in five out of the seven departments/divisions. Additionally, there were statistically significant increases in compliance with CDC guidelines in three departments/divisions (general surgery, orthopaedics and haematology-oncology). This indicates that, mandatory prescriber training is an effective tool in improving responsible opioid prescribing.

The orthopaedic surgery department and haematology-oncology division are the two service lines with the highest rates of opioid prescribing, accounting for over one-third of all opioid prescriptions written by providers annually. Both of the departments showed a significant decrease in opioid prescribing rates and significantly increased compliance with CDC guidelines, highlighting the impact provider education can have on patient care.

Additionally, haematology-oncology had the lowest rates of compliance with CDC guidelines both preintervention and postintervention when compared with other departments. This is likely owing to the fact that many of their patients, due to status as patients with chronic pain or palliative care, do not fit the populations (eg, patients with acute pain) that the guidelines are intended for. To better evaluate the appropriate management of acute pain in haematology-oncology, a study involving chart review, which could isolate only cases of acute pain management, would be necessary.

However, the training did not improve the prescribing practices in every department. Orthopaedics and haematology-oncology both prescribe opioids at a high rate, therefore, have the opportunity to practice appropriate opioid prescribing with greater frequency, making it more likely that the education they received would affect their practice. However, with the exception of general surgery, the specialties with lower preintervention rates of opioid prescribing did not improve in CDC compliance, although some did improve in opioid prescribing rates. It is possible that these providers may have found it more difficult to recall the specific CDC guidelines in practice, while they did take away the importance of judicious opioid prescribing. In other words, there may have been a change toward prescribing opioids in general, but not a focus on the particulars of the actual opioid prescription. It is possible that clinicians may not have taken the time to calculate MME’s prior to prescribing when they did prescribe. Thus, the overall number of prescriptions decreased, but those prescribed were not in compliance with CDC guidelines.

Although the prior above analysis attempts to explain the lack of improvement in CDC compliance in departments with less frequent preintervention opioid prescribing, it is not sufficient to explain the paradoxical decrease in compliance with CDC guidelines in the emergency medicine and general medicine departments. Additionally, these same departments were the only departments to not see a statistically significant decrease in opioid prescribing rate after the intervention. It is possible that, due to the academic medical centre’s status as a safety net hospital, an increasing number of uninsured patients relied on the emergency and general medicine departments for their primary care, leading to increasing rates of opioid prescribing as well as increased opioid prescribing for chronic conditions. It may also have been a factor of the intervention itself decreasing inappropriately prescribed prescriptions that pushed patients from other service lines to seek opioid prescriptions in the emergency department or from their primary care internists or hospitalists. As the CDC guidelines used in this study apply to acute pain management, this may also explain the apparent decrease in CDC compliance seen in these departments. However, additional studies are needed to further investigate these hypotheses.

Despite having a preintervention opioid prescribing rate similar to that of general medicine and emergency medicine, general ssurgery improved in both CDC compliance as well as opioid prescribing rate. This is likely due to a confounding factor, as during September 2019, the same time of this intervention, the general surgery department implemented additional trainings on appropriate opioid prescribing. Given the general surgery department’s excellent compliance with CDC guidelines, their additional trainings may be a valuable resource for other departments who are currently struggling with compliance to the CDC guidelines.

A limitation of this study is the unequal time of data collection before and after intervention. More data were originally intended on being collected postintervention, but due to concerns of the COVID-19 pandemic confounding the data due to significant volume swells and lapses, the study period was cut short. We, therefore, cannot draw conclusions about the long-term efficacy of this intervention.

Another limitation of this study was that there was no control group. Others have educated an intervention group and not educated the control group.14 The authors did not have the opportunity to perform this type of study because the hospital administration was convinced that opiate prescribing education was necessary for medical staff.

Another limitation was that the study was not designed to analyse asssociations in order to account for clustering.

One of the additional strengths of our study was to show how an electronic health record can provide easily discoverable MME and MDD metrics. This has been shown by others as well.15

Conclusions

Opioid overdose continues to claim thousands of lives annually. Medical providers have an obligation to judiciously prescribe opioids in the acute setting to prevent continued worsening of this national epidemic. This study suggests the effectiveness of mandatory training in improving opioid prescribing practices at an urban academic medical centre in a mid-sized city, most notably in departments/divisions most commonly prescribing opioids. It is important and encouraging to learn, as the opioid epidemic continues claim more lives each year, that mandatory provider trainings may be one of many successful tools mitigating the unintentional and detrimental role that inappropriate opioid prescribing can have. However, some departments saw worsening compliance with guidelines after the intervention. This phenomenon needs to be studied further and these departments may require further education to improve prescribing practices.