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Specialty-specific reduction in opioid prescribing after common pediatric surgical operations
YJPSU-59095; No of Pages 4 Journal of Pediatric Surgery xxx (xxxx) xxx
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Specialty-specific reduction in opioid prescribing after common pediatric surgical operations Joshua D Horton a,⁎, Suqrat Munawar a, Ariana Feuvrier b, Corinne Corrigan c, Mark Lockett d, David White a, Robert A Cina b a
Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA Division of Pediatric Surgery, Department of General Surgery, Medical University of South Carolina, Charleston, SC, USA Division of Pediatrics, College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA d Department of General Surgery, Medical University of South Carolina, Charleston, SC, USA b c
a r t i c l e
i n f o
Article history: Received 15 October 2018 Received in revised form 5 February 2019 Accepted 10 February 2019 Available online xxxx Key words: Opioids Postoperative pain Quality improvement Education
a b s t r a c t Background: Opioid misuse has reached epidemic proportions, and postoperative opioids have been linked to overdose, diversion, and dependency. We recently found our opioid prescribing practices following common pediatric operations to be inconsistent and excessive. In this study, we evaluate the efficacy of an educational intervention on opioid prescriptions following tonsillectomy and hernia repair. Methods: Retrospective chart review of prescriptions following outpatient tonsillectomies and hernia repairs at a single institution before and after an educational intervention was performed. The intervention consisted of a single campus-wide grand rounds presentation detailing the surgeon's role in the opioid epidemic. Results: Postoperative opioid prescriptions were significantly reduced for hernia repair following the educational intervention: 4.2 ± 2.9 vs 2.7 ± 2.6 days' supply (p = 0.004). Such a reduction was not observed for post-tonsillectomy opioid prescriptions: 6.3 ± 4.4 vs 5.4 ± 3.0 days' supply (p = 0.226). A greater decrease in interprovider variation was observed for hernia providers after the educational intervention than for tonsillectomy providers, though significant variation continued to be present for both procedures after the intervention. Conclusions: The efficacy of an educational intervention at reducing postoperative pediatric opioid prescribing may be tied to the specialty-specific role model relationship of the educator to the prescriber. Type of study: retrospective comparative chart review. Level of evidence: IV. © 2019 Elsevier Inc. All rights reserved.
Opioid abuse and overdose in adults are on the rise in the United States and continue to receive ever-increasing media coverage in not only the lay-press but also the medical literature [1–3]. Unfortunately, pediatric patients are not immune from the opioid predicament [2,4], with increasing reports of the deleterious effects being witnessed in pediatric patients, especially adolescents [5,6]. Surgeons are significant contributors to opioid overprescription and proportionally contribute to prescription drug-related patient deaths [3]. Approximately 5% of opioid naïve pediatric patients develop new persistent opioid use postoperatively, including after hernia repair or tonsillectomy, the most commonly performed pediatric surgical operations [7]. Diversion of opioids following surgery is also a public health
concern and only 5%–60% of postoperative opioids are consumed for the purposes for which they were prescribed [8]. Perhaps most concerning, more than 20% of adolescent homes contain leftover opioid medications and in 60% of these cases, parents intend to keep the opioids for possible future use by themselves or others [9]. We recently evaluated our opioid prescribing practices following hernia repair and tonsillectomy and found them to be inconsistent and excessive [10]. Recent literature has demonstrated a positive role for provider education in significantly reducing postoperative opioid prescriptions [11,12] and in this study, we sought to improve our opioid prescribing practices following pediatric hernia repair and tonsillectomy by enacting such an intervention.
Abbreviations: CPT, current procedural terminology; APAP, acetyl-para-aminophenol (acetaminophen); NSAID, nonsteroidal anti-inflammatory drug; ED, emergency department; REDCap, research electronic data capture; SPSS, statistical package for the sciences; MM, multimodal. ⁎ Corresponding author at: Department of Otolaryngology–Head and Neck Surgery, 135 Rutledge Ave, MSC 550, Charleston, SC 29425. Tel.: +1 843 830 6271. E-mail address: [email protected] (J.D. Horton).
