Inconsistency in Opioid Prescribing Practices After Pediatric Ambulatory Hernia Surgery

j o u r n a l o f s u r g i c a l r e s e a r c h  s e p t e m b e r 2 0 1 9 ( 2 4 1 ) 5 7 e6 2

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Inconsistency in Opioid Prescribing Practices After Pediatric Ambulatory Hernia Surgery Naomi-Liza Denning, MD,b,* Charlotte Kvasnovsky, MD, PhD,a Jamie M. Golden, MD, PhD,b Barrie S. Rich, MD,a,b and Aaron M. Lipskar, MDa,b a

Cohen Children’s Medical Center, Northwell Health System, Division of Pediatric Surgery, New York, New York b Zucker School of Medicine at Hofstra/Northwell Health System, Department of Surgery, Manhasset, New York

article info

abstract

Article history:

Introduction: Nonmedical opioid use is a major public health problem. There is little stan-

Received 7 December 2018

dardization in opioid-prescribing practices for pediatric ambulatory surgery, which can

Received in revised form

result in patients being prescribed large quantities of opioids. We have evaluated the

25 February 2019

variability in postoperative pain medication given to pediatric patients following routine

Accepted 22 March 2019

ambulatory pediatric surgical procedures.

Available online xxx

Methods: Following IRB approval, pediatric patients undergoing umbilical hernia repair, inguinal hernia repair, hydrocelectomy, and orchiopexy from 2/1/2017 to 2/1/2018 at our

Keywords:

tertiary care children’s hospital were retrospectively reviewed. Data collected include

Opioids

operation, surgeon, resident or fellow involvement, utilization of preoperative analgesia,

Pediatric surgery

opioid prescription on discharge, and patient follow-up.

Narcotic prescribing

Results: Of 329 patients identified, opioids were prescribed on discharge to 37.4% of pa-

Ambulatory surgery

tients (66.3% of umbilical hernia repairs, 20.6% of laparoscopic inguinal hernia repairs,

Pediatrics

and

Practice patterns

orchiopexies]). For each procedure, there was large intrasurgeon and intersurgeon

33.3%

of

open

inguinal

hernia

repairs

[including

hydrocelectomies

and

variability in the number of opioid doses prescribed. Opioid prescription ranged from 0 to 33 doses for umbilical hernia repairs, 0 to 24 doses for laparoscopic inguinal repairs, and 0 to 20 doses prescribed for open inguinal repairs, hydrocelectomies, and orchiopexies. Pediatric surgical fellows were less likely to discharge a patient with an opioid prescription than surgical resident prescribers (P < 0.01). In addition, surgical residents were more likely to prescribe more than twelve doses of opioids than pediatric surgical fellows (P < 0.01). Increasing patient age was associated with an increased likelihood of opioid prescription (P < 0.01). There were two phone calls and two clinic visits for pain control issues with equal numbers for those with and without opioid prescriptions.

* Corresponding author. Zucker School of Medicine at Hofstra/Northwell, Cohen Children‫׳‬s Medical Center, 269-01 76th Avenue, CH 158, New Hyde Park, New York, NY 11040. Tel.: 516-562-2259; fax: þ718 347-1233. E-mail address: [email protected] (N.-L. Denning). 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.03.043

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j o u r n a l o f s u r g i c a l r e s e a r c h  s e p t e m b e r 2 0 1 9 ( 2 4 1 ) 5 7 e6 2

Conclusions: There is significant variation in opioid-prescribing practices after pediatric surgical procedures; increased awareness may help minimize this variability and reduce overprescribing. Training level has an impact on the frequency and quantity of opioids prescribed. ª 2019 Elsevier Inc. All rights reserved.

