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Impact of Hospital "Best Practice" Mandates on Prescription Opioid Dispensing After an Emergency Department Visit.

ABSTRACT: OBJECTIVE:Washington State mandated seven hospital "best practices" in July 2012, several of which may affect emergency department (ED) opioid prescribing and provide a policy template for addressing the opioid prescription epidemic. We tested the hypothesis that the mandates would reduce opioid dispensing after an ED visit. We further assessed for a selective effect in patients with prior risky or chronic opioid use. METHODS:We performed a retrospective, observational analysis of ED visits by Medicaid fee-for-service beneficiaries in Washington State, between July 1, 2011, and June 30, 2013. We used an interrupted time-series design to control for temporal trends and patient characteristics. The primary outcome was any opioid dispensing within 3 days after an ED visit. The secondary outcome was total morphine milligram equivalents (MMEs) dispensed within 3 days. RESULTS:We analyzed 266,614 ED visits. Mandates were associated with a small reduction in opioid dispensing after an ED visit (-1.5%, 95% confidence interval [CI] = -2.8% to -0.15%). The mandates were associated with decreased opioid dispensing in 42,496 ED visits by patients with prior risky opioid use behavior (-4.7%, 95% CI = -7.1% to -2.3%) and in 20,238 visits by patients with chronic opioid use (-3.6%, 95% CI = -5.6% to -1.7%). Mandates were not associated with reductions in MMEs per dispense in the overall cohort or in either subgroup. CONCLUSIONS:Washington State best practice mandates were associated with small but nonselective reductions in opioid prescribing rates. States should focus on alternative policies to further reduce opioid dispensing in subgroups of high-risk and chronic users.

SUBMITTER: Sun BC

PROVIDER: S-EPMC5552416 | biostudies-literature | 2017 Aug

REPOSITORIES: biostudies-literature

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Impact of Hospital "Best Practice" Mandates on Prescription Opioid Dispensing After an Emergency Department Visit.

Sun Benjamin C BC Lupulescu-Mann Nicoleta N Charlesworth Christina J CJ Kim Hyunjee H Hartung Daniel M DM Deyo Richard A RA John McConnell K K

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 20170726 8

<h4>Objective</h4>Washington State mandated seven hospital "best practices" in July 2012, several of which may affect emergency department (ED) opioid prescribing and provide a policy template for addressing the opioid prescription epidemic. We tested the hypothesis that the mandates would reduce opioid dispensing after an ED visit. We further assessed for a selective effect in patients with prior risky or chronic opioid use.<h4>Methods</h4>We performed a retrospective, observational analysis of ...[more]

PMID: 28544288

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Project description:STUDY OBJECTIVE:We assess whether an automated prescription drug monitoring program intervention in emergency department (ED) settings is associated with reductions in opioid prescribing and quantities. METHODS:We performed a retrospective cohort study of ED visits by Medicaid beneficiaries. We assessed the staggered implementation (pre-post) of automated prescription drug monitoring program queries at 86 EDs in Washington State from January 1, 2013, to September 30, 2015. The outcomes included any opioid prescribed within 1 day of the index ED visit and total dispensed morphine milligram equivalents. The exposure was the automated prescription drug monitoring program query intervention. We assessed program effects stratified by previous high-risk opioid use. We performed multiple sensitivity analyses, including restriction to pain-related visits, restriction to visits with a confirmed prescription drug monitoring program query, and assessment of 6 specific opioid high-risk indicators. RESULTS:The study included 1,187,237 qualifying ED visits (898,162 preintervention; 289,075 postintervention). Compared with the preintervention period, automated prescription drug monitoring program queries were not significantly associated with reductions in the proportion of visits with opioid prescribing (5.8 per 1,000 encounters; 95% confidence interval [CI] -0.11 to 11.8) or the amount of prescribed morphine milligram equivalents (difference 2.66; 95% CI -0.15 to 5.48). There was no evidence of selective reduction in patients with previous high-risk opioid use (1.2 per 1,000 encounters, 95% CI -9.5 to 12.0; morphine milligram equivalents 1.22, 95% CI -3.39 to 5.82). The lack of a selective reduction in high-risk patients was robust to all sensitivity analyses. CONCLUSION:An automated prescription drug monitoring program query intervention was not associated with reductions in ED opioid prescribing or quantities, even in patients with previous high-risk opioid use.

