Opioid Prescribing
Conditions
Keywords
Opioid Epidemic, Inappropriate Prescribing, Opioid-Related Disorders, Practice Guideline, Peer Influence, Nudges
Brief summary
This study tests the effectiveness of two email-based behavioral nudges, one based on peer behavior and one based on best practice guidelines, in reducing excessive opioid prescriptions after surgery. It will be conducted in three surgical specialties (general surgery, orthopedic surgery, and obstetric/gynecological surgery) at 19 hospitals within one healthcare system. These specialties will each be randomized to a control group or one of two nudge groups. Each month for one year, surgeons in the nudge groups will receive emails comparing their opioid prescribing either to their peers' prescribing or to prescribing guidelines. Both types of email-based nudges are expected to reduce opioid prescribing after surgery.
Interventions
BEHAVIORALGuideline-Based (Injunctive Norm) Nudges
Surgeons in this arm will receive an email with the following content at the end of each month in which at least two of their patients are discharged with an opioid prescription that exceeds the prescribing guideline for the procedure performed. Dear Dr. \[Name\], In \[month\], at least XX of your patients were discharged with opioid prescriptions exceeding the amounts recommended by safety guidelines for these procedures. For patient safety, Sutter Health recommends prescribing within the ranges below for these procedures. Doing so will also meet best-practice safety guidelines for post-operative opioid prescribing. We will continue to send you opioid prescribing safety reports. Sincerely, \[Signature\] \[Table displaying recommended ranges of 5mg oxycodone tablets for each procedure\]
BEHAVIORALPeer-Based (Social Norm) Nudges
Surgeons in this arm will receive an email with the following content at the end of each month in which at least two of their patients are discharged with an opioid prescription that exceeds the prescribing guideline for the procedure performed. Dear Dr. \[Name\], In \[month\], at least XX of your patients were discharged with opioid prescriptions exceeding the amount prescribed by YY% of your peers for these procedures. YY% of \[specialty\] surgeons at Sutter Health prescribe within the ranges below for these procedures. We will continue to send you opioid prescribing safety reports. Sincerely, \[Signature\] \[Table displaying recommended ranges of 5mg oxycodone tablets for each procedure\] The ranges of 5mg oxycodone tablets displayed will be the same as the ranges stipulated by the prescribing guidelines, but this nudge will not mention guidelines.
Sponsors
Sutter Health
University of California, Los Angeles
University of Southern California
University of Michigan
RAND
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
DOUBLE (Subject, Caregiver)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
The nudges that a surgeon in either intervention arm will receive are based on that surgeon's eligible discharge opioid prescriptions in the previous month. Eligible prescriptions meet all of the following criteria: * the patient is at least 18 years old at the date of surgery * the patient is discharged to their home * the surgical procedure has an applicable post-operative opioid prescribing guideline * the surgical procedure is the only surgical procedure performed during the patient's hospital stay * the prescription is for an opioid taken orally (tablets, capsules, or liquid solution) To avoid contamination between the intervention arms, surgeons who operate across multiple surgical specialties (defined as surgeons who performed less than 90% of their total procedures in one specialty between June 2020 and May 2021) will not be eligible.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Proportion of Discharges With Opioid Prescriptions Above Prescribing Guidelines | 12 months | Prescriptions will be compared to prescribing guidelines via morphine milligram equivalents (MMEs) and coded as within or above guidelines. If no opioid is prescribed at discharge, this will be coded as within guidelines. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Days' Supply of Opioids Prescribed at Discharge | 12 months | Continuous variable indicating the number of days' supply of opioids prescribed at discharge |
| Proportion of Discharges Where Any Opioid Was Prescribed | 12 months | Derived from a binary variable indicating whether any opioid was prescribed at discharge |
| Proportion of Patients on Opioids for Greater Than 3 Months Post-discharge | 3-6 months post-discharge | Derived from a binary variable indicating whether the patient has any opioid prescriptions between 3 and 6 months after surgery |
| Morphine Milligram Equivalents (MMEs) Prescribed at Discharge | 12 months | Continuous measure of the total morphine milligram equivalents prescribed at discharge |
| Number of 30-day All-cause Hospitalizations | 0-30 days post-discharge | Number of hospital admissions the post-operative patient has in the 30 days after the initial procedure |
| Proportion of Discharge Opioid Prescriptions Above Prescribing Guidelines in the Year After the Intervention Ends | 12 months (months 13-24 of the study) | Prescriptions will be compared to prescribing guidelines via morphine milligram equivalents (MMEs) and coded as within or above guidelines. If no opioid is prescribed at discharge, this will be coded as within guidelines. |
| Number of 30-day All-cause Emergency Department Visits | 0-30 days post-discharge | Number of emergency department visits the post-operative patient has in the 30 days after the initial procedure |
Countries
United States
Participant flow
Recruitment details
Start date: October 19, 2021; Primary Completion Date: October 18, 2022; Study completion date: October 18, 2023. Participants were recruited from hospitals in the Sutter care health system.