Introduction The opioid epidemic in the United States has been widely discussed in the popular press. Media coverage occasionally pinpoints physician prescription of opioids as one of the initial instigating factors in the opioid public health crisis.1,2 This assignment of culpability is not without cause; in the United States, opioid deaths involving prescription drug overdose were five times higher in 2016 than 1999. During this time frame, there have been more than 200,000 deaths from prescription opioid overdose.3 Several recent studies have demonstrated that across medical and surgical specialties, there are significant variations in the dosage, frequency, and quantity of opioids prescribed to adult patients for the treatment of similar ailments.4-6 Given the common utilization of opioids for analgesia after surgical procedures, the opioidprescribing practices of surgeons warrant particular consideration. Among surgical patients, data indicate that approximately 3%-10% of adult opioid naive patients who receive opioid prescriptions after surgery continue to take opioids up to a year postoperatively. These percentages are not significantly different between low-pain, short-stay procedures, and major abdominal surgery.7-9 More than 70% of the opioids prescribed go unused by the patient for whom the medication was prescribed.10 This creates the opportunity for opioid diversion and misuse. In the adult surgical population, efforts are underway to improve postoperative opioid stewardship through implementation of institution-specific guidelines. These guidelines are frequently based on retrospective data examining prescriber variability, patient pain scores, and careful consideration of patient risk factors for opioid abuse or diversion.11-13 However, there is a relative paucity of such data in the pediatric surgical population, rendering these guidelines difficult to extrapolate and implement in the pediatric population. A 2017 study based on insurance industry data provided evidence of significant variability in opioidprescribing practices after pediatric ambulatory surgery14 but did not provide sufficient information about interhospital or intrahospital variability and lacked follow-up data. A recent study demonstrated that among opioid naı¨ve adolescents undergoing a surgical procedure and prescribed an opioid on discharge, persistent opioid use, as defined as occurring more than 90 days postoperatively, was found in almost 5% of patients.15 Further highlighting a drawback of opioid prescriptions for children, a 2018 study by Anderson et al. demonstrated that patients prescribed opioids on discharge after simple appendectomy had increased complications including a 3.3x higher odds ratio of postoperative emergency department visits, most of which were for constipation-related abdominal pain.16 In addition, a 2018 study by Cartmill et al. suggests that nearly 50% of patients undergoing umbilical hernia repair fill an opioid prescription

postoperatively. The percentage of patients that filled prescriptions varied based on geographical location and age of the patient. Furthermore, 6% of patients refilled an opioid prescription; this did not depend on the duration of initial opioid prescription.17 Identifying specific factors, particularly modifiable factors, impacting the inconsistency in opioid-prescribing practices is necessary before standardization can occur, which would pave a path for a reduction in narcotic prescribing. The development and implementation of these guidelines to assist in opioid stewardship in the pediatric population is crucial. Our study is a retrospective review of opioid-prescribing practices and their associated factors at a tertiary care children’s hospital after ambulatory hernia repair.

Methods After Institutional Review Board approval, the records of all children undergoing umbilical hernia repair (UHR), laparoscopic (LHR) or open inguinal hernia repair (IHR), hydrocelectomy (HC), and orchiopexy (OP) by the Division of Pediatric Surgery from 2/1/2017 to 2/1/2018 at our tertiary care children’s hospital were retrospectively reviewed. A waiver of informed consent was obtained. All pediatric patients under 18 years of age undergoing the above procedures were initially reviewed. Children were excluded from analysis if they underwent a concomitant nonambulatory procedure. Patients were also excluded for emergent procedures for incarcerated hernias with compromised viscera. Patients were classified according to the primary procedure as designated by the operative surgeon. This results in some overlap among the types of hernia repair, but each patient was only analyzed according to primary procedure. Demographics including age, weight, body mass index, and comorbidities were collected. Surgeon of record and surgical resident or fellow involvement was tracked. Umbilical hernia size, in centimeters, as documented in the formal operative dictation was noted. Operative details including the utilization of regional blocks, the intraoperative use of intravenous acetaminophen, ketorolac, narcotics, or benzodiazepines, and any concomitant procedures were recorded. Frequency and quantity of opioid prescriptions were tracked. Recommendations for acetaminophen or ibuprofen on discharge were also examined. We defined high quantity of opioid prescription as at least 12 doses given at discharge. Follow-up data were analyzed for telephone calls or clinic visits for inadequate postoperative pain control. Thirtyday readmission rates and emergency department visits were also studied. Statistical analysis was performed with unpaired t-tests or one-way analysis of variance for continuous data and a zscore for two population proportions for categorical data.

