Testing a Provider-Level Feedback Intervention to Optimize Postoperative Prescribing - Aim 3 Phase 1
Phase: NA
Conditions: Opioid Prescribing
Sponsor: University of Michigan

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Testing a Provider-Level Feedback Intervention to Optimize Postoperative Prescribing  
Principal Investigators: 
Jennifer Waljee, MD, MPH, MS 
Chad Brummett, MD 
University of Michigan, Ann Arbor 
 
 
 
IRB Approval Date: August 2, 2023 
NCT04776928 
 
 
 
 
 
 
 
 
 

 
A. Objective 
The objective of this project is to leverage the Michigan Surgical Quality Collaborative’s (MSQC) 
existing network and surgeon performance feedback platform to improve opioid prescribing practices 
for surgeons within the network found to be prescribing in a manner discordant with published 
guidelines. This work will test how effective this intervention and mechanism are for changing 
surgeon prescribing behavior and will inform best practices for future surgical quality improvement 
initiatives. 
 
B. Specific Aim/Hypothesis 
To test the effectiveness of a provider-level feedback intervention in optimizing postoperative opioid 
prescribing. Further, we will assess the acceptability, appropriateness, and adoption of this 
intervention through survey and qualitative interview mechanisms. We hypothesize that provider-level 
feedback will allow clinicians to tailor postoperative prescribing more closely to patient consumption 
and reduce excess postoperative prescribing. 
 
C. Background InformationC1 Project Rationale 
Opioid use in the United States is a national public health crisis, with 130 Americans dying each day 
from opioid overdose1. The state of Michigan has been particularly impacted by the opioid epidemic. 
In 2017, Michigan ranked number 11 in highest rate of opioid involved deaths in the country2. While 
prescription opioids are routinely used to treat pain following surgery, over-prescription of these same 
medications increases the risk of new persistent use for the patient and for diversion of excess pills 
into the community. Decreasing opioid prescribing following surgery presents an opportunity to 
reduce the amount of risk to the patient and to the community. 
 
Provider-facing feedback interventions - such as the “push reports” utilized in this project - are a 
promising tool for decreasing post-surgical overprescribing. There is evidence of the success and 
effectiveness of similar interventions among other aspects of care, such as perioperative antibiotic 
prophylaxis and electronic health record utilization 3,4,5. Creating tools that integrate opioid prescribing 
and procedure-specific recommendations could allow clinicians to tailor opioid prescriptions to pain 
requirements and prevent new opioid dependence.  
 
C2 OPEN and the Michigan Surgical Quality Collaborative 
This project is a collaborative effort between the Opioid Prescribing Engagement Network (Michigan 
OPEN) and the Michigan Surgical Quality Collaborative (MSQC). 
 
OPEN 
The Opioid Prescribing Engagement Network works to steward safe opioid prescribing Michigan by 
developing evidence-based pain management recommendations for providers, educating patients 
about safe use and disposal of opioids, and reducing excess opioid pills within the community. OPEN 
has developed procedure specific prescribing recommendations to curb over-prescribing of 
postoperative opioids. These recommendations for patients with no preoperative opioid use, were 
informed by patient-reported data, published studies, and expert opinion. As of February 2020, 
Michigan OPEN has developed recommendations for 27 procedures for surgical procedures including 
abdominal, breast, and orthopedic procedures. 
 
MSQC 

The Michigan Surgical Quality Collaborative (MSQC) is one of the largest surgical collaborative 
quality improvement programs in the U.S. and captures more than 90% of all general and vascular 
surgical procedures in Michigan. The MSQC includes surgeons and hospitals statewide that collect 
and analyze data to improve the quality of care for patients undergoing surgery in Michigan. They are 
also designated at a Patient Safety Organization designated by the Agency for Healthcare Research 
and Quality Clinical nurse abstractors (Surgical Clinical Quality Reviewers (SCQRs)) from over 70 
hospitals across the state enter procedure and outcomes data – including opioid prescribing 
information and patient reported outcomes – into the MSQC platform at regular intervals.  This data is 
used for quality improvement and to provide surgeons with regular surgeon specific reports on 
MSQC’s secure web-based platform. These reports contain real-time, risk adjusted, personalized 
feedback on both surgeon and hospital levels. Providers can also use this platform to easily view their 
performance in comparison with other de-identified member institutions, drill down into specific cases, 
and export their own data for further analysis. Each MSQC site also has a surgeon champion who is 
designated to oversee the implementation and administration of the MSQC program at their institution 
including supporting the SCQR, promoting and participating in activities directed at improving surgical 
quality improvement and sharing best practices, and regularly attending the MSQC Quarterly 
Meetings, Annual Conference, and Surgeon Champion Conference Calls. The role of the MSQC and 
the Surgeon Champion is not punitive toward individual sites or surgeons. 
 
