Peer and Patient Feedback to Increase Adherence to Postoperative Opioid Prescribing Guidelines: A Stepped-Wedge Cluster Randomized Clinical Trial.

Abstract

Prescribing more opioids than patients need following surgery is associated with long-term use, misuse, and diversion. Interventions are needed to increase adherence to procedure-specific guidelines while preserving the ability to manage pain. To test whether providing clinicians monthly feedback with peer comparisons and patient-reported outcomes would increase adherence to postoperative opioid prescribing guidelines. This stepped-wedge cluster randomized clinical trial was conducted at 6 surgical departments or divisions caring for patients undergoing 30 high-volume surgical procedures in a 5-hospital academic health system in Pennsylvania and New Jersey. Surgical clinicians (attending surgeons, advanced practice professionals, and resident physicians) with 5 or more opioid prescriptions per month for eligible procedures during a 3-month period at baseline were eligible for inclusion. Six clinician clusters were randomly assigned to the intervention in 3 steps offset by 2 months. Each step included a 9-month baseline, a 6-month intervention, and a 6-month follow-up. The first step of the intervention began on June 8, 2022. Follow-up concluded in October 2023, and data analysis was performed from November 2023 to April 2024. Clinicians were emailed a report on their most frequently performed procedures, which contained a figure of the following mean numbers: pills prescribed relative to guidelines, pills peer clinicians prescribed, and pills patients reported using after a procedure; an additional figure displayed patients' self-reported ability to manage pain. Monthly reports included prescribing trends, peer comparison feedback, and reminders about how many pills patients take and how well patients reported pain management with guideline-adherent prescriptions. The primary outcome was the proportion of guideline-adherent opioid prescriptions; secondary outcomes included patient-reported ability to manage pain (measured on a 0 to 10 scale, with 0 being not at all able), pain score, pills prescribed, pills leftover, and refill rate. A total of 143 surgical clinicians treating 20 557 patients were included (10 069 at baseline, 5382 during the intervention, and 5106 at follow-up). Mean (SD) patient age was 57.0 (15.7) years, and 10 996 patients (53.5%) were female. The baseline guideline adherence rate was 57.2%. During the intervention, adherence increased to 71.8%, with an adjusted intervention effect of 5.3% (95% CI, 2.0%-8.7%). The impact of the intervention increased over time, and adherence remained above baseline at follow-up (74.4%). The largest change was noted for orthopedic procedures of knee, hip, and shoulder arthroplasty. Patient-reported pain and ability to manage pain were unchanged. In this stepped-wedge cluster randomized clinical trial, a feedback intervention using peer comparisons and patient-reported data increased opioid guideline adherence without compromising patients' ability to manage pain. ClinicalTrials.gov Identifier: NCT05358522.