Discussion:
Main Findings
In our retrospective sample of women undergoing cesarean section, opioid
prescription patterns altered following the NYSDOH mandated opioid
prescriber training course. After this intervention, we found a
statistically significant shift towards a lower amount of narcotic
prescribed. Our data also suggests that amount of opioid prescribed did
not correlate with opioid consumption in the hospital, patient
demographic factors (i.e. BMI, age, race), surgical factors (surgery
length, indication for cesarean, estimated blood loss, skin incision,
closure, anesthesia), and hospital factors (length of stay, infection).
Cesarean section is the most common surgery undergone by women. There is
a paucity of data on opioid prescription patterns and normative opioid
consumption after cesarean delivery, which poses a challenge for
obstetricians who are attempting to prescribe an appropriate amount of
narcotic for pain control. In light of the opioid epidemic, there have
been statewide and national attempts towards decreasing narcotic use.
Our study demonstrated that the provider training course mandated by the
NYSDOH altered prescriber practices after January 1, 2018 at our
institution.
The median amount of prescribed narcotic was 150 MME both pre and
post-intervention because the most common prescription in both groups
was 20 pills of 5mg oxycodone or Percocet which converts into 150 MME.
Though 150 MME remained the median amount of narcotic prescribed, we
observed a decline in the percentage of prescriptions >150
MME (21.3%) post-training as opposed to prior to training, a reduction
that was particularly apparent in residents.
This apparent decline of prescriptions >150 MME especially
in residents is important because at many academic institutions,
residents are primarily responsible for prescribing a large number of
narcotics following all procedures. Although many states now require an
opioid training course for providers prior to allowing prescriptions,
New York is the only state, which mandates residents take a narcotic
training course. The positive shift in our institution prescribing
patterns after the mandated opioid training course helps support the
argument that residents be mandated to take a course and have opioid
training/education be included as part of the residency curriculum. This
is especially significant since residents will move on to become
prescribing Attendings themselves
Strengths
The main strength of our study is that we reviewed an extensive cohort
of women in the pre and post intervention groups and we were able to
look at prescriber patterns for a large number of diverse providers of
varying levels using a reliable EMR system. This, therefore, provides an
accurate picture of what is occurring at our facility.
Limitations
It is important to note that our study has some limitations. It is a
retrospective study with a high risk, urban patient population, which
may not be generalizable of all cesarean deliveries in the United States
other countries. In addition, there was a significant difference in BMI
and race between the groups. We can explain this by the large percentage
of “unknown” race and BMI. We gathered the information about race and
BMI from EPIC chart review, and usually secretaries enter in these
demographics. We do not feel that our patient population changed after
the intervention. In addition, between the two groups there was a
significant difference in surgery time, estimated blood loss and skin
closure. Surgeries were longer post-intervention. We speculate that this
was due to an increased number of newer and younger hires on faculty.
Frequently junior attendings have longer surgical times when compared to
more experienced faculty. The difference in estimated blood loss between
groups may be explained by the implementation of “Quantitative Blood
Loss” measurements where nurses calculated blood loss for deliveries
using a standard formula. At our institution we noted that quantitative
blood loss measurements tended to be higher than the providers estimated
blood loss. Though we used estimated blood loss in our study, we
understand the measurement of quantitative blood loss may bias
providers’ estimations as well. The majority of cases were closed using
sutures. Though the decrease in the use of staples post-intervention was
significant, we do not believe that this is clinically relevant, and
would have to perform future studies on narcotic use with different
methods of skin closure to determine a true association.
Our study only looked at our provides’ prescription habits, and this may
not accurately depict which prescriptions were filled by the patients
and/or amount of narcotic consumed. There were a variable number of
providers in each level, with the largest number of prescriptions being
written by residents. Our total analysis did not account for
prescription habits between providers of different levels. However, we
do not feel that controlling for provider level would alter the effect
since in general PGY1-2 in the pre-intervention group were PGY 3-4 in
the postintervention group. Another limitation is that our institution
piloted an Enhanced Recovery After Surgery or ERAS protocol around the
same time-period that we performed our chart review. This trial included
58 patients and used an inpatient only post-operative EPIC order set.
Data from the protocol demonstrated that ERAS was not associated with a
reduction in postoperative narcotic use.9 Though there
is a possibility the pilot may have affected our results post
intervention, it is unlikely to be relevant since as mentioned above,a priori adjusted model showed no statistical significance
between in house narcotic use and prescription doses.
Conclusion
Our study suggests that the mandated opioid training course had an
effect on prescribing patterns after cesarean section. In addition, we
interestingly noted that neither amount of opioid consumed in the
hospital, nor patient demographic, surgical or hospital factors played a
part in influencing narcotic prescriptions. This is important as one
would expect the amount of narcotic use inhouse to predict future use at
home in the immediate post-operative setting, and therefore should be
factored in when writing these prescriptions.
Next steps would include a prospective study looking at the percentage
of patients that filled their opioid prescriptions and actual patient
opioid consumption upon discharge. Although we demonstrated that
prescription patterns at our hospital were not correlated with inpatient
narcotic use, patient demographics or surgery characteristics, it is
possible that outpatient opioid use may be associated with these
characteristics. A future project would include developing an algorithm
to combine relevant patient characteristics or surgery factors with
actual patient use at home in order to guide providers in writing
appropriate narcotic prescriptions upon discharge.
The difference in amount of narcotic prescribed after the training for
patients post cesarean section may indicate a shift in provider
attitudes surrounding opioids before and after the mandated New York
State opioid training. However, it is important to note that this shift
may be a result of the intervention or simply to a general increase in
awareness about the opioid crisis during this time through the media and
news. Our study addresses the validity of this mandated opioid training
course as a means for altering provider narcotic prescribing habits. Our
study is relevant outside of New York, as most other states require a
similar opioid prescriber training program prior to allowing providers
to send narcotic prescriptions.