1. Methods We conducted a retrospective review of outpatient tonsillectomies and hernia repairs for one year prior to (January 1, 2017 to December 31, 2017) and four months after (January 3, 2018 to May 3, 2018) the opioid educational intervention (described below). For tonsillectomy,
https://doi.org/10.1016/j.jpedsurg.2019.02.008 0022-3468/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: J.D. Horton, S. Munawar, A. Feuvrier, et al., Specialty-specific reduction in opioid prescribing after common pediatric surgical operations, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.02.008
2
J.D. Horton et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
current procedural terminology (CPT) codes 42820 and 42825 were included and children aged 6 to 12-years-old were evaluated. For umbilical/inguinal hernia repair, CPT codes 49491–96, 49500–07, 49520–21, 49580–87, and 49650–53 were included and children aged 1 to 18-years-old were evaluated. Only patients undergoing outpatient elective surgery were included. Data were retrieved from the medical record including patient demographics, opioid type and dose, multimodal prescription type and dose (acetyl-para-aminophenol [APAP, acetaminophen], nonsteroidal anti-inflammatory drug [NSAID, ibuprofen]). Hydrocodoneacetaminophen oral solution and oxycodone oral solution were the two prescribed opioids for these procedures during the study period. There was significant variation between weight-based and nonweight-based dosing and frequency (every 4 hours as needed vs every 6 hours as needed), so opioid prescriptions were converted to “days' supply” for comparison. “Days' supply” was defined as the number of days a given opioid prescription would last if the patient took a prescribed dose at every possible interval time (every 4 hours or every 6 hours postoperatively) until depleted. As prescriptions were only every 4 or 6 hours, a 5 days' supply (for example) corresponds to 20–30 weight-based doses of opioid being dispensed. It is our institutional policy that children less than six years-old undergoing tonsillectomy (an extrapolation of the FDA black box warning for codeine after tonsillectomy) and less than one year-old undergoing hernia repair not be prescribed opioids as postoperative pain control. Data on individual providers were also retrieved and providers were evaluated if they prescribed three or more opioid prescriptions during the given study period. All included providers were resident physicians and there was no overlap between the specialties (i.e. no otolaryngology residents rotating on general surgery and prescribing opioids after hernia). No advanced practice providers or attending physicians wrote prescriptions included in the study data. Study data were collected and managed using REDCap electronic data capture tools hosted by the Medical University of South Carolina [13]. REDCap (Research Electronic Data Capture) is a secure, webbased application designed to support data capture for research studies, providing 1) an intuitive interface for validated data entry; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for importing data from external sources. On January 2, 2018, campus wide surgical Grand Rounds were hosted by the Department of General Surgery at our institution. The topic of the presentation was The Surgeon's Contribution to the Opioid Epidemic and all surgical subspecialty attending physicians, house staff, and advanced practice providers were expected to attend and were freed of clinical responsibilities during the presentation. The grand rounds consisted of a one hour presentation detailing the recent literature on postoperative opioid prescribing, patient use, diversion, and complications. Attendance was not taken. Given by general surgery faculty, the presentation discussed literature pertaining to several different surgical subspecialties. At the conclusion, a pamphlet was distributed which made specific opioid quantity recommendations for the most common general surgery procedures, including hernia repair. There
was a suggestion that each subspecialty generate and distribute similar recommendations for their specialties based on the subspecialty literature; this did not occur for Otolaryngology during the study period. Statistical Package for the Social Sciences (SPSS), version 23.0 (IBM SPSS, Chicago, IL) was used for data analysis. Continuous data are reported as mean and standard deviation. Normality of data was determined by Shapiro–Wilk test. Student's t-test was used to compare two normally distributed means. One-way ANOVA and chi-squared contingency tables were used for nonparametric comparison. Values were considered significant at the level of p b 0.05. This study was deemed exempt from Institutional Review Board evaluation and patient consent as it met criteria as a Medical University of South Carolina Quality Improvement Project (adapted from the University of WisconsinMadison's “IRB QI/Program Evaluation Self-Certification Tool”). 2. Results The pre-education cohort (January 1, 2017–December 31, 2017) included 180 hernia repairs and 140 tonsillectomies and the post-education cohort (January 3, 2018–May 3, 2018) included 61 hernia repairs and 40 tonsillectomies. Mean age for hernia repair pre-education was 5.0 ± 3.4 and post-education was 5.2 ± 2.8 (p = 0.67). Mean age for tonsillectomy was 7.9 ± 1.5 pre-education and 8.1 ± 1.9 post-education (p- = 0.49). 