Assessment of a quality improvement intervention to decrease opioid prescribing in a regional health system

Abstract

Background: Opioids are prescribed in excess after surgery. We leveraged our continuous quality improvement infrastructure to implement opioid prescribing guidelines and subsequently evaluate changes in postoperative opioid prescribing, consumption and patient satisfaction/pain in a statewide regional health system.

Methods: We collected data regarding postoperative prescription size, opioid consumption and patient-reported outcomes from February 2017 to May 2019, from a 70-hospital surgical collaborative. Three iterations of prescribing guidelines were released. An interrupted time series analysis before and after each guideline release was performed. Linear regression was used to identify trends in consumption and patient-reported outcomes over time.

Results: We included 36 022 patients from 69 hospitals who underwent one of nine procedures in the guidelines, of which 15 174 (37.3%) had complete patient-reported outcomes data following surgery. Before the intervention, prescription size was decreasing over time (slope: -0.7 tablets of 5 mg oxycodone/month, 95% CI -1.0 to -0.5 tablets, p<0.001). After the first guideline release, prescription size declined by -1.4 tablets/month (95% CI -1.8 to -1.0 tablets, p<0.001). The difference between these slopes was significant (p=0.006). The second guideline release resulted in a relative increase in slope (-0.3 tablets/month, 95% CI -0.1 to -0.6, p<0.001). The third guideline release resulted in no change (p=0.563 for the intervention). Overall, mean (SD) prescription size decreased from 25 (17) tablets of 5 mg oxycodone to 12 (8) tablets. Opioid consumption also decreased from 11 (16) to 5 (7) tablets (p<0.001), while satisfaction and postoperative pain remained unchanged.

Conclusions: The use of procedure-specific prescribing guidelines reduced statewide postoperative opioid prescribing by 50% while providing satisfactory pain care. These results demonstrate meaningful impact on opioid prescribing using evidence-based best practices and serve as an example of successful utilisation of a regional health collaborative for quality improvement.

Keywords: clinical practice guidelines; continuous quality improvement; health policy; patient satisfaction; quality improvement.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1

Prescription size before and after guideline release. After the prescribing guidelines were released in October 2017, postoperative opioid prescription size declined significantly. Change in slope (ie, decrease in prescription size in tablets of 5 mg oxycodone per month) from before to after guideline release was statistically significant at p

Figure 2

Opioid consumption and patient-reported outcomes. Patient-reported opioid consumption decreased by 50% over the study time period, while patient-reported satisfaction with care and pain in the week after surgery remained stable (n=15 552).

Figure 3

Change in coefficient of variation for prescription size before and after guideline release. Change in coefficient of variation represents the proportional change in coefficient of variation from before the release of the first guidelines to after the release of the third guidelines. Negative values result from less variability in prescribing in the postguideline release period, while positive values result from more variability in prescribing.