Project description:BACKGROUND:Although homelessness and opioid overdose are major public health issues in the U.S., evidence is limited as to whether homelessness is associated with an increased risk of opioid overdose. OBJECTIVE:To compare opioid-related outcomes between homeless versus housed individuals in low-income communities. DESIGN, SETTING, AND PARTICIPANTS:Cross-sectional analysis of individuals who had at least one ED visit or hospitalization in four states (Florida, Maryland, Massachusetts, and New York) in 2014. MEASUREMENTS:Risk of opioid overdose and opioid-related ED visits/hospital admissions were compared between homeless versus low-income housed individuals, adjusting for patient characteristics and hospital-specific fixed effects (effectively comparing homeless versus low-income housed individuals treated at the same hospital). We also examined whether risk of opioid-related outcomes varied by patients' sex and race/ethnicity. RESULTS:A total of 96,099 homeless and 2,869,230 low-income housed individuals were analyzed. Homeless individuals had significantly higher risk of opioid overdose (adjusted risk, 1.8% for homeless vs. 0.3% for low-income housed individuals; adjusted risk difference [aRD], +1.5%; 95%CI, +1.0% to +2.0%; p < 0.001) and opioid-related ED visit/hospital admission (10.4% vs. 1.5%; aRD, +8.9%; 95%CI, +7.2% to +10.6%; p < 0.001) compared to low-income housed individuals. Non-Hispanic White females had the highest risk among the homeless population, whereas non-Hispanic White males had the highest risk among the low-income housed population. LIMITATIONS:Individuals with no ED visit or hospitalization in 2014 were not included. CONCLUSION:Homeless individuals had disproportionately higher adjusted risk of opioid-related outcomes compared to low-income housed individuals treated at the same hospital. Among homeless individuals, non-Hispanic White females incurred the highest risk. These findings highlight the importance of recognizing the homeless population-especially the non-Hispanic White female homeless population-as a high-risk population for opioid overdose.

Project description:ObjectiveAt our emergency department (ED), opioid prescribing guidelines were implemented in September 2016. The opioid prescribing guidelines were adopted and revised from collective efforts and advocacy of the Michigan College of Emergency Physicians for ED-led opioid stewardship. We performed a retrospective before and after study to determine if opioid prescribing guidelines would change the use of intravenous opioids per patient and the morphine equivalent units (MEU) per patient in a suburban academic ED.MethodsA retrospective observational study was conducted at a tertiary care level 1 trauma center with an annual ED volume of ≈ 130,000 visits. All intravenous orders of fentanyl, morphine, and hydromorphone for adult patients from January 1, 2015, through December 31, 2017, were tabulated. A 3-month (August 2016-October 2016) washout period was used. Poisson and ordinary linear regression analyses were employed to evaluate any difference in number of intravenous opioids ordered before and after adoption of the guidelines. Within our opioid prescribing guidelines was also guidance for oral opioid orders within the ED and oral opioid prescriptions for discharge, although these elements were not included in this investigation.ResultsA total of 108,327 intravenous opioid orders were included in the final analysis. After adoption of the opioid prescribing guidelines, the expected number of intravenous opioids ordered dropped by 3.1% (eβ, 0.969; 95% confidence interval [CI], 0.779-1.209), and there was an additional decrease of 0.1% per month (eβ, 0.999; 95% CI, 0.990-1.010). After the adoption of opioid prescribing guidelines, the average MEU dropped by 0.3 mg (95% CI, -0.47 to -0.13), and there was decrease of 0.01 mg per month (95% CI, -0.02 to -0.004).ConclusionAfter the adoption of opioid prescribing guidelines, our analysis suggests that opioid prescribing guidelines are associated with clinically small but statistically significant changes in MEU ordered in ED. We cannot determine if this represented a continued trend of decreased opioid use or associated with the opioid prescribing guidelines.

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Impact of Hospital "Best Practice" Mandates on Prescription Opioid Dispensing After an Emergency Department Visit.

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Impact of Hospital "Best Practice" Mandates on Prescription Opioid Dispensing After an Emergency Department Visit.

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