2.1. Hernia repair For the hernia repair cohort, the mean days' supply of opioid prescribed prior to the educational intervention was 4.2 ± 2.9 days (16.8–25.2 doses dispensed) and after the educational intervention was 2.7 ± 2.6 days (10.8–16.2 doses dispensed), as depicted in Table 1 and Fig. 1A. This was a statistically significant reduction (p = 0.004, Fig. 2). Prior to the educational intervention, there was significant interprovider variation (p b 0.0001 by ANOVA, Fig. 3A) and this variation was still present after the intervention, though to a lesser degree (p = 0.035, Fig. 3B). Though all hernia providers demonstrated trends toward reduction in days' supply of postoperative opioids prescribed (Fig. 3B), only two (P3 and P12) did so to a significant degree (Fig. 3B). The providers who did not demonstrate significant reductions were noted to have relatively low average prescription days' supply prior to the educational intervention. 2.2. Tonsillectomy For the tonsillectomy cohort, the mean days' supply of opioid prescribed prior to the educational intervention was 6.3 ± 4.4 days (25.6–37.8 doses dispensed) and after the educational intervention was 5.4 ± 3.0 days (21.6–32.4 doses dispensed), as depicted in Table 1 and Fig. 1B. This was not a statistically significant reduction (p = 0.226, Fig. 2). Prior to the educational intervention, there was significant interprovider variation (p b 0.0001 by ANOVA, Fig. 3C) and this variation persisted after the intervention to the same degree (p b 0.0001, Fig. 3D). Two tonsillectomy providers (P1 and P10) demonstrated significant reductions in days' supply of postoperative opioids
Table 1 Analgesic medication prescribing data. Opioid Prescription
Hernia Tonsil
Pre Post Pre Post
n
n
%
180 61 140 40
164 50 119 32
91.1 82.0 85.0 80.0
p⁎
Opioid Days' Supply
p⁎⁎
mean ± SD 0.0503 0.448
4.2 ± 2.9 2.7 ± 2.6 6.3 ± 4.4 5.4 ± 3.0
0.0005 0.226
APAP and/or NSAID Prescription n
%
30 16 49 16
16.7 26.3 35.0 40.0
P⁎
0.101 0.561
⁎ Chi squared. ⁎⁎ Student's t-test.
Please cite this article as: J.D. Horton, S. Munawar, A. Feuvrier, et al., Specialty-specific reduction in opioid prescribing after common pediatric surgical operations, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.02.008
J.D. Horton et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
3
Fig. 1. Distribution of total days' supply of postoperative opioids prescribed before (gray) and after (black) the educational intervention for hernia repair (A) and tonsillectomy (B). y-axis is frequency (percent) of a particular days' supply prescription (x-axis).
prescribed (Fig. 3D), though the statistical strength of these reductions was less robust (p = 0.016 and p = 0.004, respectively) than those in the hernia providers. 3. Discussion Our results suggest that a low-fidelity educational intervention may be effective at reducing both the amount and the interprovider variation in postoperative opioid prescribing in children after hernia repair. Hill et al. recently demonstrated significant reductions in opioid prescribing after several adult general surgery operations following opioid reduction education of general surgeons by general surgeons [11]. Similarly, Stanek et al. reduced postoperative opioids after 2 of 4 hand surgeries using an educational assist device developed and instituted by hand surgeons [12]. These studies taken together with our findings suggest that simple educational activities can be effective in reducing excessive postoperative opioid prescribing. However, we did not see a similar reduction in postoperative opioid prescriptions after tonsillectomy following the educational intervention. The intervention was not different between the two procedures — hernia providers and tonsillectomy providers attended the same educational presentation. For tonsillectomy, post-education opioid prescription amounts and interprovider variation were unchanged. We hypothesize that this inconsistency may be because of the relationship between the educator and the providers. The educational intervention was formally presented by a high-ranking general surgery attending physician to an audience containing attending and resident physicians from all surgical subspecialties. It could be inferred that the presenter's direct role model relationship to the general surgery providers in the audience contributed to their immediate reduction
in postoperative opioid prescription after hernia repair. Conversely, tonsillectomy prescribers in the audience had no professional ties to the presenter, perhaps giving less impetus to change their behavior. An alternative explanation for this disparity is that a card with prescribing guidelines for common general surgical procedures was provided to general surgeons but not tonsillectomy providers following the intervention. While the presenter encouraged other services to create prescribing guidelines for their procedures, no such guide was developed by Otolaryngology during the study period. It is certain that this tool contributed at least partially to the improvements in opioid prescribing by general surgeons, and there is precedent for success with such a tool in hand surgery as mentioned above [12]. In academic medicine both historically and currently, physicians tend to model their behavior after practitioners that they respect and trust [14,15] and this is known to occur consciously and unconsciously [16]. Having established themself as a role model to the general surgery providers in the audience, the presenter was optimally positioned to incite the greatest amount of behavioral change in those providers who perceived him as such. Though other explanations are certainly plausible and should be explored, we posit that the majority of the disparate change in prescribing practices between tonsillectomy and hernia providers can be attributed to the role model position the presenter embodied to the hernia providers and the lack of this relationship to the tonsillectomy providers. The addition of a physical card may have added to the impact of the presentation for general surgeons, but was not