Reducing Daily Dosing in Opioid Prescriptions in 11 Safety Net Emergency Departments

From the 2023 HVPA National Conference

Da Wi Shin BE (Icahn School of Medicine at Mount Sinai), Daniel Alaiev BBA (New York City Health + Hospitals), Hyung Cho MD, Surafel Tsega MD, Mona Krouss MD

The United States continues to face a significant issue with opioid misuse, overprescribing, dependency, and overdose. Electronic health record (EHR) interventions have shown to be an effective tool to modify opioid prescribing behaviors. Most previous EHR interventions were done in single center, high-resourced settings such as academic institutions. The effectiveness and the variation in multi-hospital settings, particularly in resource-limited safety net systems deserve further study.

This quality improvement project describes an EHR intervention to reduce daily dosing in opioid prescriptions in 11 emergency departments (ED) across the largest safety net health system in the US.

The dosing defaults on the preference list for oxycodone-acetaminophen 5-325 mg products were uniformly changed to ‘every 6 hours as needed’ and ‘1 tablet’, respectively, across 11 EDs. The pre-intervention refill, duration, and dispense quantity were unchanged and remained accordant to the guidelines. The primary outcome measure was the proportion of prescriptions exceeding 50 morphine milligram equivalents per day (MMED); also stratified by individual hospitals and clinician type

The percentage of prescriptions greater than or equal to 50 MMED decreased from 46.0% (1624 of 3530 prescriptions) to 1.6% (52 of 3165 prescriptions) (96.4% relative reduction; p<0.001). All 11 hospitals had a significant reduction in prescriptions exceeding 50 MMED. Nurse practitioners had the highest relative reduction of prescriptions exceeding 50 MMED at 100% (p<0.001), and the attendings/fellows had the lowest relative reduction at 95.6% (p<0.001).

Default nudges are a simple yet powerful intervention that can strongly influence opioid prescribing patterns.

Clinical Implications:
Our initiative successfully reduced the total daily dose of opioids prescribed across 11 EDs in the largest safety net system in the US. This expands on previous work in using defaults nudges in the EHR to achieve change, but focuses specifically on MMED. This is a crucial outcome measure given that opioid dosages above 50 MMED are associated with minimal pain improvement without any functional benefit, while the incidence of serious harms increases, such as misuse, overdose, and death.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog