J. B. Bach1, K. T. Anderson1,2, D. M. Ferguson1,2, M. A. Bartz-Kurycki1,2, A. L. Kawaguchi1,2, M. T. Austin1,2, K. P. Lally1,2, K. Tsao1,2 1McGovern Medical School at UTHealth,Department Of Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Department Of Pediatric Surgery,Houston, TX, USA
Introduction: Opioid prescriptions, commonly written for post-operative pain, are an important component of the opioid epidemic. While physician awareness of excessive opioid prescribing has increased, few surgeon-level interventions for prescription reduction have been described. The aim of this study was to evaluate the impact of a simple audit and feedback intervention on pediatric surgeon opioid prescriptions in post-operative appendectomy patients at discharge.
Methods: Pediatric (<18 years) patients who underwent appendectomy for simple appendicitis from October 2016 through May 2018 were included in a retrospective review of discharge opioid prescriptions. Patients were discharged from a tertiary care Children’s Hospital located in a state in which only fully-licensed (primarily attending) physicians can prescribe out-of-hospital opioids. Prescription data were captured from a state prescription monitoring program database. At the end of October 2017, discharge opioid prescriptions for simple appendectomies over the previous 6 months were audited. These data were fed back to attending pediatric surgeons in a 10-minute presentation, providing descriptive statistics of their opioid prescribing patterns as a group. No specific guideline was established regarding opioid prescribing. The Cochran-Armitage test for trend was used to evaluate for prescription trends over time. Student’s t-test, Wilcoxon rank sum and test for trend were used to compare pre- (10/1/16-10/31/17) and post- (11/1/17-5/31/18) intervention dosing.
Results:Amongst the nine attending pediatric surgeons, opioid prescriptions at discharge for pediatric patients with simple appendicitis decreased significantly over time, (p<0.005) from a zenith of 84% of patients receiving a prescription in January 2017 to 0% receiving a prescription in February and March 2018. Morphine milliequivalents per day (mme/d) prescribed also declined significantly in mean dose (20.5 mme/d ± 12.7 pre-intervention vs. 16.5 mme/d ± 13.6 post-intervention, p<0.005) . Number of days for which opioids were prescribed also decreased from a median of 5 days (IQR 3-6) to a median of 3 days (IQR 3-4), p=0.05.
Conclusion: Although the rate of opioid prescription was already falling, a simple educational intervention dramatically accelerated the rate of decline. Audit and feedback of individual or local group prescribing practices may help prescribers recognize their contribution to unnecessary opioid use.
