THE DEVELOPMENT AND ASSESSMENT OF APPROPRIATENESS MEASURES FOR POSTOPERATIVE OPIOID PRESCRIBING

The U.S. opioid overdose epidemic was declared a national public health emergency in 2017. It began with the increased prescribing of opioids in the 1990s. Nearly 500,000 people died from an overdose involving any opioid from 1999-2019. Postoperative opioid prescribing contributes to this problem with evidence of wide variation and excessive dosage after common surgical procedures. Recent data suggest that 70-80% of prescribed opioids are unused after surgery. Our aim was to develop procedure-specific postoperative opioid prescribing appropriateness measures and assess impact on prescribing patterns. Appropriateness measures, outlined in Chapter 1, are developed with the input of clinical experts and can be used to evaluate individual physician practices in order to drive improvements in care. Chapters 2 and 3 describe findings of wide variation in opioid prescribing after common surgical procedures in Medicare claims data and demonstrate that procedure-specific prescribing patterns are highly measurable in a cohort of opioid-naïve patients. We then developed consensus guidelines for postoperative opioid prescribing, implemented portions of the guidelines through a quality improvement project, and performed a randomized controlled trial using a peer data benchmarking intervention for a common surgical procedure. Chapter 4 details the use of the modified Delphi method to develop procedure-specific recommendations for twenty common surgical procedures with a multidisciplinary panel of experts and patient representation to provide a framework for limiting unwarranted prescribing variation. Chapter 5 summarizes an educational intervention for surgical residents and nurses that improved patient-specific opioid prescribing by more closely aligning postoperative opioid prescriptions with individual patient opioid use in the 24 hours before hospital discharge. Chapter 6 reports evidence from a randomized controlled trial which found that a peer data benchmarking intervention for surgeons performing open inguinal hernia repair operations can drive physician behavior change towards high-value care. This work has impacted policies at the health system, local, and national levels. Consensus guideline development has broadened to other procedural specialties. Peer data benchmarking interventions based on procedure-specific guidelines should be expanded to reduce excessive opioid overprescribing. This data-driven approach to the development and assessment of appropriateness measures is a model for addressing other areas of low-value care