Drivers of variation in postpartum opioid prescribing across hospitals participating in a statewide maternity care quality collaborative.
cesarean birth
dilation and curettage
pain management
quality improvement
vaginal birth
Journal
Birth (Berkeley, Calif.)
ISSN: 1523-536X
Titre abrégé: Birth
Pays: United States
ID NLM: 8302042
Informations de publication
Date de publication:
30 Dec 2023
30 Dec 2023
Historique:
revised:
06
10
2023
received:
10
03
2023
accepted:
04
12
2023
medline:
2
1
2024
pubmed:
2
1
2024
entrez:
30
12
2023
Statut:
aheadofprint
Résumé
We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics. We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner- and hospital-level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient. Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient-level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8-1066.7) and third-/fourth-degree perineal laceration (aOR 25.7, 95% CI 17.4-37.9). Receiving care from a certified nurse-midwife (aOR 0.63, 95% CI 0.48-0.82) or family medicine physician (aOR 0.60, 95%CI 0.39-0.91) was associated with lower prescribing rates. Hospital-level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61-15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15-0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%). Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner- and hospital-level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms.
Sections du résumé
BACKGROUND
BACKGROUND
We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics.
METHODS
METHODS
We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner- and hospital-level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient.
RESULTS
RESULTS
Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient-level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8-1066.7) and third-/fourth-degree perineal laceration (aOR 25.7, 95% CI 17.4-37.9). Receiving care from a certified nurse-midwife (aOR 0.63, 95% CI 0.48-0.82) or family medicine physician (aOR 0.60, 95%CI 0.39-0.91) was associated with lower prescribing rates. Hospital-level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61-15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15-0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%).
DISCUSSION
CONCLUSIONS
Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner- and hospital-level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Subventions
Organisme : NIH HHS
Pays : United States
Informations de copyright
© 2023 The Authors. Birth published by Wiley Periodicals LLC.
Références
Fisher ES, Bynum JP, Skinner JS. Slowing the growth of health care costs-lessons from regional variation. N Engl J Med. 2009;360(9):849-852.
Newhouse JP, Garber AM. Geographic variation in health care spending in the United States: insights from an Institute of Medicine report. JAMA. 2013;310(12):1227-1228.
Kozhimannil KB, Law MR, Virnig BA. Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Aff. 2013;32(3):527-535.
Friedman AM, Ananth CV, Prendergast E, D'Alton ME, Wright JD. Variation in and factors associated with use of episiotomy. JAMA. 2015;313(2):197-199.
Tita AT, Landon MB, Spong CY, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med. 2009;360(2):111-120.
Wong CA, Girard T. Undertreated or overtreated? Opioids for postdelivery analgesia. Br J Anaesth. 2018;121(2):339-342.
Peahl AF, Dalton VK, Montgomery JR, Lai YL, Hu HM, Waljee JF. Rates of new persistent opioid use after vaginal or cesarean birth among US women. JAMA Netw Open. 2019;2(7):e197863.
Bateman BT, Franklin JM, Bykov K, et al. Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naive women. Am J Obstet Gynecol. 2016;215(3):353 e351-353 e318.
Osmundson SS, Wiese AD, Min JY, et al. Delivery type, opioid prescribing, and the risk of persistent opioid use after delivery. Am J Obstet Gynecol. 2019;220(4):405-407.
Peahl AF, Morgan DM, Dalton VK, et al. New persistent opioid use after acute opioid prescribing in pregnancy: a nationwide analysis. Am J Obstet Gynecol. 2020;223(4):566 e561-566 e513.
Peahl AF, Morgan DM, Langen ES, et al. Variation in opioid prescribing after vaginal and cesarean birth: a statewide analysis. Womens Health. 2023;33(2):182-190.
Main EK, Moore D, Farrell B, et al. Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. Am J Obstet Gynecol. 2006;194(6):1644-1651; discussion 1651-1642.
Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6):e170504.
Zhu Y, Huybrechts KF, Desai RJ, et al. Prescription opioid use after vaginal delivery and subsequent persistent opioid use and misuse. Am J Obstet Gynecol MFM. 2021;3(2):100304.
Badreldin N, Grobman WA, Yee LM. Racial disparities in postpartum pain management. Obstet Gynecol. 2019;134(6):1147-1153.
Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight - reconsidering the use of race correction in clinical algorithms. N Engl J Med. 2020;383(9):874-882.
Robert Graham Center. Social Deprivation Index (SDI). Accessed February 27, 2023.https://www.graham-center.org/maps-data-tools/social-deprivation-index.html
Centers for Medicare & Medicaid Services. Data Dissemination. Accessed November 21, 2022. https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/DataDissemination
American Association of Birth Centers, Association of Women's Health Obstetric and Neonatal Nurses, American College of Obstetricians and Gynecologists, et al. Obstetric care consensus #9: levels of maternal care. Am J Obstet Gynecol. 2019;221(6):B19-B30.