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denning et al  inconsistency in pediatric opioid prescribing

Table 1 e Patient demographics by procedure. Number of patients

Age, y mean  SD (range)

Male

Weight (kg)

BMI

UHR

101

6.1  3.7 (0.16-17.8)

49 (48.5%)

24.5  15.9

17.6  3.6

LHR

155

5.1  4.7 (0.08-17.9)

91 (58.7%)

21.3  18.0

16.9  2.6

IHR

57

5.3  4.6 (0.16-16.0)

42 (73.7%)

20.9  15.4

16.8  2.8

HC

8

4.1  3.5 (1.4-11.0)

8 (100%)

16.8  7.5

17.3  2.6

OP

8

4.0  2.6 (1.5-8.3)

8 (100%)

16.8  3.7

16.9  2.4

Procedure

Nonparametric Pearson’s correlation was used to assess relationship between umbilical hernia size and number of opioid doses prescribed. All continuous data are expressed as mean values  standard deviation. To further investigate variables involved in opioid prescribing practices, for patients undergoing umbilical hernia repair, we assessed univariate predictors of no, some (1-11 doses), and high (greater than 11) dose narcotics. We further performed a multivariate logistic regression for the prescription of high-dose opioids as compared to low-dose opioids, using risk factors significant on univariate analysis as well as those with biologic plausibility.

Results Three hundred twenty-nine patients were identified (101 UHR, 155 LHR, 57 IHR, 8 HC, and 8 OP). Patients ranged in age from 1 month to 17 years. Patients were 60.2% male. Patients were ethnically diverse, with 40.7% Caucasians, 29.2% AfricanAmericans, 10.3% Asians, 17.6% multiracial, and 2.2% of unknown ethnicity. Patient demographics by procedure are listed in Table 1. Patients were generally healthy but 25% had documented comorbidities ranging in severity from mild reactive airway disease to ex-prematurity and corrected congenital heart disease. Of the 101 UHR, 23 had concurrent procedures (14 laparoscopic inguinal hernia repairs, 2 hydrocele repairs, 3 epigastric hernia repairs, and 4 other minor procedures including circumcision, removal of supernumerary digit, and excision of benign soft tissue masses). Of the 57 IHR, 18 had one or more concurrent procedures (2 ventral hernia repairs, 14 hydrocelectomies, 2 circumcisions, and 1 dental restoration). Of the 155 LHR, 11 had concurrent procedures (5 umbilical hernia repairs, 1 orchiopexy, 3 circumcisions, 1 removal of benign skin lesion, and 1 direct laryngoscopy). Nonopioid analgesia was used frequently at our institution (Table 2). Regional nerve blocks were performed by the anesthesia department for 80.9% of cases. Open inguinal hernia

repairs had the lowest percentage of anesthesia-provided regional blocks, occurring only 54.4% of the time. However, local anesthesia was administered by the surgeon for almost all procedures where a regional block was not performed. Intravenous acetaminophen was utilized intraoperatively in 74.5% of cases and ketorolac was used in 38.9% of patients. As a result, intraoperatively, opioids and benzodiazepines were used in 55.3% and 8.5% of cases, respectively (Table 2). Opioids given postoperatively in the recovery room were not tracked; however, as these were ambulatory surgeries, patients would not typically remain in the recovery room for a long enough time frame to receive more than one dose of opioids. Furthermore, anesthesia postoperative order sets typically include at least one PRN dose of opioid at our institution. Opioids were prescribed on discharge to 37.4% of patients (66.3% of UHR, 20.6% of LHR, and 33.3% of IHR, including HC and OP), with 123 total opioid prescriptions being written. For all procedures, there was large intrasurgeon and intersurgeon variability in the number of opioid doses prescribed (P < 0.01). Opioid prescription ranged from 0 to 33 doses for UHR, 0 to 24 doses for LHR, and 0 to 20 doses prescribed for IHR, HC, and OP. Descriptive statistics for each procedure are listed in Table 3. Opioid dose distribution by surgeon is displayed in Figure. Among UHR, there was a small correlation between hernia size and number of opioid doses prescribed, with a pattern of the smaller hernia defects being prescribed none or a lower number of opioid doses than larger defects, Spearman correlation coefficient r ¼ 0.22 (P < 0.05). Increasing patient age was associated with an increased likelihood of opioid prescription (P < 0.01), with 1.5% of children under 1 year of age being prescribed opioids as compared to 91.6% of children aged 15 to 17 y (Table 4). Although customary practice among attending surgeons at our institution is to verbally instruct patients and parents to schedule acetaminophen or ibuprofen for the first few postoperative days, review of discharge paperwork indicates that 88.8% of our patients were discharged with written instructions recommending acetaminophen or ibuprofen usage on an as-needed basis. Discharge

Table 2 e Intraoperative medication utilization. Procedure

Preoperative regional block

IV acetaminophen in OR

Ketorolac in OR

Opioid in OR

Benzodiazepine in OR*

UHR

94 (93.1%)

67 (66.3%)

44 (43.6%)

57 (56.4%)

14 (13.9%)

LHR

130 (83.8%)

122 (78.7%)

56 (36.1%)

78 (50.3%)

7 (4.5%)

IHR/HC/OP

42 (60.3%)

56 (76.7%)

28 (38.4%)

47 (64.4%)

7 (9.6%)

*

Some benzodiazepine given preoperatively as an anxiolytic; included in the anesthesia electronic medical record.