available for Otolaryngologists. Given the increased societal and academic awareness of the opioid epidemic over the last year, the effect observed may not be related to the intervention itself, but rather because of increased provider awareness. The fact that there was a reduction by general surgeons but not otolaryngologists would argue against this, though an effect cannot be ruled out. It is also possible that the general surgery faculty who administered the initial intervention continued to champion the change in opioid prescribing following the intervention among general surgery residents and therefore augmented the effect of the intervention for hernia providers specifically. This is a retrospective chart review study before and after a single timepoint intervention and has all of the limitations of such a study, including lack of control groups, selection bias, and minimal knowledge of confounders. Additionally, a significant gap in our data is information on the amount of pain medication actually consumed and the degree of pain control as it correlates to specific medication regimens. While our focus is decreasing excessive and inconsistent postoperative opioid prescriptions, we must be diligent in evaluating these patient-level outcomes to ensure adequate pain control is maintained. 4. Conclusion
Fig. 2. Significant reduction in days' supply of prescribed opioids following hernia repair after the educational intervention (solid bars, ***p = 0.0004); no significant reduction seen after tonsillectomy (checked bars, p = 0.226).
This study shows that a single educational intervention can significantly reduce postoperative opioid prescriptions after pediatric hernia repair in a specialty-specific manner. However, opioid prescribing
Please cite this article as: J.D. Horton, S. Munawar, A. Feuvrier, et al., Specialty-specific reduction in opioid prescribing after common pediatric surgical operations, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.02.008
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J.D. Horton et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
Fig. 3. Box-and-whisker plots of provider-level postoperative opioid prescription for hernia before (A) and after (B) and for tonsillectomy before (C) and after (D) the educational intervention. p-values in top left corner of each panel represent overall variance in the data by ANOVA. For specific providers, stars represent significance of change relative to preeducation prescription data by Student's t-test. (*p b 0.05, **p b 0.005, ****p b 0.0001).
practices did not change after tonsillectomy owing at least in part to the specialty difference between the presenter and the audience and the need for a procedure-specific tangible prescribing guide. Specialtyspecific educational interventions may be necessary to see robust and durable improvements in our opioid prescribing practices. 5. Acknowledgments The authors would like to thank the members of the pediatric postoperative opioid reduction working group at the Medical University of South Carolina including David Bundy, MD; William Basco, MD, MS; Karina Phang, MD; and Kathy Chessman, PharmD. We would also especially like to thank Kaitlynn Kerr and Katie Rogers for significant data collection in the early phases of the project. References [1] Manchikanti L, Helm S, 2nd, Fellows B, Janata JW, Pampati V, Grider JS, et al. Opioid epidemic in the United States. Pain physician 2012;15(3 Suppl):Es9–38. [2] Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011;305(13):1315–21. [3] Lev R, Lee O, Petro S, et al. Who is prescribing controlled medications to patients who die of prescription drug abuse? Am J Emerg Med 2016;34(1):30–5. [4] McCabe SE, West BT, Veliz P, McCabe VV, Stoddard SA, Boyd CJ. Trends in medical and nonmedical use of prescription opioids among US adolescents: 1976–2015. Pediatrics 2017;139(4).
[5] Gaither JR, Leventhal JM, Ryan SA, et al. National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012. JAMA Pediatr 2016;170 (12):1195–201. [6] Allen JD, Casavant MJ, Spiller HA, Chounthirath T, Hodges NL, Smith GA. Prescription opioid exposures among children and adolescents in the United States: 2000–2015. Pediatrics 2017;139(4). [7] Harbaugh CM, Lee JS, Hu HM, et al, surgery Persistent opioid use among pediatric patients after. Pediatrics 2018:141(1). [8] Feinberg AE, Chesney TR, Srikandarajah S, et al. Opioid use after discharge in postoperative patients: a systematic review. Ann Surg 2018;267(6):1056–62. [9] Garbutt JM, Kulka K, Dodd S, Sterkel R, Plax K. Opioids in adolescents' homes: prevalence, caregiver attitudes, and risk reduction opportunities. Academic pediatrics 2018 (ePub ahead of print July 6, 2018). [10] Horton JD, Munawar S, Corrigan C, White D, Cina RA. Inconsistent and excessive opioid prescribing after common pediatric surgical operations. Journal of pediatric surgery 2018 (ePub ahead of print July 7, 2018). [11] Hill MV, Stucke RS, McMahon ML, et al. An educational intervention decreases opioid prescribing after general surgical operations. Ann Surg 2018;267(3):468–72. [12] Stanek JJ, Renslow MA, Kalliainen LK. The effect of an educational program on opioid prescription patterns in hand surgery: a quality improvement program. J Hand Surg Am 2015;40(2):341–6. [13] Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42(2):377–81. [14] Cruess SR, Cruess RL, Steinert Y. Role modelling—making the most of a powerful teaching strategy. BMJ (Clinical research ed) 2008;336(7646):718–21. [15] Cote L, Leclere H. How clinical teachers perceive the doctor–patient relationship and themselves as role models. Acad Med 2000;75(11):1117–24. [16] Skeff KM, Mutha S. Role models—guiding the future of medicine. N Engl J Med 1998; 339(27):2015–7.
