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Randomized Controlled Trial
. 2023 Aug 1;139(2):186-196.
doi: 10.1097/ALN.0000000000004607.

Best Practice Alerts Informed by Inpatient Opioid Intake to Reduce Opioid Prescribing after Surgery (PRIOR): A Cluster Randomized Multiple Crossover Trial

Megan L Rolfzen  1 , Abraham Wick  2 , Edward J Mascha  3 , Karan Shah  3 , Martin Krause  4 , Ana Fernandez-Bustamante  5 , Jean S Kutner  6 , P Michael Ho  6 , Daniel I Sessler  7 , Karsten Bartels  8
Affiliations
Randomized Controlled Trial

Best Practice Alerts Informed by Inpatient Opioid Intake to Reduce Opioid Prescribing after Surgery (PRIOR): A Cluster Randomized Multiple Crossover Trial

Megan L Rolfzen et al. Anesthesiology. .

Abstract

Background: Overprescription of opioids after surgery remains common. Residual and unnecessarily prescribed opioids can provide a reservoir for nonmedical use. This study therefore tested the hypothesis that a decision-support tool embedded in electronic health records guides clinicians to prescribe fewer opioids at discharge after inpatient surgery.

Methods: This study included 21,689 surgical inpatient discharges in a cluster randomized multiple crossover trial from July 2020 to June 2021 in four Colorado hospitals. Hospital-level clusters were randomized to alternating 8-week periods during which an electronic decision-support tool recommended tailored discharge opioid prescriptions based on previous inpatient opioid intake. During active alert periods, the alert was displayed to clinicians when the proposed opioid prescription exceeded recommended amounts. No alerts were displayed during inactive periods. Carryover effects were mitigated by including 4-week washout periods. The primary outcome was oral morphine milligram equivalents prescribed at discharge. Secondary outcomes included combination opioid and nonopioid prescriptions and additional opioid prescriptions until day 28 after discharge. A vigorous state-wide opioid education and awareness campaign was in place during the trial.

Results: The total postdischarge opioid prescription was a median [quartile 1, quartile 3] of 75 [0, 225] oral morphine milligram equivalents among 11,003 patients discharged when the alerts were active and 100 [0, 225] morphine milligram equivalents in 10,686 patients when the alerts were inactive, with an estimated ratio of geometric means of 0.95 (95% CI, 0.80 to 1.13; P = 0.586). The alert was displayed in 28% (3,074 of 11,003) of the discharges during the active alert period. There was no relationship between the alert and prescribed opioid and nonopioid combination medications or additional opioid prescriptions written after discharge.

Conclusions: A decision-support tool incorporated into electronic medical records did not reduce discharge opioid prescribing for postoperative patients in the context of vigorous opioid education and awareness efforts. Opioid prescribing alerts might yet be valuable in other contexts.(Anesthesiology 2023; 139:186-96).

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Conflict of interest statement

AFB reports research funding from the NIH/NHLBI, US Department of Defense, the Merck Investigator-initiated Studies Program and the IHQSE for projects not relevant to the discussed work. The other authors declare no competing interests.

Figures

Figure 1:
Figure 1:. Consort flow diagram.
In this cluster randomized multiple crossover trial, each hospital was randomized to eight-week periods of the best practice alert being active versus inactive and four-week washout periods, which were based on the date of discharge.
Figure 2:
Figure 2:. Opioid prescription amount at discharge by alert condition.
MME: morphine milligram equivalents.
See this image and copyright information in PMC

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