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Table 3 e Characteristics of opioid prescriptions by procedure. Procedure

Range, number of opioid doses prescribed

Number of opioid doses prescribed, Average  SD

Number of opioid doses, Average  SD among patients prescribed opioids

% of patients discharged with opioid prescription

Range, percentage of patients prescribed opioids, by surgeon

UHR

0-33

9.5  8.5

14.3  6.1

66.3%

0%-83.3%

LHR

0-24

2.2  4.7

10.5  4.4

20.6%

5%-66.6%

IHR/HC/OP

0-20

3.8  5.9

11.4  4.1

32.9%

0%-45.8%

paperwork for four patients (1.2%) instructs parents to schedule acetaminophen and ibuprofen. Two patients (0.6%) were instructed to schedule acetaminophen, and 9.4% of patients were discharged with paperwork that did not mention acetaminophen or ibuprofen. At our institution, there are seven attending pediatric surgeons. Our institution employs one new pediatric surgical fellow per year, each for a 2-y fellowship, resulting in three different fellows during this study. During this time frame, approximately 40 surgical residents of differing post graduate years rotated on the pediatric surgical service. Despite having done only 35% of the cases, of the 123 total opioid prescriptions, 75 (61%) were written by surgical residents. Pediatric surgical fellows were less likely to discharge a patient with an opioid prescription than surgical resident prescribers (P < 0.001). Figure contains a graphical representation of the number of opioid doses prescribed according to training level of the prescriber. Pediatric surgical fellows discharged a

patient without an opioid prescription in 72.6% of cases. In comparison, surgical residents only discharged a patient without an opioid prescription in 34.8% of cases. Among patients who were discharged with an opioid prescription, 33.3% were prescribed greater than 12 doses of opioid. Twelve doses are equivalent to 3 d of opioid given every 6 h. Surgical residents were significantly more likely to prescribe more than 12 doses of opioids than pediatric surgical fellows (P < 0.01). Of all opioid prescriptions, 17.9% were written for 20 or more doses. This corresponds to 17.8% of patients undergoing UHR (26.9% of all opioid prescriptions for UHR), 1.3% of patients undergoing laparoscopic inguinal hernia repair (6.3% of all opioid prescriptions for LHR), and 2.7% of patients undergoing IHR (8.3% of all narcotic prescriptions for IHR). To better understand differences in prescribing practices, we assessed risk factors for the prescription of a high number of doses (greater than 11 tablets) in children undergoing UHR. Of 96 UHR where the first assistant and/or prescriber was a

Fig e Number of Opioid Doses Prescribed after Hernia Repair by Surgeon. There were significant differences in the number of narcotic doses prescribed by each surgeon. Graphs along the top row display all doses prescribed, organized by surgeon, superimposed on a line pot, with horizontal lines indicating mean and standard deviations. Graphs along the bottom row display all doses prescribed, classified by training level of the prescriber, superimposed on a box plot with horizontal lines indicating mean and standard deviation.

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denning et al  inconsistency in pediatric opioid prescribing

Table 4 e Percentage of patients prescribed opioids, by age. Age

Total number of patients

Number of patients prescribed opioids

Age  1

65

1 (1.5%)

1 < age  2

28

2 (7.1%)

2 < age  5

85

21 (24.7%)

5 < age  10

106

63 (59.4%)

10 < age  12

13

10 (76.9%)

12 < age  15

20

15 (75%)

15 < age < 18

12

11 (96.7%)