Please cite this article as: J.D. Horton, S. Munawar, A. Feuvrier, et al., Specialty-specific reduction in opioid prescribing after common pediatric surgical operations, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.02.008
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Specialty-specific reduction in opioid prescribing after common pediatric surgical operations Joshua D Horton a,⁎, Suqrat Munawar a, Ariana Feuvrier b, Corinne Corrigan c, Mark Lockett d, David White a, Robert A Cina b a
Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA Division of Pediatric Surgery, Department of General Surgery, Medical University of South Carolina, Charleston, SC, USA Division of Pediatrics, College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA d Department of General Surgery, Medical University of South Carolina, Charleston, SC, USA b c
a r t i c l e
i n f o
Article history: Received 15 October 2018 Received in revised form 5 February 2019 Accepted 10 February 2019 Available online xxxx Key words: Opioids Postoperative pain Quality improvement Education
a b s t r a c t Background: Opioid misuse has reached epidemic proportions, and postoperative opioids have been linked to overdose, diversion, and dependency. We recently found our opioid prescribing practices following common pediatric operations to be inconsistent and excessive. In this study, we evaluate the efficacy of an educational intervention on opioid prescriptions following tonsillectomy and hernia repair. Methods: Retrospective chart review of prescriptions following outpatient tonsillectomies and hernia repairs at a single institution before and after an educational intervention was performed. The intervention consisted of a single campus-wide grand rounds presentation detailing the surgeon's role in the opioid epidemic. Results: Postoperative opioid prescriptions were significantly reduced for hernia repair following the educational intervention: 4.2 ± 2.9 vs 2.7 ± 2.6 days' supply (p = 0.004). Such a reduction was not observed for post-tonsillectomy opioid prescriptions: 6.3 ± 4.4 vs 5.4 ± 3.0 days' supply (p = 0.226). A greater decrease in interprovider variation was observed for hernia providers after the educational intervention than for tonsillectomy providers, though significant variation continued to be present for both procedures after the intervention. Conclusions: The efficacy of an educational intervention at reducing postoperative pediatric opioid prescribing may be tied to the specialty-specific role model relationship of the educator to the prescriber. Type of study: retrospective comparative chart review. Level of evidence: IV. © 2019 Elsevier Inc. All rights reserved.
Opioid abuse and overdose in adults are on the rise in the United States and continue to receive ever-increasing media coverage in not only the lay-press but also the medical literature [1–3]. Unfortunately, pediatric patients are not immune from the opioid predicament [2,4], with increasing reports of the deleterious effects being witnessed in pediatric patients, especially adolescents [5,6]. Surgeons are significant contributors to opioid overprescription and proportionally contribute to prescription drug-related patient deaths [3]. Approximately 5% of opioid naïve pediatric patients develop new persistent opioid use postoperatively, including after hernia repair or tonsillectomy, the most commonly performed pediatric surgical operations [7]. Diversion of opioids following surgery is also a public health
concern and only 5%–60% of postoperative opioids are consumed for the purposes for which they were prescribed [8]. Perhaps most concerning, more than 20% of adolescent homes contain leftover opioid medications and in 60% of these cases, parents intend to keep the opioids for possible future use by themselves or others [9]. We recently evaluated our opioid prescribing practices following hernia repair and tonsillectomy and found them to be inconsistent and excessive [10]. Recent literature has demonstrated a positive role for provider education in significantly reducing postoperative opioid prescriptions [11,12] and in this study, we sought to improve our opioid prescribing practices following pediatric hernia repair and tonsillectomy by enacting such an intervention.
