Reducing Opioid Overprescription in Outpatient General Surgery
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This document discusses reducing overprescription of opioids in outpatient general surgery at the University of Utah. It finds that prescription practices for common procedures like laparoscopic cholecystectomy vary widely between surgeons, with some prescribing far more opioids than estimated patient need. A proposed intervention is to standardize opioid prescriptions for certain procedures through use of order sets. This is expected to significantly reduce the number of opioids prescribed without negatively impacting patient satisfaction or management of acute post-operative pain. Outcomes will be evaluated by analyzing prescription data and conducting patient surveys.
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Reducing Opioid Overprescription in Outpatient General Surgery
- 1. © U N I V E R S I T Y O F U T A H H E A L T H , REDUCING OVERUSE OF OPIOID PRESCRIPTIONS IN OUTPATIENT GENERAL SURGERY SURGERY VALUE SYMPOSIUM BENJAMIN BROOKE, MD, AUSTIN CANNON, MD, ADAM DZUIBA, MD, LILY GUTNIK, MD, LUKE MARTIN, MD, SEAN STOKES, MD, MARK TAYLOR, MD
- 2. © U N I V E R S I T Y O F U T A H H E A L T H , DISCLOSURES • None
- 3. © U N I V E R S I T Y O F U T A H H E A L T H , Defining the Problem
- 4. © U N I V E R S I T Y O F U T A H H E A L T H ,
- 6. © U N I V E R S I T Y O F U T A H H E A L T H , ”Until clinicians stop prescribing opioids far in excess of clinical need, this crisis will continue unabated.” Califf RM,Woodcock J, Ostroff S. A proactive response to prescription opioid abuse. New Engl J Med. 2016;374:1480–1485. Robert Califf, MD Former Commissioner of the FDA
- 7. © U N I V E R S I T Y O F U T A H H E A L T H , Acute Pain Over Rx How much do prescription practices vary at the University of Utah for common general surgery procedures? Hypothesis: Outpatient general surgery prescription practices vary widely and standardization will reduce cost and narcotic over-prescription without effects on patient satisfaction OUR QUESTION
- 8. © U N I V E R S I T Y O F U T A H H E A L T H , Analysis/Investigation
- 9. © U N I V E R S I T Y O F U T A H H E A L T H , WHERE CAN WE MAKE A DIFFERENCE?
- 10. © U N I V E R S I T Y O F U T A H H E A L T H , PRESCRIBED TAKEN • Partial mastectomy • Partial mastectomy + SLNB • Laparoscopic cholecystectomy • Laparoscopic Inguinal Hernia Repair • Open Inguinal Hernia Repair
- 11. © U N I V E R S I T Y O F U T A H H E A L T H , • 17,167 tablets prescribed • 7,360 estimated tablets prescribed (42.8%) Estimated Need for post-operative General Surgery patients Partial mastectomy – 5 pills Partial mastectomy w/ SLNB – 10 pills Lap chole – 15 pills Lap IHR – 15 pills Open IHR – 15 pills
- 12. © U N I V E R S I T Y O F U T A H H E A L T H , “PORCA” – PAIN ORCA • Operating Room Cost Accountability (ORCA) • Pain “ORCA” = PORCA • Utility that allows tracking of prescribing practices by practitioner and CPT code
- 14. © U N I V E R S I T Y O F U T A H H E A L T H , LAPAROSCOPIC CHOLECYSTECTOMY (7/4/2016-6/29/2017) Surgeon (de-identified) AverageTabletsRx PercentTotalPopulation Tablets Prescribed15 tablets
- 15. © U N I V E R S I T Y O F U T A H H E A L T H , ESTIMATED IMPACT – LAP CHOLE • 421 lap chole cases • 11, 773 tablets prescribed (avg. 28 tabs/case) • Using proposed standardized Rx practice – Reduce to 6,315 tablets prescribed (53.6%)
- 16. © U N I V E R S I T Y O F U T A H H E A L T H , Proposed Intervention
- 17. © U N I V E R S I T Y O F U T A H H E A L T H ,
- 18. © U N I V E R S I T Y O F U T A H H E A L T H , ORDER SET • Standardize prescriptions for the procedures of interest – Lap chole – IHR – open and lap – VHR – Lumpectomy +/- SLNB
- 20. © U N I V E R S I T Y O F U T A H H E A L T H , Impact
- 21. © U N I V E R S I T Y O F U T A H H E A L T H , GOING FORWARD • Patient perception of acute pain management • Analysis of Rx practice within PORCA • Post-intervention patient perception Aug Sept Oct Nov Dec Jan Feb Mar Pre-intervention Survey Intervention Data Collection/Analysis
- 22. © U N I V E R S I T Y O F U T A H H E A L T H , PercentTotalPopulation Tablets Prescribed Overall Goal
- 23. © U N I V E R S I T Y O F U T A H H E A L T H , Questions?
