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Original Investigation
July 18, 2018

Association of Lowering Default Pill Counts in Electronic Medical Record Systems With Postoperative Opioid Prescribing

Author Affiliations
  • 1Department of Surgery, Yale School of Medicine, New Haven, Connecticut
  • 2National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 3Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 4Department of Pediatric Surgery, Connecticut Children’s Medical Center, Hartford
JAMA Surg. Published online July 18, 2018. doi:10.1001/jamasurg.2018.2083
Key Points

Question  What is the association of lowering prescription defaults for postoperative opioids in an electronic medical record system with prescribing?

Finding  In a prepost intervention study of 1447 procedures before the default change and 1463 procedures after the default change, lowering the default from 30 pills to 12 pills decreased the amount of opioid prescribed by more than 15% across an entire health system.

Meaning  Lowering the default number of opioid pills prescribed in an electronic medical record system is a simple, effective, cheap, and potentially scalable intervention to decrease the amount of opioid prescribed after procedures.

Abstract

Importance  Reliance on prescription opioids for postprocedural analgesia has contributed to the opioid epidemic. With the implementation of electronic medical record (EMR) systems, there has been increasing use of computerized order entry systems for medication prescriptions, which is now more common than handwritten prescriptions. The EMR can autopopulate a default number of pills prescribed, and 1 potential method to alter prescriber behavior is to change the default number presented via the EMR system.

Objective  To investigate the association of lowering the default number of pills presented when prescribing opioids in an EMR system with the amount of opioid prescribed after procedures.

Design, Setting, and Participants  A prepost intervention study was conducted to compare postprocedural prescribing patterns during the 3 months before the default change (February 18 to May 17, 2017) with the 3 months after the default change (May 18 to August 18, 2017). The setting was a multihospital health care system that uses Epic EMR (Hyperspace 2015 IU2; Epic Systems Corporation). Participants were all patients in the study period undergoing 1 of the 10 most common operations and discharged by postoperative day 1.

Intervention  The default number of opioid pills autopopulated in the EMR when prescribing discharge analgesia was lowered from 30 to 12.

Main Outcomes and Measures  Linear regression estimating the change in the median number of opioid pills and the total dose of opioid prescribed was performed. Opioid doses were converted into morphine milligram equivalents (MME) for comparison. The frequency of patients requiring analgesic prescription refills was also evaluated.

Results  There were 1447 procedures (mean [SD] age, 54.4 [17.3] years; 66.9% female) before the default change and 1463 procedures (mean [SD] age, 54.5 [16.4] years; 67.0% female) after the default change. After the default change, the median number of opioid pills prescribed decreased from 30 (interquartile range, 15-30) to 20 (interquartile range, 12-30) per prescription (P < .001). The percentage of prescriptions written for 30 pills decreased from 39.7% (554 of 1397) before the default change to 12.9% (183 of 1420) after the default change (P < .001), and the percentage of prescriptions written for 12 pills increased from 2.1% (29 of 1397) before the default change to 24.6% (349 of 1420) after the default change (P < .001). Regression analysis demonstrated a decrease of 5.22 (95% CI, −6.12 to −4.32) opioid pills per prescription after the default change, for a total decrease of 34.41 (95% CI, −41.36 to −27.47) MME per prescription. There was no statistical difference in opioid refill rates (3.0% [4 of 135] before the default change vs 1.5% [2 of 135] after the default change, P = .41).

Conclusions and Relevance  Lowering the default number of opioid pills prescribed in an EMR system is a simple, effective, cheap, and potentially scalable intervention to change prescriber behavior and decrease the amount of opioid medication prescribed after procedures.

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