Assessment of Postoperative Opioid Prescriptions Before and After Implementation of a Mandatory Prescription Drug Monitoring Program.
Assessment of Postoperative Opioid Prescriptions Before and After Implementation of a Mandatory Prescription Drug Monitoring Program.
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DOI：
10.1001/jamahealthforum.2021.2924
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发表时间：
2021-10
期刊：
影响因子：
--
通讯作者：
Watkins KE
中科院分区：
文献类型：
--
作者：
Shenoy R;Wagner Z;Kirkegaard A;Romanelli RJ;Mudiganti S;Mariano L;Martinez M;Zanocco K;Watkins KE
实施强制性咨询处方药监测计划（PGEAR），该计划整合了与普外科、妇产科和骨科手术后出院时处方的阿片类药物的术后数量变化相关的电子健康记录（EHR）警报？在一项大型医疗保健系统内接受阿片类药物术后处方的93760例成人患者的横断面研究中，在考虑实施前处方模式后实施强制性PALTH咨询并基于EHR警报的季度内，术后阿片类药物处方量显著减少。这项研究发现，实施立法强制执行药物咨询和使用EHR警报可能与术后阿片类药物处方行为的变化和流通中阿片类药物片剂过量的减少有关。2018年10月2日，在加州实施了要求与处方药监测计划（PAPK）进行协商的立法。这一规定要求在开受管制物质处方前进行药物咨询，并整合了基于电子健康记录（EHR）的警报;如果处方者处方的阿片类药物供应不超过5天，则可免除该规定。虽然以前的研究已经检查了强制性Paddle咨询的后果，但很少有人专门分析强制执行后术后阿片类药物处方的变化。检查强制性PAPs咨询与同时基于EHR的警报的实施是否与出院时处方的术后阿片类药物量的变化相关。这项横断面研究对2015年1月1日至2020年2月1日期间北方加州的大型医疗保健系统（Sutter Health）内的阿片类药物处方模式进行了中断时间序列分析。共纳入了93760例在接受普通、产科和妇科（产科/妇科）或骨科手术后出院时接受阿片类药物处方的成人患者。阿片类药物处方前的强制性药物咨询，同时整合EHR警报。如果处方者在术后不超过5天的阿片类药物供应，则可免除这一要求。主要结局是执行PALGOR指令前后出院时处方的阿片类药物总量（吗啡毫克当量[MME]和阿片类片剂数量），按外科专业（普通科、产科/妇科和骨科）和每个专业内最常见的外科手术（腹腔镜胆囊切除术、剖宫产和膝关节镜检查）进行单独分析。次要结局是持续时间超过5天的处方比例。在出院时接受阿片类药物处方的93760例患者（平均[SD]年龄，46.7 [17.6]岁; 67.9%为女性）中，65911例在PALGOR强制执行前接受处方，27849例在PALGOR强制执行后接受处方。大多数患者接受了普外科或妇产科手术（分别为48.6%和30.1%），无糖尿病（90.3%），从不吸烟（66.0%）。在执行阿片类药物授权之前，阿片类药物处方量已经出现下降趋势。在实施的季度内，所有3个外科专科出院时处方的MME总数进一步下降（例如，普通外科的中位数：β = −10.00 [95% CI，−19.52至−0.48];产科/妇科手术：β = −18.65 [95% CI，−22.00至−15.30];骨科手术：β = −30.59 [95%CI，−40.19至−21.00]）。处方的片剂总数也在各专业之间下降（例如，普外科的中位数：β = −3.02 [95%CI，−3.47至−2.57];妇产科手术：β = −4.86 [95%CI，−5.38至−4.34];骨科手术：β = −4.06 [95%CI，−5.07至−3.04]）。这些减少在最常见的外科手术中并不一致。对于剖腹产，在实施的季度中，处方的片剂中位数减少（β = −10.00; 95% CI，−10.10至−9.90），但中位MME没有（β = 0; 95% CI，−9.97至9.97），而中位MME和处方片剂数量均下降（MME：β = −33.33 [95% CI，−38.48至−28.19];片剂：β = −10.00 [95% CI，−11.17至−8.82]）。对于膝关节镜检查，中位MME或处方片剂数量均未减少（MME：β = 10.00 [95% CI，−22.33至42.33;片剂：β = 0.83; 95% CI，−3.39至5.05）。在所有3个外科专科的实施季度中，超过5天的处方比例也显著下降。在这项横断面研究中，实施强制性的PAPs咨询，同时进行基于EHR的警报，与3个外科专业的阿片类药物处方立即减少有关。这些发现可能是由于开处方者试图满足授权豁免并绕过PADER咨询，而不是PADER咨询本身。虽然政策加上EHR警报可能与术后阿片类药物处方行为的变化有关，但它们需要精心设计，以优化循证阿片类药物处方。本横断面研究旨在探讨强制咨询处方药监测计划的实施是否与加州医疗保健系统中成人患者出院时处方的术后阿片类药物数量变化相关。
Was the implementation of mandatory consultation with a prescription drug monitoring program (PDMP) that integrates electronic health record (EHR) alerts associated with changes in the postoperative quantity of opioid medications prescribed at discharge after general, obstetric and gynecologic, and orthopedic surgery? In this cross-sectional study of 93 760 adult patients within a large health care system who received a postoperative prescription for an opioid medication, implementation of mandatory PDMP consultation with EHR-based alerts was associated with significant decreases in postoperative opioid prescription quantities during the quarter in which the mandate was implemented after accounting for preimplementation prescribing patterns. This study found that implementation of legislation mandating PDMP consultation and the use of EHR alerts may be associated with changes in postoperative opioid prescribing behavior and decreases in the excess number of opioid tablets in circulation. Legislation mandating consultation with a prescription drug monitoring program (PDMP) was implemented in California on October 2, 2018. This mandate requires PDMP consultation before prescribing a controlled substance and integrates electronic health record (EHR)–based alerts; prescribers are exempt from the mandate if they prescribe no more than a 5-day postoperative opioid supply. Although previous studies have examined the consequences of mandated PDMP consultation, few have specifically analyzed changes in postoperative opioid prescribing after mandate implementation. To examine whether the implementation of mandatory PDMP consultation with concurrent EHR-based alerts was associated with changes in postoperative opioid quantities prescribed at discharge. This cross-sectional study performed