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.