- A team of researchers at Dartmouth-Hitchcock Medical Center determined prescription drug monitoring program (PDMP) use negatively affects clinical efficiency without offering much benefit as a tool for reducing opioid prescribing for patients undergoing elective surgical procedures.
This finding comes in a recent JAMA Surgery study led by Ryland Stucke, MD, and others at the New Hampshire-based academic hospital.
The team conducted a prospective observational cohort study of 1,057 patients undergoing representative elective general surgery from July 1, 2016 to June 30, 2017.
The study period spanned the six months before and after a change in New Hampshire legislation mandated that providers query the hospital’s PDMP and opioid abuse risk calculator for all patients receiving an outpatient opioid prescription for acute pain.
Researchers collected and analyzed data including patient demographic information, procedure type, and whether a PDMP query or opioid risk assessment was performed.
“We identified a subset of patients for whom a PDMP query was performed but an opioid prescription was not written,” explained researchers in the study report. “For these patients, we repeated the PDMP query to assess if these individual patients had findings indicating a high risk of opioid abuse that would discourage a surgical clinician from writing an opioid prescription.”
Patients deemed high risk included those who had obtained multiple or frequent opioid prescriptions from multiple clinicians or pharmacies during the six months prior to the operation.
Dartmouth-Hitchcock providers can access the PDMP link through a hyperlink imbedded in the EHR system. While the hyperlink is accessible through the EHR system, users can only access PDMP information through an external website requiring a separate login and password.
The opioid risk calculator is integrated directly into the EHR system. Providers must complete EHR clinical documentation for each step of the process.
“If the prescriber fails to document the query, a decision support interruptive alert appears that informs the prescriber of the mandatory requirement to perform the query,” clarified researchers. “The prescription will not be disbursed unless the prescriber affirms that the query was performed.”
Of the patients included in the study, 536 underwent surgery before the legislation took effect and 521 patients were in surgery after.
Before the PDMP use mandate went into effect, 80 percent of patients were given an opioid prescription at the time of hospital discharge. After, 77 percent of patients received an opioid prescription.
“There was no significant change in case mix between the 2016 and 2017 groups,” wrote researchers.
“The PDMP query and risk calculator did not lead to a prescription being withheld for any patient in our series,” continued researchers.
Furthermore, the mean number of opioid pills prescribed decreased more significantly in the six months prior to the PDMP use mandate than in the six months after the mandate was put in place.
The average number of pills prescribed decreased by 22 percent in the six months before the mandate was implemented, and only 3.9 percent afterwards.
Researchers also quantified how much time providers spent completing additional requirements to measure administrative burden associated with the new mandate.
“Direct observation of 8 surgical clinicians during 21 patient encounters revealed a median time to complete the PDMP query and risk calculator together of 7 minutes,” stated researchers.
“An additional median time of 6 minutes (range, 4-15 minutes) was required to complete our institutional informed consent process,” stated researchers. “Together, these additional mandatory requirements for prescribing opioid medication to patients who underwent surgical procedures took 13 minutes for each patient.”
Ultimately, researchers determined legislation mandating PDMP queries and risk calculator use are largely ineffective for avoiding opioid prescriptions.
“We found that there was no decrease in the percentage of patients who were given an opioid prescription for postoperative pain, and in no cases was a prescription withheld from a patient owing to risk factors for abuse or suspicious PDMP findings,” the team said.
While PDMP use can be effective in outpatient care settings and for patients with chronic pain, researchers suggested PDMP use is unnecessarily burdensome for providers delivering elective surgical procedures.
“Our data do not support the use of a mandatory PDMP as a useful tool to curb opioid prescriptions written for patients undergoing general surgical procedures,” wrote researchers.
“In addition, these requirements create a significant additional burden of time and administrative responsibilities for surgical clinicians and trainees who already think that documentation requirements are excessive and compromise the time spent with patients,” researchers continued.
The mean turnover time between cases at Dartmouth-Hitchcock’s outpatient surgical center is 15 minutes. Adding up to 13 minutes per patient nearly doubles patient turnover time and inhibits clinical efficiency.
“New legislative efforts must be practical, feasible, and not impede the workflow of surgical clinicians,” researchers maintained.