Participants by arm
| Arm | Count |
|---|---|
| Guideline-Based Nudges Guideline-Based (Injunctive Norm) Nudges: Surgeons in this arm will receive an email with the following content at the end of each month in which at least two of their patients are discharged with an opioid prescription that exceeds the prescribing guideline for the procedure performed.
Dear Dr. \[Name\],
In \[month\], at least XX of your patients were discharged with opioid prescriptions exceeding the amounts recommended by safety guidelines for these procedures.
For patient safety, Sutter Health recommends prescribing within the ranges below for these procedures. Doing so will also meet best-practice safety guidelines for post-operative opioid prescribing.
We will continue to send you opioid prescribing safety reports.
Sincerely, \[Signature\]
\[Table displaying recommended ranges of 5mg oxycodone tablets for each procedure\] | 216 |
| Peer-Based Nudges Peer-Based (Social Norm) Nudges: Surgeons in this arm will receive an email with the following content at the end of each month in which at least two of their patients are discharged with an opioid prescription that exceeds the prescribing guideline for the procedure performed.
Dear Dr. \[Name\],
In \[month\], at least XX of your patients were discharged with opioid prescriptions exceeding the amount prescribed by YY% of your peers for these procedures.
YY% of \[specialty\] surgeons at Sutter Health prescribe within the ranges below for these procedures.
We will continue to send you opioid prescribing safety reports.
Sincerely, \[Signature\]
\[Table displaying recommended ranges of 5mg oxycodone tablets for each procedure\]
The ranges of 5mg oxycodone tablets displayed will be the same as the ranges stipulated by the prescribing guidelines, but this nudge will not mention guidelines. | 207 |
| Control No intervention | 217 |
| Total | 640 |
Baseline characteristics
| Characteristic | Guideline-Based Nudges | Peer-Based Nudges | Control | Total |
|---|---|---|---|---|
| Age, Continuous | 49.4 years STANDARD_DEVIATION 17.6 | 50.1 years STANDARD_DEVIATION 17.3 | 53.7 years STANDARD_DEVIATION 17.7 | 51.3 years STANDARD_DEVIATION 17.6 |
| Race and Ethnicity Not Collected | — | — | — | 0 Participants |
| Sex: Female, Male Female | 83 Participants | 87 Participants | 87 Participants | 257 Participants |
| Sex: Female, Male Male | 133 Participants | 120 Participants | 130 Participants | 383 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk |
|---|---|---|---|
| deaths Total, all-cause mortality | 0 / 0 | 0 / 0 | 0 / 0 |
| other Total, other adverse events | 3,045 / 15,459 | 1,752 / 10,752 | 1,617 / 12,024 |
| serious Total, serious adverse events | 1,096 / 15,459 | 755 / 10,752 | 849 / 12,024 |
Outcome results
Primary
Proportion of Discharges With Opioid Prescriptions Above Prescribing Guidelines
Prescriptions will be compared to prescribing guidelines via morphine milligram equivalents (MMEs) and coded as within or above guidelines. If no opioid is prescribed at discharge, this will be coded as within guidelines.
Time frame: 12 months
Population: The units analyzed are the discharges of patients operated on by surgeons enrolled in the study.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Guideline-Based Nudges | Proportion of Discharges With Opioid Prescriptions Above Prescribing Guidelines | 0.254 Proportion of discharges |
| Peer-Based Nudges | Proportion of Discharges With Opioid Prescriptions Above Prescribing Guidelines | 0.275 Proportion of discharges |
| Control | Proportion of Discharges With Opioid Prescriptions Above Prescribing Guidelines | 0.368 Proportion of discharges |
Secondary
Days' Supply of Opioids Prescribed at Discharge
Continuous variable indicating the number of days' supply of opioids prescribed at discharge
Time frame: 12 months
Population: Contrary to initial expectations, the days' supply of opioids prescribed at discharge was not captured by the Sutter Health electronic health records system. This outcome measure could therefore not be assessed.~The quantity of opioids prescribed at discharge is still captured similarly by the outcome measure Morphine Milligram Equivalents (MMEs) Prescribed at Discharge.
