Postdischarge Opioid Prescription after Cesarean: A Quality Improvement Initiative

Abstract

Objective This study aims to determine if adoption of a user-friendly algorithm for individualized opioid prescribing at discharge would decrease the number of opioids prescribed after cesarean delivery.

Study Design As part of a quality initiative, we developed and implemented an algorithm for opioid prescribing at discharge for patients after cesarean delivery. The intervention group comprised patients delivering by cesarean in the 6 months following initiation of the intervention. The intervention group was divided into three groups based on inpatient opioid needs 24 to 48 hours after delivery. Oxycodone tablets were prescribed at discharge based on inpatient group. The control group comprised patients delivering at the same institution in the 6 months prior to initiation of the intervention. The primary outcome was number of oxycodone tablets prescribed at discharge. The secondary outcome was the proportion of patients with a pain-related encounter or additional oxycodone prescription up to 6 weeks after delivery.

Results From July to December 2020, a total of 382 subjects met criteria for the intervention. The comparison group consisted of 391 subjects discharged from January to June 30, 2020, after cesarean. Baseline characteristics and inpatient opioid use 24 to 48 hours after delivery did not differ between the groups. Compared with the control group, subjects in the intervention group had fewer oxycodone tablets prescribed at discharge (11.1 vs. 15.8, p < 0.001). The number of pain-related encounters within 6 weeks of delivery did not differ between the intervention and comparison groups (10.5 vs. 10.3%, p = 0.82). There was no increase in the additional number of oxycodone prescriptions after discharge (4.7% in the intervention group vs. 4.3% in the control group, p = 0.81).

Conclusion Discharge opioid prescribing based on inpatient use after cesarean reduces the number of opioids prescribed without increasing the number of pain-related encounters after discharge. A simple algorithm may ensure compliance from prescribers.

Key Points

• Previous research has shown that most opioids prescribed after cesarean delivery are unused after discharge. We implemented an algorithm for opioid discharge prescribing after cesarean delivery based on inpatient opioid consumption.

• Implementing an individualized approach to opioid prescribing reduced the number of tablets prescribed at discharge after cesarean delivery. The decrease in discharge prescribing did not correspond to an increase in pain-related encounters or additional narcotic prescriptions in the 6 weeks following delivery.

• The overprescription of opioids at discharge after cesarean delivery is well-established, and previous authors have found success in prescribing opioids at discharge based on inpatient use. Our study proposes a simple, reproducible algorithm for opioid prescribing at discharge after cesarean.

Keywords

cesarean delivery - cohort - enhanced recovery - opioid prescribing - opioids - quality improvement

Publikationsverlauf

Eingereicht: 31. Oktober 2022

Angenommen: 26. September 2023

Accepted Manuscript online:
03. Oktober 2023

Artikel online veröffentlicht:
30. November 2023

• References

• 1 Wilson N, Kariisa M, Seth P, Smith IV H, Davis NL. Drug and opioid-involved overdose deaths - United States, 2017-2018. MMWR Morb Mortal Wkly Rep 2020; 69 (11) 290-297
• 2 Pfuntner A, Wier LM, Stocks C. Most Frequent Procedures Performed in U.S. Hospitals, 2010. . HCUP Statistical Brief #149. February 2013. Rockville, MD: Agency for Healthcare Research and Quality;
• 3 American College of Obstetricians and Gynecologists. Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1. Obstet Gynecol 2021; 138: 507-517
• 4 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 (03) 247.e1-247.e9
• 5 Osmundson SS, Schornack LA, Grasch JL, Zuckerwise LC, Young JL, Richardson MG. Postdischarge opioid use after cesarean delivery. Obstet Gynecol 2017; 130 (01) 36-41
• 6 Bateman BT, Cole NM, Maeda A. et al. Patterns of opioid prescription and use after cesarean delivery. Obstet Gynecol 2017; 130 (01) 29-35
• 7 Carrico JA, Mahoney K, Raymond KM. et al. Predicting opioid use following discharge after cesarean delivery. Ann Fam Med 2020; 18 (02) 118-126
• 8 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 (03) 624-630
• 9 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 (01) 42-46