Postoperative Nudges to Reduce Opioid Prescribing (POST-OP)

Reducing Inappropriate Prescription Opioid Prescribing at Hospital Discharge

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.

Study Overview

• Status: Completed
• Conditions: Opioid Prescribing
• Intervention / Treatment: Behavioral: Guideline-Based (Injunctive Norm) Nudges; Behavioral: Peer-Based (Social Norm) Nudges

• Study Type: Interventional
• Enrollment (Actual): 640
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • California
    • Sacramento, California, United States, 95833
      • Sutter Health

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

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.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Control
Experimental: Guideline-Based Nudges	Behavioral: 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]
Experimental: Peer-Based Nudges	Behavioral: 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.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
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.	12 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Morphine Milligram Equivalents (MMEs) Prescribed at Discharge	Continuous measure of the total morphine milligram equivalents prescribed at discharge	12 months
Days' Supply of Opioids Prescribed at Discharge	Continuous variable indicating the number of days' supply of opioids prescribed at discharge	12 months
Proportion of Discharges Where Any Opioid Was Prescribed	Derived from a binary variable indicating whether any opioid was prescribed at discharge	12 months
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	3-6 months post-discharge
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	0-30 days post-discharge
Number of 30-day All-cause Hospitalizations	Number of hospital admissions the post-operative patient has in the 30 days after the initial procedure	0-30 days post-discharge
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.	12 months (months 13-24 of the study)

Collaborators and Investigators

• Sponsor: RAND
• Collaborators: University of California, Los Angeles; University of Michigan; University of Southern California; Sutter Health
• Investigators: Principal Investigator: Katherine E Watkins, MD, MSHS, RAND

Publications and helpful links

General Publications

• Kirkegaard A, Wagner Z, Mariano LT, Martinez MC, Yan XS, Romanelli RJ, Watkins KE. Evaluating the effectiveness of email-based nudges to reduce postoperative opioid prescribing: study protocol of a randomised controlled trial. BMJ Open. 2022 Sep 19;12(9):e061980. doi: 10.1136/bmjopen-2022-061980.

Study record dates

Study Major Dates

• Study Start (Actual): October 19, 2021
• Primary Completion (Actual): October 18, 2022
• Study Completion (Actual): October 18, 2023

Study Registration Dates

• First Submitted: September 21, 2021
• First Submitted That Met QC Criteria: October 4, 2021
• First Posted (Actual): October 7, 2021

Study Record Updates

• Last Update Posted (Actual): April 8, 2025
• Last Update Submitted That Met QC Criteria: March 19, 2025
• Last Verified: March 1, 2025

More Information

Terms related to this study

• Keywords: Opioid-Related Disorders; Nudges; Inappropriate Prescribing; Opioid Epidemic; Practice Guideline; Peer Influence
• Other Study ID Numbers: R01DA046226 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Deidentified data will be made available upon reasonable request.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No