Secondary
Morphine Milligram Equivalents (MMEs) Prescribed at Discharge
Continuous measure of the total morphine milligram equivalents prescribed at discharge
Time frame: 12 months
Population: The units analyzed are the discharges of patients operated on by surgeons enrolled in the study.
| Arm | Measure | Value (MEAN) |
|---|---|---|
| Guideline-Based Nudges | Morphine Milligram Equivalents (MMEs) Prescribed at Discharge | 78.7 Morphine milligram equivalents (MMEs) |
| Peer-Based Nudges | Morphine Milligram Equivalents (MMEs) Prescribed at Discharge | 58.6 Morphine milligram equivalents (MMEs) |
| Control | Morphine Milligram Equivalents (MMEs) Prescribed at Discharge | 67.6 Morphine milligram equivalents (MMEs) |
Secondary
Number of 30-day All-cause Emergency Department Visits
Number of emergency department visits the post-operative patient has in the 30 days after the initial procedure
Time frame: 0-30 days post-discharge
Population: The units analyzed are the post-operative discharges of patients operated on by surgeons enrolled in the study. For patients who had multiple procedures in multiple admissions over the study period, each discharge is counted separately.
| Arm | Measure | Value (MEAN) |
|---|---|---|
| Guideline-Based Nudges | Number of 30-day All-cause Emergency Department Visits | 0.062 Emergency department visits |
| Peer-Based Nudges | Number of 30-day All-cause Emergency Department Visits | 0.057 Emergency department visits |
| Control | Number of 30-day All-cause Emergency Department Visits | 0.062 Emergency department visits |
Secondary
Number of 30-day All-cause Hospitalizations
Number of hospital admissions the post-operative patient has in the 30 days after the initial procedure
Time frame: 0-30 days post-discharge
Population: The units analyzed are the post-operative discharges of patients operated on by surgeons enrolled in the study. For patients who had multiple procedures in multiple admissions over the study period, each discharge is counted separately.
| Arm | Measure | Value (MEAN) |
|---|---|---|
| Guideline-Based Nudges | Number of 30-day All-cause Hospitalizations | 0.023 Hospital admissions |
| Peer-Based Nudges | Number of 30-day All-cause Hospitalizations | 0.029 Hospital admissions |
| Control | Number of 30-day All-cause Hospitalizations | 0.023 Hospital admissions |
Secondary
Proportion of Discharge Opioid Prescriptions Above Prescribing Guidelines in the Year After the Intervention Ends
Prescriptions will be compared to prescribing guidelines via morphine milligram equivalents (MMEs) and coded as within or above guidelines. If no opioid is prescribed at discharge, this will be coded as within guidelines.
Time frame: 12 months (months 13-24 of the study)
Population: The units analyzed are the discharges of patients operated on by surgeons enrolled in the study.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Guideline-Based Nudges | Proportion of Discharge Opioid Prescriptions Above Prescribing Guidelines in the Year After the Intervention Ends | 0.253 Proportion of discharges |
| Peer-Based Nudges | Proportion of Discharge Opioid Prescriptions Above Prescribing Guidelines in the Year After the Intervention Ends | 0.250 Proportion of discharges |
| Control | Proportion of Discharge Opioid Prescriptions Above Prescribing Guidelines in the Year After the Intervention Ends | 0.363 Proportion of discharges |
Secondary
Proportion of Discharges Where Any Opioid Was Prescribed
Derived from a binary variable indicating whether any opioid was prescribed at discharge
Time frame: 12 months
Population: The units analyzed are the discharges of patients operated on by surgeons enrolled in the study.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Guideline-Based Nudges | Proportion of Discharges Where Any Opioid Was Prescribed | 0.484 Proportion of discharges |
| Peer-Based Nudges | Proportion of Discharges Where Any Opioid Was Prescribed | 0.476 Proportion of discharges |
| Control | Proportion of Discharges Where Any Opioid Was Prescribed | 0.518 Proportion of discharges |
Secondary
Proportion of Patients on Opioids for Greater Than 3 Months Post-discharge
Derived from a binary variable indicating whether the patient has any opioid prescriptions between 3 and 6 months after surgery
Time frame: 3-6 months post-discharge
Population: The units analyzed are the discharges of patients operated on by surgeons enrolled in the study.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Guideline-Based Nudges | Proportion of Patients on Opioids for Greater Than 3 Months Post-discharge | 0.123 Proportion of discharges |
| Peer-Based Nudges | Proportion of Patients on Opioids for Greater Than 3 Months Post-discharge | 0.099 Proportion of discharges |
| Control | Proportion of Patients on Opioids for Greater Than 3 Months Post-discharge | 0.102 Proportion of discharges |