Abbreviations: CPT, current procedural terminology; APAP, acetyl-para-aminophenol (acetaminophen); NSAID, nonsteroidal anti-inflammatory drug; ED, emergency department; REDCap, research electronic data capture; SPSS, statistical package for the sciences; MM, multimodal. ⁎ Corresponding author at: Department of Otolaryngology–Head and Neck Surgery, 135 Rutledge Ave, MSC 550, Charleston, SC 29425. Tel.: +1 843 830 6271. E-mail address: [email protected] (J.D. Horton).
1. Methods We conducted a retrospective review of outpatient tonsillectomies and hernia repairs for one year prior to (January 1, 2017 to December 31, 2017) and four months after (January 3, 2018 to May 3, 2018) the opioid educational intervention (described below). For tonsillectomy,
https://doi.org/10.1016/j.jpedsurg.2019.02.008 0022-3468/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: J.D. Horton, S. Munawar, A. Feuvrier, et al., Specialty-specific reduction in opioid prescribing after common pediatric surgical operations, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.02.008
2
J.D. Horton et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
current procedural terminology (CPT) codes 42820 and 42825 were included and children aged 6 to 12-years-old were evaluated. For umbilical/inguinal hernia repair, CPT codes 49491–96, 49500–07, 49520–21, 49580–87, and 49650–53 were included and children aged 1 to 18-years-old were evaluated. Only patients undergoing outpatient elective surgery were included. Data were retrieved from the medical record including patient demographics, opioid type and dose, multimodal prescription type and dose (acetyl-para-aminophenol [APAP, acetaminophen], nonsteroidal anti-inflammatory drug [NSAID, ibuprofen]). Hydrocodoneacetaminophen oral solution and oxycodone oral solution were the two prescribed opioids for these procedures during the study period. There was significant variation between weight-based and nonweight-based dosing and frequency (every 4 hours as needed vs every 6 hours as needed), so opioid prescriptions were converted to “days' supply” for comparison. “Days' supply” was defined as the number of days a given opioid prescription would last if the patient took a prescribed dose at every possible interval time (every 4 hours or every 6 hours postoperatively) until depleted. As prescriptions were only every 4 or 6 hours, a 5 days' supply (for example) corresponds to 20–30 weight-based doses of opioid being dispensed. It is our institutional policy that children less than six years-old undergoing tonsillectomy (an extrapolation of the FDA black box warning for codeine after tonsillectomy) and less than one year-old undergoing hernia repair not be prescribed opioids as postoperative pain control. Data on individual providers were also retrieved and providers were evaluated if they prescribed three or more opioid prescriptions during the given study period. All included providers were resident physicians and there was no overlap between the specialties (i.e. no otolaryngology residents rotating on general surgery and prescribing opioids after hernia). No advanced practice providers or attending physicians wrote prescriptions included in the study data. Study data were collected and managed using REDCap electronic data capture tools hosted by the Medical University of South Carolina [13]. REDCap (Research Electronic Data Capture) is a secure, webbased application designed to support data capture for research studies, providing 1) an intuitive interface for validated data entry; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for importing data from external sources. On January 2, 2018, campus wide surgical Grand Rounds were hosted by the Department of General Surgery at our institution. The topic of the presentation was The Surgeon's Contribution to the Opioid Epidemic and all surgical subspecialty attending physicians, house staff, and advanced practice providers were expected to attend and were freed of clinical responsibilities during the presentation. The grand rounds consisted of a one hour presentation detailing the recent literature on postoperative opioid prescribing, patient use, diversion, and complications. Attendance was not taken. Given by general surgery faculty, the presentation discussed literature pertaining to several different surgical subspecialties. At the conclusion, a pamphlet was distributed which made specific opioid quantity recommendations for the most common general surgery procedures, including hernia repair. There
