Post-Surgical Opioid Prescribing via Rule-Based Guidelines Derived from In-Hospital Consumption: An Assessment of Efficacy Based on Actual Patient-Reported Post-Discharge Opioid Consumption
Brendin Beaulieu-Jones*1, Margaret T. Berrigan1, Kortney A. Robinson1, Larry A. Nathanson2, Aaron Fleishman1, Gabriel A. Brat1
1Surgery, Beth Israel Deaconess Medical Center, Boston, MA; 2Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
Objective: Many institutions have developed operation-specific, consensus opioid prescribing guidelines to mitigate the harms experienced by post-surgical patients due to under- and over-prescribing. These guidelines rarely incorporate patient-level factors, including in-hospital opioid consumption, which has been shown to be highly correlated with post-hospital consumption. As a result, several groups have sought to develop approaches that are tailored to individual patients. In the current study, we compare outcomes of several experimental, rule-based guidelines with a previously validated, rule-based guideline and our current institutional practice based on historical post-discharge opioid consumption.
Design: Retrospective, cohort study (2017-2019)
Setting: Urban, academic medical center
Patients: Adults ("‰¥18 years) undergoing surgery at our institution
Interventions: Several rule-based opioid prescribing guidelines, derived from in-hospital consumption (specifically the quantity of opioids consumed on day of hospital discharge), were used to specify the theoretical quantity of opioid prescribed on discharge. The efficacy of the experimental guidelines was compared to two references: (a) a prospectively validated, rule-based guideline (Porter et al., PMID: 33640521) and (b) our current institutional practice in which based on their in-hospital opioid use, patients are prescribed either the median or 75th percentile of typical opioid use among patients who previously underwent the same operation at our hospital.
Main outcome: Based on the theoretically prescribed quantity in each scenario, we calculated several outcomes: penalized residual sum of squares (reflecting the composite deviation from actual patient consumption, with 15% penalty for over-prescribing) and the proportion of opioids consumed relative to the quantity prescribed (0%, 0-50%, 50-100%, 100-150%, >150%).
Results: 1862 patients underwent surgery during the study period. Mean (SD) and median [IQR] quantity of opioids consumed on discharge day was 7.9 (23.3) MME and 0 [0 to 7.5] MME. Median [IQR] post-discharge consumption was 22.5 [0-135] MME. For each scenario, outcomes regarding the quantity prescribed relative to consumed are presented in Table 1. Our hospital guideline and the previously validated rule-based guideline outperform alternate approaches, with penalized residual sum of squares of 43,130,753 and 60,427,573, respectively. Relative performance is unchanged when restricting the cohort to patients admitted for "‰¥24 hours.
Conclusion: Prescribing guidelines derived from actual post-discharge opioid consumption among historical patients at our institution are superior to rule-based guidelines. Still, given barriers to collecting institutional, post-hospital consumption data, rule-based guidelines offer a straightforward and reliable method for tailoring opioid prescribing to in-hospital consumption, rather than relying on fixed quantities for specific operations.
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