- 24. © U N I V E R S I T Y O F U T A H H E A L T H , REFERENCES 1. Hill, Maureen V., et al. "Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures." Annals of surgery 265.4 (2017): 709-714. 2. Wunsch, Hannah, et al. "Opioids prescribed after low-risk surgical procedures in the United States, 2004- 2012." Jama 315.15 (2016): 1654-1657. 3. https://dopl.utah.gov/programs/csdb/ 4. Olsen, Yngvild. "The CDC guideline on opioid prescribing: rising to the challenge." Jama 315.15 (2016): 1577-1579. 5. Lillernoe, Keith D. "Annals of Surgery Looks at The Opioid Crisis." Annals of surgery 265.4 (2017). 6. Brummett, Chad M., et al. "New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults." JAMA surgery (2017): e170504-e170504. 7. Utah Department of Health Opioid Prescribing Guidelines 8. Hill, Maureen V., et al. "An Educational Intervention Decreases Opioid Prescribing After General Surgical Operations." Annals of Surgery (2017). 9. http://www.cnn.com/2016/09/23/health/heroin-opioid-drug-overdose-deaths-visual-guide/index.html
Editor's Notes
- Over the last two years, the so-called ”opioid epidemic” has gathered increased attention nationally. There have been a number of publications, both in the mainstream media and the scientific literature calling healthcare providers to action to help fight the opioid epidemic. This has been escalated to the include the top officials in the government including the former surgeon general, Dr. Vivek Murthy who puplished a special letter in the New England Journal in December of last year. President Obama appeared at the drug abuse summit in Atlanta pledging $22 million dollars to go toward medical treatment of opioid abuse as well as increasing patient limits for providers who treat these patients. 2012 – 82.5 opioid prescriptions were written per 100 persons, quadrupled since 1999 (3-7) Estimated to supply every adult American with 5 mg of hydrocodone every 6 hours for 45 days.
- Taking this to a more local level, the state of Utah is, unfortunately, high on the list of states that is combatting problem. #10 nationally.
- Given the magnitude of the opioid problem in this country, the logical next question is how are we, as surgeons, contributing. There have been studies after surgical procedures and in patients in the Emergency room, that first time Rx of opioids for acute pain can increase the likelihood of later addiction. This quote in a recent article in the NEJM summarizes our role in this crisis: 2012 – 82.5 opioid prescriptions were written per 100 persons, quadrupled since 1999 (3-7) Estimated to supply every adult American with 5 mg of hydrocodone every 6 hours for 45 days.
- So considering that we may be contributing to this crisis by prescribing far in excess of clinical need, we asked, “how much variation is there amongst surgeons in our institution for common general surgery procedures?” Our hypothesis was that outpatient Rx vary widely, and if we were to standardize these practices we would reduce cost and narcotic over-prescription.
- So how are we doing now? And where do we start?
- As part of our value project, we created this process map to identify areas where we can intervene in per—operative pain management. This describes four phases of care: the clinic pre-op appointment, pre-operative holding, the OR, and recovery. We identified these areas as places where we could intervene – pre-operative pain need assessment, managing patient expectations in clinic, the actual number of pain medications prescribed, and the d/c education given to the patient as they leave the hospital. We chose to focus on the number of pain medications prescribed as we felt we would have the the highest effect for a small intervention. If we change the number of medications we prescribe, we can decrease the excess narcotics given, but this leads to the difficult question: how many tablets do patients need?