Total

329

123 (37.4%)

resident or fellow, 43 patients (44.8%) were discharged with at least 12 doses of narcotic. Odds of discharge with high-dose opioids were highest when the prescriber was a resident (OR 8.51 [95% CI 2.90-24.98], P < 0.0001 and with each year of increasing age (Table 5). On multivariate analysis, the assistance of a resident remained the strongest predictor, with odds of high opioid prescription 7.66 times those of when a fellow was assisting (95% CI 2.01-29.18, P ¼ 0.0003). Among the 329 patients, there were two readmissions within 30 d of the procedure. One patient developed appendicitis, and another infant was admitted to the intensive care unit with a viral respiratory illness. There were 11 emergency department visits within 30 d of the procedure. Six of those visits were for viral gastrointestinal or respiratory illnesses. Two visits were for constipation, one in a patient discharged with opioids and one in a patient discharged without opioids. Three patients presented whose parents were concerned about the surgical site; none required any intervention. There were two telephone calls and two clinic visits for inadequate pain control with equal numbers for those with and without opioid prescriptions. There were no refills of opioid prescriptions.

Discussion Consistent with previously published literature, there was a wide range in the frequency and quantity of opioid prescriptions among individual surgeons and between surgeons for the same procedure. More alarming, nearly 18% of opioid

prescriptions were written for 20 or more doses for an ambulatory, minimally invasive surgical procedure. Interestingly, surgical residents were more likely than pediatric surgical fellows to discharge a patient with an opioid prescription. Surgical residents were also more likely to prescribe a larger quantity of opioids than pediatric surgical fellows. The cause of these findings is likely multifactorial and may include the fact that surgical residents are more accustom to prescribing their adult patients a larger quantity of narcotics or that fellows, who care for pediatric patients daily, are more mindful of the special needs of children. Our data demonstrate that patients undergoing UHR were prescribed opioids with higher frequency and with more doses than patients undergoing LIH or IHR. This is consistent with the fact that surgical residents were the primary assistant in 67.3% of UHR as compared to 14.2% of LHR and 24.7% of IHR/ HC/OP. The differential in opioid-prescribing practices between surgical residents and surgical fellows suggests that level of training impacts opioid-prescribing practices. Our study is limited by its retrospective nature. Furthermore, we were only able to identify narcotics prescribed and could not quantify the number of prescriptions filled. In addition, the number of pediatric surgery fellows included in this study may be a limitation, as person-specific factors may be at play. Furthermore, opioid requirements in the postoperative care unit were not investigated and may have impacted the quantity of opioids prescribed for some children. Finally, patient factors such as pain tolerance, previous postoperative experiences, and parental requests were not accounted for in this analysis. Our data suggest that standardized institution-specific postoperative prescription guidelines for ambulatory hernia repair may be beneficial. These data are likely generalizable to other ambulatory pediatric surgical procedures at our institution. Standardized guidelines would eliminate high quantity prescribing for low-pain procedures. In addition, education regarding opioid-prescribing practices should be increased. Given the stark differences between the prescribing practices of residents and fellows, education interventions aimed at residents and increased resident supervision from attending surgeons and fellows may reduce opioid prescriptions, a first step in the reduction of opioid usage. It should be noted that after this study period we performed an educational session on opioid stewardship for umbilical hernia repair as part of a multicenter trial. This session was presented to all the faculty in Division of Pediatric surgery,

Table 5 e Univariate and multivariate factors associated with high quantity opioid prescription following ambulatory umbilical hernia repair. Patient characteristics

Point estimate (95% CI)

P Value

Point estimate (95% CI)

P Value

Male

1.11 (0.50-2.47)

0.8

2.57 (0.83-8.01)

0.1

BMI  25

2.59 (0.23-29.51)

0.44

0.55 (0.04-8.32)

0.67

Resident*

8.51 (2.90-24.98)

<0.0001

7.66 (2.01-29.18)

0.003

Age

1.20 (1.06-1.36)

0.004

1.25 (1.04-1.49)

0.02

Defect size

1.11 (0.79-1.58)

0.54

1.46 (0.97-2.20)

0.07

Significant P values are highlighted with bold type. * Resident both assisting and/or prescribing, versus fellow assisting and/or prescribing.

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and we subsequently saw a significant decrease both in the number of prescriptions written and the quantity of doses in each prescription. Increased education and standardized protocols will hopefully play a role in reducing the likelihood of persistent opioid usage, recreational usage, and/or opioid diversion.

Acknowledgment All authors have made substation contribution to this article including study design, data acquisition and analysis and drafting and critical revision of the article. Specifically, study design was conducted by A.L. and B.R. Data collection and data analysis and interpretation was performed by N.L.D., C.K., and J.G. Article was drafted by N.L.D., and critical revision was performed by N.L.D., C.K., J.G., B.R., and A.L. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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