was a suggestion that each subspecialty generate and distribute similar recommendations for their specialties based on the subspecialty literature; this did not occur for Otolaryngology during the study period. Statistical Package for the Social Sciences (SPSS), version 23.0 (IBM SPSS, Chicago, IL) was used for data analysis. Continuous data are reported as mean and standard deviation. Normality of data was determined by Shapiro–Wilk test. Student's t-test was used to compare two normally distributed means. One-way ANOVA and chi-squared contingency tables were used for nonparametric comparison. Values were considered significant at the level of p b 0.05. This study was deemed exempt from Institutional Review Board evaluation and patient consent as it met criteria as a Medical University of South Carolina Quality Improvement Project (adapted from the University of WisconsinMadison's “IRB QI/Program Evaluation Self-Certification Tool”). 2. Results The pre-education cohort (January 1, 2017–December 31, 2017) included 180 hernia repairs and 140 tonsillectomies and the post-education cohort (January 3, 2018–May 3, 2018) included 61 hernia repairs and 40 tonsillectomies. Mean age for hernia repair pre-education was 5.0 ± 3.4 and post-education was 5.2 ± 2.8 (p = 0.67). Mean age for tonsillectomy was 7.9 ± 1.5 pre-education and 8.1 ± 1.9 post-education (p- = 0.49). 2.1. Hernia repair For the hernia repair cohort, the mean days' supply of opioid prescribed prior to the educational intervention was 4.2 ± 2.9 days (16.8–25.2 doses dispensed) and after the educational intervention was 2.7 ± 2.6 days (10.8–16.2 doses dispensed), as depicted in Table 1 and Fig. 1A. This was a statistically significant reduction (p = 0.004, Fig. 2). Prior to the educational intervention, there was significant interprovider variation (p b 0.0001 by ANOVA, Fig. 3A) and this variation was still present after the intervention, though to a lesser degree (p = 0.035, Fig. 3B). Though all hernia providers demonstrated trends toward reduction in days' supply of postoperative opioids prescribed (Fig. 3B), only two (P3 and P12) did so to a significant degree (Fig. 3B). The providers who did not demonstrate significant reductions were noted to have relatively low average prescription days' supply prior to the educational intervention. 2.2. Tonsillectomy For the tonsillectomy cohort, the mean days' supply of opioid prescribed prior to the educational intervention was 6.3 ± 4.4 days (25.6–37.8 doses dispensed) and after the educational intervention was 5.4 ± 3.0 days (21.6–32.4 doses dispensed), as depicted in Table 1 and Fig. 1B. This was not a statistically significant reduction (p = 0.226, Fig. 2). Prior to the educational intervention, there was significant interprovider variation (p b 0.0001 by ANOVA, Fig. 3C) and this variation persisted after the intervention to the same degree (p b 0.0001, Fig. 3D). Two tonsillectomy providers (P1 and P10) demonstrated significant reductions in days' supply of postoperative opioids
Table 1 Analgesic medication prescribing data. Opioid Prescription
Hernia Tonsil
Pre Post Pre Post
n
n
%
180 61 140 40
164 50 119 32
91.1 82.0 85.0 80.0
p⁎
Opioid Days' Supply
p⁎⁎
mean ± SD 0.0503 0.448
4.2 ± 2.9 2.7 ± 2.6 6.3 ± 4.4 5.4 ± 3.0
0.0005 0.226
APAP and/or NSAID Prescription n
%
30 16 49 16
16.7 26.3 35.0 40.0
P⁎
0.101 0.561
⁎ Chi squared. ⁎⁎ Student's t-test.
Please cite this article as: J.D. Horton, S. Munawar, A. Feuvrier, et al., Specialty-specific reduction in opioid prescribing after common pediatric surgical operations, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.02.008
J.D. Horton et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
3
Fig. 1. Distribution of total days' supply of postoperative opioids prescribed before (gray) and after (black) the educational intervention for hernia repair (A) and tonsillectomy (B). y-axis is frequency (percent) of a particular days' supply prescription (x-axis).