- We took a look at the literature to help answer this. There hasn’t been much published regarding actual patient need, however during the course of this project, a study was published in Annals of Surgery looking at common general surgery procedures as listed. It took a subset of patients and looked at the prescriber variability of the pain medications handed out. The investigators then called patients post-operatively to identify how many medications were taken. As you can see, the amount of medicaiton prescribed is far in excess of what patients reported as to have taken. 2012 – 82.5 opioid prescriptions were written per 100 persons, quadrupled since 1999 (3-7) Estimated to supply every adult American with 5 mg of hydrocodone every 6 hours for 45 days. 5 common outpatient general surgery procedures performed in 2015 (partial mastectomy, partial mastectomy with SLNB, lap chole, lap inguinal hernia, open inguinal hernia) Contacted 330 patients, 147 patients answered, asked about opioid prescription and if they needed a refill. Excluded – recent opioid abuse and post-operative complications Calculated the “ideal” number of pills to prescribe for each operation by determining the number of pills that would satisfy approximately 80% of patients’ post-operative opioid use. Partial mastectomy – 5 pills Partial mastectomy w/ SLNB – 10 pills Lap chole – 15 pills Lap IHR – 15 pills Open IHR – 15 pills 17,167 pills prescribed to 642 patients, only 7360 would have been prescribed using the ideal numbers. 117/127 patients had excess pills, 9% disposed of excess opioids in FDA approved fashion
- As a result of their analysis, the investigators calculated their estimated clinical need for each procedure of interest. They estimated that they could have reduced their tablets prescribed by nearly 60% if they had followed the estimated need. Partial mastectomy – 5 pills Partial mastectomy w/ SLNB – 10 pills Lap chole – 15 pills Lap IHR – 15 pills Open IHR – 15 pills 17,167 pills prescribed to 642 patients, only 7360 would have been prescribed using the ideal numbers. 117/127 patients had excess pills, 9% disposed of excess opioids in FDA approved fashion
- So how are we doing? In order to answer this question, we used the unique resources at the University of Utah to develop a utility to have ease of access to pain medication prescriptions post-operatively arranged by CPT code.
- This is a screenshot of the PORCA tool when searching for the CPT codes for laparoscopic choleycstectomy. It gives complete characterization of the prescribing practices of the providers who perform lap choles under a specific date range
- Here is the data over the past year. This first graph is a good representation of the prescriber variability. This gives a snapshot of the mean tablets prescribed by surgon. As you can see the mean varies from ~18 to nearly 50 tablets after a lap chole. When we look at the number of tablets prescribed per patient, this second graph shows that mostly we give 20-30 tablets post-operatively have a cholecystectomy. When we overlay the 15 tablet recommendation from the prior paper, we are well over the estimated need for many patients.
- We can then estimate the impact of adopting this recommendation. 421 lap choles were performed during this time frame, and 11,773 tablets were prescribed for an average of 28 tablets per case. Using the proposed Rx practice, we would reduce this number to 6,315 tablets, 53.6% of our prior total.
- So our proposed intervention
- In Epic, we have the ability to change ordersets to reflect this recommendation
- When you scroll to discharge medications, we can alter the default numbers of tablets prescribed for specific medications listed
- We can also add in a chart with recommendations for different procedures similar to the Caprini score seen on the admission order-set
- Now that we have introduced an intervention, what is our plan going forward and monitoring of the impact.
- We are hoping to take a look, not just changes in prescriber practices, but also patient perception of their pain control after we institute this change. We are developing a patient satisfaction survey to be provided in general surgery clinics to see how patient’s perceive their pain control currently. We will then implement these Epic changes nad provide resident/attending education regarding the changes. We will then measure the outcomes as it relates to patient satisfaction and the raw changes of tablets prescribed.
- Our hope is that, after instituting this basic change, we are able to shift our curve to the left, without affecting acute pain control.