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By Default: The Effect of Prepopulated Prescription Quantities on Opioid Prescribing in the Emergency Department.
West J Emerg Med. 2018 Mar; 19(2):392-397.WJ

Abstract

Introduction

Opioid prescribing patterns have come under increasing scrutiny with the recent rise in opioid prescriptions, opioid misuse and abuse, and opioid-related adverse events. To date, there have been limited studies on the effect of default tablet quantities as part of emergency department (ED) electronic order entry. Our goal was to evaluate opioid prescribing patterns before and after the removal of a default quantity of 20 tablets from ED electronic order entry.

Methods

We performed a retrospective observational study at a single academic, urban ED with 58,000 annual visits. We identified all adult patients (18 years or older) seen in the ED and discharged home with prescriptions for tablet forms of hydrocodone and oxycodone (including mixed formulations with acetaminophen). We compared the quantity of tablets prescribed per opioid prescription 12 months before and 10 months after the electronic order-entry prescription default quantity of 20 tablets was removed and replaced with no default quantity. No specific messaging was given to providers, to avoid influencing prescribing patterns. We used two-sample Wilcoxon rank-sum test, two-sample test of proportions, and Pearson's chi-squared tests where appropriate for statistical analysis.

Results

A total of 4,104 adult patients received discharge prescriptions for opioids in the pre-intervention period (151.6 prescriptions per 1,000 discharged adult patients), and 2,464 post-intervention (106.69 prescriptions per 1,000 discharged adult patients). The median quantity of opioid tablets prescribed decreased from 20 (interquartile ration [IQR] 10-20) to 15 (IQR 10-20) (p<0.0001) after removal of the default quantity. While the most frequent quantity of tablets received in both groups was 20 tablets, the proportion of patients who received prescriptions on discharge that contained 20 tablets decreased from 0.5 (95% confidence interval [CI] [0.48-0.52]) to 0.23 (95% CI [0.21-0.24]) (p<0.001) after default quantity removal.

Conclusion

Although the median number of tablets differed significantly before and after the intervention, the clinical significance of this is unclear. An observed wider distribution of the quantity of tablets prescribed after removal of the default quantity of 20 may reflect more appropriate prescribing patterns (i.e., less severe indications receiving fewer tabs and more severe indications receiving more). A default value of 20 tablets for opioid prescriptions may be an example of the electronic medical record's ability to reduce practice variability in medication orders actually counteracting optimal patient care.

Authors+Show Affiliations

University of Wisconsin School of Medicine and Public Health, BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin.University of Wisconsin School of Medicine and Public Health, BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin.University of Wisconsin School of Medicine and Public Health, BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin.University of California San Francisco, Zuckerberg San Francisco General. Kaiser Permanente Oakland Medical Center, Emergency Department, Oakland, California.University of Wisconsin School of Medicine and Public Health, BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin.University of Wisconsin School of Medicine and Public Health, BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin. Health Innovation Program, University of Wisconsin-Madison, Madison, Wisconsin.

Pub Type(s)

Journal Article
Observational Study

Language

eng

PubMed ID

29560071

Citation

Santistevan, Jamie R., et al. "By Default: the Effect of Prepopulated Prescription Quantities On Opioid Prescribing in the Emergency Department." The Western Journal of Emergency Medicine, vol. 19, no. 2, 2018, pp. 392-397.
Santistevan JR, Sharp BR, Hamedani AG, et al. By Default: The Effect of Prepopulated Prescription Quantities on Opioid Prescribing in the Emergency Department. West J Emerg Med. 2018;19(2):392-397.
Santistevan, J. R., Sharp, B. R., Hamedani, A. G., Fruhan, S., Lee, A. W., & Patterson, B. W. (2018). By Default: The Effect of Prepopulated Prescription Quantities on Opioid Prescribing in the Emergency Department. The Western Journal of Emergency Medicine, 19(2), 392-397. https://doi.org/10.5811/westjem.2017.10.33798
Santistevan JR, et al. By Default: the Effect of Prepopulated Prescription Quantities On Opioid Prescribing in the Emergency Department. West J Emerg Med. 2018;19(2):392-397. PubMed PMID: 29560071.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - By Default: The Effect of Prepopulated Prescription Quantities on Opioid Prescribing in the Emergency Department. AU - Santistevan,Jamie R, AU - Sharp,Brian R, AU - Hamedani,Azita G, AU - Fruhan,Scott, AU - Lee,Andrew W, AU - Patterson,Brian W, Y1 - 2018/02/12/ PY - 2017/01/30/received PY - 2017/10/11/revised PY - 2017/10/09/accepted PY - 2018/3/22/entrez PY - 2018/3/22/pubmed PY - 2018/8/28/medline SP - 392 EP - 397 JF - The western journal of emergency medicine JO - West J Emerg Med VL - 19 IS - 2 N2 - Introduction: Opioid prescribing patterns have come under increasing scrutiny with the recent rise in opioid prescriptions, opioid misuse and abuse, and opioid-related adverse events. To date, there have been limited studies on the effect of default tablet quantities as part of emergency department (ED) electronic order entry. Our goal was to evaluate opioid prescribing patterns before and after the removal of a default quantity of 20 tablets from ED electronic order entry. Methods: We performed a retrospective observational study at a single academic, urban ED with 58,000 annual visits. We identified all adult patients (18 years or older) seen in the ED and discharged home with prescriptions for tablet forms of hydrocodone and oxycodone (including mixed formulations with acetaminophen). We compared the quantity of tablets prescribed per opioid prescription 12 months before and 10 months after the electronic order-entry prescription default quantity of 20 tablets was removed and replaced with no default quantity. No specific messaging was given to providers, to avoid influencing prescribing patterns. We used two-sample Wilcoxon rank-sum test, two-sample test of proportions, and Pearson's chi-squared tests where appropriate for statistical analysis. Results: A total of 4,104 adult patients received discharge prescriptions for opioids in the pre-intervention period (151.6 prescriptions per 1,000 discharged adult patients), and 2,464 post-intervention (106.69 prescriptions per 1,000 discharged adult patients). The median quantity of opioid tablets prescribed decreased from 20 (interquartile ration [IQR] 10-20) to 15 (IQR 10-20) (p<0.0001) after removal of the default quantity. While the most frequent quantity of tablets received in both groups was 20 tablets, the proportion of patients who received prescriptions on discharge that contained 20 tablets decreased from 0.5 (95% confidence interval [CI] [0.48-0.52]) to 0.23 (95% CI [0.21-0.24]) (p<0.001) after default quantity removal. Conclusion: Although the median number of tablets differed significantly before and after the intervention, the clinical significance of this is unclear. An observed wider distribution of the quantity of tablets prescribed after removal of the default quantity of 20 may reflect more appropriate prescribing patterns (i.e., less severe indications receiving fewer tabs and more severe indications receiving more). A default value of 20 tablets for opioid prescriptions may be an example of the electronic medical record's ability to reduce practice variability in medication orders actually counteracting optimal patient care. SN - 1936-9018 UR - https://www.unboundmedicine.com/medline/citation/29560071/By_Default:_The_Effect_of_Prepopulated_Prescription_Quantities_on_Opioid_Prescribing_in_the_Emergency_Department_ L2 - https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/29560071/ DB - PRIME DP - Unbound Medicine ER -