prescribed (Fig. 3D), though the statistical strength of these reductions was less robust (p = 0.016 and p = 0.004, respectively) than those in the hernia providers. 3. Discussion Our results suggest that a low-fidelity educational intervention may be effective at reducing both the amount and the interprovider variation in postoperative opioid prescribing in children after hernia repair. Hill et al. recently demonstrated significant reductions in opioid prescribing after several adult general surgery operations following opioid reduction education of general surgeons by general surgeons [11]. Similarly, Stanek et al. reduced postoperative opioids after 2 of 4 hand surgeries using an educational assist device developed and instituted by hand surgeons [12]. These studies taken together with our findings suggest that simple educational activities can be effective in reducing excessive postoperative opioid prescribing. However, we did not see a similar reduction in postoperative opioid prescriptions after tonsillectomy following the educational intervention. The intervention was not different between the two procedures — hernia providers and tonsillectomy providers attended the same educational presentation. For tonsillectomy, post-education opioid prescription amounts and interprovider variation were unchanged. We hypothesize that this inconsistency may be because of the relationship between the educator and the providers. The educational intervention was formally presented by a high-ranking general surgery attending physician to an audience containing attending and resident physicians from all surgical subspecialties. It could be inferred that the presenter's direct role model relationship to the general surgery providers in the audience contributed to their immediate reduction
in postoperative opioid prescription after hernia repair. Conversely, tonsillectomy prescribers in the audience had no professional ties to the presenter, perhaps giving less impetus to change their behavior. An alternative explanation for this disparity is that a card with prescribing guidelines for common general surgical procedures was provided to general surgeons but not tonsillectomy providers following the intervention. While the presenter encouraged other services to create prescribing guidelines for their procedures, no such guide was developed by Otolaryngology during the study period. It is certain that this tool contributed at least partially to the improvements in opioid prescribing by general surgeons, and there is precedent for success with such a tool in hand surgery as mentioned above [12]. In academic medicine both historically and currently, physicians tend to model their behavior after practitioners that they respect and trust [14,15] and this is known to occur consciously and unconsciously [16]. Having established themself as a role model to the general surgery providers in the audience, the presenter was optimally positioned to incite the greatest amount of behavioral change in those providers who perceived him as such. Though other explanations are certainly plausible and should be explored, we posit that the majority of the disparate change in prescribing practices between tonsillectomy and hernia providers can be attributed to the role model position the presenter embodied to the hernia providers and the lack of this relationship to the tonsillectomy providers. The addition of a physical card may have added to the impact of the presentation for general surgeons, but was not available for Otolaryngologists. Given the increased societal and academic awareness of the opioid epidemic over the last year, the effect observed may not be related to the intervention itself, but rather because of increased provider awareness. The fact that there was a reduction by general surgeons but not otolaryngologists would argue against this, though an effect cannot be ruled out. It is also possible that the general surgery faculty who administered the initial intervention continued to champion the change in opioid prescribing following the intervention among general surgery residents and therefore augmented the effect of the intervention for hernia providers specifically. This is a retrospective chart review study before and after a single timepoint intervention and has all of the limitations of such a study, including lack of control groups, selection bias, and minimal knowledge of confounders. Additionally, a significant gap in our data is information on the amount of pain medication actually consumed and the degree of pain control as it correlates to specific medication regimens. While our focus is decreasing excessive and inconsistent postoperative opioid prescriptions, we must be diligent in evaluating these patient-level outcomes to ensure adequate pain control is maintained. 4. Conclusion
Fig. 2. Significant reduction in days' supply of prescribed opioids following hernia repair after the educational intervention (solid bars, ***p = 0.0004); no significant reduction seen after tonsillectomy (checked bars, p = 0.226).
This study shows that a single educational intervention can significantly reduce postoperative opioid prescriptions after pediatric hernia repair in a specialty-specific manner. However, opioid prescribing
Please cite this article as: J.D. Horton, S. Munawar, A. Feuvrier, et al., Specialty-specific reduction in opioid prescribing after common pediatric surgical operations, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.02.008
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Fig. 3. Box-and-whisker plots of provider-level postoperative opioid prescription for hernia before (A) and after (B) and for tonsillectomy before (C) and after (D) the educational intervention. p-values in top left corner of each panel represent overall variance in the data by ANOVA. For specific providers, stars represent significance of change relative to preeducation prescription data by Student's t-test. (*p b 0.05, **p b 0.005, ****p b 0.0001).
practices did not change after tonsillectomy owing at least in part to the specialty difference between the presenter and the audience and the need for a procedure-specific tangible prescribing guide. Specialtyspecific educational interventions may be necessary to see robust and durable improvements in our opioid prescribing practices. 5. Acknowledgments The authors would like to thank the members of the pediatric postoperative opioid reduction working group at the Medical University of South Carolina including David Bundy, MD; William Basco, MD, MS; Karina Phang, MD; and Kathy Chessman, PharmD. We would also especially like to thank Kaitlynn Kerr and Katie Rogers for significant data collection in the early phases of the project. References [1] Manchikanti L, Helm S, 2nd, Fellows B, Janata JW, Pampati V, Grider JS, et al. Opioid epidemic in the United States. Pain physician 2012;15(3 Suppl):Es9–38. [2] Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011;305(13):1315–21. [3] Lev R, Lee O, Petro S, et al. Who is prescribing controlled medications to patients who die of prescription drug abuse? Am J Emerg Med 2016;34(1):30–5. [4] McCabe SE, West BT, Veliz P, McCabe VV, Stoddard SA, Boyd CJ. Trends in medical and nonmedical use of prescription opioids among US adolescents: 1976–2015. Pediatrics 2017;139(4).
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Please cite this article as: J.D. Horton, S. Munawar, A. Feuvrier, et al., Specialty-specific reduction in opioid prescribing after common pediatric surgical operations, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.02.008