an interrupted time series analysis of opioid prescribing patterns within a large health care system (Sutter Health) in northern California between January 1, 2015, and February 1, 2020. A total of 93 760 adult patients who received an opioid prescription at discharge after undergoing general, obstetric and gynecologic (obstetric/gynecologic), or orthopedic surgery were included. Mandatory PDMP consultation before opioid prescribing, with concurrent integration of an EHR alert. Prescribers are exempt from this mandate if prescribing no more than a 5-day opioid supply postoperatively. The primary outcome was the total quantity of opioid medications (morphine milligram equivalents [MMEs] and number of opioid tablets) prescribed at discharge before and after implementation of the PDMP mandate, with separate analyses by surgical specialty (general, obstetric/gynecologic, and orthopedic) and most common surgical procedure within each specialty (laparoscopic cholecystectomy, cesarean delivery, and knee arthroscopy). The secondary outcome was the proportion of prescriptions with a duration of longer than 5 days. Of 93 760 patients (mean [SD] age, 46.7 [17.6] years; 67.9% female) who received an opioid prescription at discharge, 65 911 received prescriptions before PDMP mandate implementation, and 27 849 received prescriptions after implementation. Most patients received general or obstetric/gynecologic surgery (48.6% and 30.1%, respectively), did not have diabetes (90.3%), and had never smoked (66.0%). Before the PDMP mandate was implemented, a decreasing pattern in opioid prescribing quantities was already occurring. During the quarter of implementation, total MMEs prescribed at discharge further decreased for all 3 surgical specialties (eg, medians for general surgery: β = −10.00 [95% CI, −19.52 to −0.48]; obstetric/gynecologic surgery: β = −18.65 [95% CI, −22.00 to −15.30]; and orthopedic surgery: β = −30.59 [95% CI, −40.19 to −21.00]) after adjusting for the preimplementation prescribing pattern. The total number of tablets prescribed also decreased across specialties (eg, medians for general surgery: β = −3.02 [95% CI, −3.47 to −2.57]; obstetric/gynecologic surgery: β = −4.86 [95% CI, −5.38 to −4.34]; and orthopedic surgery: β = −4.06 [95% CI, −5.07 to −3.04]) compared with the quarters before implementation. These reductions were not consistent across the most common surgical procedures. For cesarean delivery, the median number of tablets prescribed decreased during the quarter of implementation (β = −10.00; 95% CI, −10.10 to −9.90), but median MMEs did not (β = 0; 95% CI, −9.97 to 9.97), whereas decreases were observed in both median MMEs and number of tablets prescribed (MMEs: β = −33.33 [95% CI, −38.48 to −28.19]; tablets: β = −10.00 [95% CI, −11.17 to −8.82]) for laparoscopic cholecystectomy. For knee arthroscopy, no decreases were found in either median MMEs or number of tablets prescribed (MMEs: β = 10.00 [95% CI, −22.33 to 42.33; tablets: β = 0.83; 95% CI, −3.39 to 5.05). The proportion of prescriptions written for longer than 5 days also decreased significantly during the quarter of implementation across all 3 surgical specialties. In this cross-sectional study, the implementation of mandatory PDMP consultation with a concurrent EHR-based alert was associated with an immediate decrease in opioid prescribing across the 3 surgical specialties. These findings might be explained by prescribers’ attempts to meet the mandate exemption and bypass PDMP consultation rather than the PDMP consultation itself. Although policies coupled with EHR alerts may be associated with changes in postoperative opioid prescribing behavior, they need to be well designed to optimize evidence-based opioid prescribing. This cross-sectional study examines whether the implementation of mandated consultation with a prescription drug monitoring program was associated with changes in the quantity of postoperative opioid medications prescribed at discharge among adult patients in a health care system in California.
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影响因子：
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