Agency for Healthcare Research and Quality. Healthcare Cost & Utilization Project: NIS Description of Data Elements. Accessed January 17, 2023. www.hcup-us.ahrq.gov/db/vars/hosp_locteach/nisnote.jsp
White VanGompel E, Perez S, Wang C, Datta A, Cape V, Main E. Measuring labor and delivery unit culture and clinicians' attitudes toward birth: revision and validation of the labor culture survey. Birth. 2019;46(2):300-310.
Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361(14):1368-1375.
Krell RW, Girotti ME, Dimick JB. Extended length of stay after surgery: complications, inefficient practice, or sick patients? JAMA Surg. 2014;149(8):815-820.
Leonard PSJ, Crouse DL, Boudreau JG, Gupta N, McDonald JT. Practitioner volume and maternal complications after Caesarean section: results from a population-based study. BMC Pregnancy Childbirth. 2020;20(1):37.
Killip S, Mahfoud Z, Pearce K. What is an intracluster correlation coefficient? Crucial concepts for primary care researchers. Ann Fam Med. 2004;2(3):204-208.
Agarwal S, Bryan JD, Hu HM, et al. Association of state opioid duration limits with postoperative opioid prescribing. JAMA Netw Open. 2019;2(12):e1918361.
Howard R, Alameddine M, Klueh M, et al. Spillover effect of evidence-based postoperative opioid prescribing. J Am Coll Surg. 2018;227(3):374-381.
Declercq E, Barger M, Cabral HJ, et al. Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstet Gynecol. 2007;109(3):669-677.
Chidgey BA, McGinigle KL, McNaull PP. When a vital sign leads a country astray-the opioid epidemic. JAMA Surg. 2019;154(11):987-988.
Ecker J, Abuhamad A, Hill W, et al. Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine. Am J Obstet Gynecol. 2019;221(1):B5-B28.
Wiles A, Korn E, Dinglas C, Bentley B, Rosne J, Rahimi S. Disparities in post cesarean section pain management. J Clin Gynecol Obstet. 2022;11(2):27-32.
Johnson JD, Asiodu IV, McKenzie CP, et al. Racial and ethnic inequities in postpartum pain evaluation and management. Obstet Gynecol. 2019;134(6):1155-1162.
American College of Nurse-Midwives. Our Philosophy of Care. Accessed January 17, 2023. https://www.midwife.org/our-philosophy-of-care
Leziak K, Yee LM, Grobman WA, Badreldin N. Patient experience with postpartum pain Management in the Face of the opioid crisis. J Midwifery Womens Health. 2021;66(2):203-210.
Macones GA, Caughey AB, Wood SL, et al. Guidelines for postoperative care in cesarean delivery: enhanced recovery after surgery (ERAS) society recommendations (part 3). Am J Obstet Gynecol. 2019;221(3):247 e241-247 e249.
Peahl AF, Smith R, Johnson TRB, Morgan DM, Pearlman MD. Better late than never: why obstetricians must implement enhanced recovery after cesarean. Am J Obstet Gynecol. 2019;221(2):117 e111-117 e117.
White VanGompel E, Perez S, Datta A, Wang C, Cape V, Main E. Cesarean overuse and the culture of care. Health Serv Res. 2019;54(2):417-424.
Prabhu M, Dubois H, James K, et al. Implementation of a quality improvement initiative to decrease opioid prescribing after cesarean delivery. Obstet Gynecol. 2018;132(3):631-636.
MacGregor CA, Neerhof M, Sperling MJ, et al. Post-cesarean opioid use after implementation of enhanced recovery after surgery protocol. Am J Perinatol. 2021;38(7):637-642.
Shinnick JK, Ruhotina M, Has P, et al. Enhanced recovery after surgery for cesarean delivery decreases length of hospital stay and opioid consumption: a quality improvement initiative. Am J Perinatol. 2020;38(S 01):e215-e223.
McCoy JA, Gutman S, Hamm RF, Srinivas SK. The association between implementation of an enhanced recovery after cesarean pathway with standardized discharge prescriptions and opioid use and pain experience after cesarean delivery. Am J Perinatol. 2021;38(13):1341-1347.
Prabhu M, McQuaid-Hanson E, Hopp S, et al. A shared decision-making intervention to guide opioid prescribing after cesarean delivery. Obstet Gynecol. 2017;130(1):42-46.
Osmundson SS, Raymond BL, Kook BT, et al. Individualized compared with standard postdischarge oxycodone prescribing after cesarean birth: a randomized controlled trial. Obstet Gynecol. 2018;132(3):624-630.
Mills JR, Huizinga MM, Robinson SB, et al. Draft opioid-prescribing guidelines for uncomplicated normal spontaneous vaginal birth. Obstet Gynecol. 2019;133(1):81-90.
Vu JV, Howard RA, Gunaseelan V, Brummett CM, Waljee JF, Englesbe MJ. Statewide implementation of postoperative opioid prescribing guidelines. N Engl J Med. 2019;381(7):680-682.