C3 Project Innovation and Impact 
Currently, MSQC provides a robust platform for quality improvement through tailored and modifiable 
feedback reports regarding important aspects of perioperative and postoperative care, including 
complications, mortality, and healthcare utilization. Each quarter, MSQC hospitals receive 
dashboards regarding benchmarks of surgical care in which hospital performance is displayed 
against blinded peer data. In this study, we will harness this robust infrastructure to identify surgeons 
who are outliers in surgical opioid prescribing and deliver specific feedback to them through an email 
push reporting mechanism. 
 
D. Methodology 
Figure 1 Overview of Study Methodology 
           
 
 
 
D1 Identification of Surgeon Outliers 
Using existing MSQC data from 1/1/2019 – 2/28/2021, 217 surgeons have been identified as outliers 
by the MSQC team. Only cases that had valid prescribing data and surgeon National Provider 
Identifier (NPI) were considered. Prescribing data for the following surgeries were included: 
Laparoscopic Cholecystectomy, Open Cholecystectomy, Laparoscopic Appendectomy, Open 
Appendectomy, Minor Hernia, Abdominal Hernia, Laparoscopic Colectomy, Open Colectomy, Vaginal 
Identify outlier prescribers
Collect Exhibit B-1 
Send Push Reports 
and Surveys
Continue 
collecting 
prescribing data
Analyze prescribing data

Hysterectomy, Laparoscopic Hysterectomy, Total Abdominal Hysterectomy, Thyroidectomy, Carotid 
Endarterectomy, Laparoscopic Anti-Reflux and Hiatal Hernia Surgery, Creation, Re-siting, or Closure 
of Ileostomy or Colostomy, Open Small Bowel Resection or Enterolysis. These procedures were then 
grouped into categories based on the number of pills (5 mg oxycodone equivalents) recommended by 
opioid prescribing guidelines. We will use 2019 guidelines for 2019 data and 2020 guidelines for 2020 
and 2021 data 
 
Table 1: Prescribing Guidelines by Procedure Group 
Procedure 
category 
Procedures 
0-5 pills 
Thyroidectomy 
0-10 pills 
Laparoscopic Anti-Reflux and Hiatal Hernia Surgery, 
Laparoscopic Appendectomy, Open Appendectomy, 
Minor Hernia, Abdominal Hernia, Laparoscopic 
Cholecystectomy, Carotid Endarterectomy 
0-15 pills 
Open Cholecystectomy, Laparoscopic Colectomy, 
Open Colectomy,  Vaginal Hysterectomy, 
Laparoscopic Hysterectomy, Total Abdominal 
Hysterectomy, and Creation, Re-siting, or Closure of 
Ileostomy or Colostomy 
0-20 pills 
Open Small Bowel Resection or Enterolysis 
 
 
 
 
Median prescribing was calculated using all cases in a specific procedure category at a specific site 
for which there is a prescribing guideline. If median prescribing of the surgeon was >1 pill (7.5 MME) 
above current guidelines, they were considered outliers. 
D2 Site Enrollment and Protections 
Prior to initiation of the research described in this protocol, the study team will contact hospitals with 
surgeons identified as outliers. Sites that agree to participate in the research by allowing the team to 
access their identifiable data and send push reports will be required to sign an Exhibit B-1 authorizing 
the release of the Patient Safety Work Product (PSWP) pursuant to the purpose of Opioid Prescribing 
Engagement Network Research Activities. This Exhibit B-1 will outline how the site’s data will be used 
in research but will not include information that would bias the study. Exhibit B-1 language will have 
appropriate approval from legal reviewers at the University of Michigan. The study team will work with 
the Surgeon Champion and the Surgical Clinical Quality Reviewer at each selected site to identify the 
appropriate signatory for such a document and to get the document signed and returned to the study 
team (either through directing the team to the appropriate individual or routing the paperwork to the 
appropriate individual and returning the paperwork to the study team depending on the preference of 
the site and the Surgeon Champion/SCQR). The individual administrator who signs the Exhibit B-1 for 
the site will not be alerted as to which surgeon(s) at their site may be receiving the intervention push 
report.  
 

For sites who do not complete this paperwork we will look only at de-identified data at the site level to 
examine prescribing changes. This control arm will not receive the push report intervention.  
 
 
D3 Control Arm 
The study team will enroll sites that did not sign the Exhibit B-1 and surgeons at sites who signed the 
Exhibit B-1 but for whom no contact was available into a control arm. The study team will not have 
access to identifiable data for sites that did not sign the Exhibit B-w and will obtain and analyze only 
de-identified site level data.. Those who are moved back to the control arm will be de-identified before 
re-inclusion in the data file. The study team will use this data to examine prescribing changes.  
 
D4 Individual Level Push Report Intervention 
All surgeons belonging to sites that signed the Exhibit B-1 document and identified as outliers will be 
eligible to receive the push-report intervention The template for provider-level push-report emails has 
been developed by the study team and informed by surgeon specific reports already available 
through MSQC and previous quality improvement work led by the OPEN team. During this study, the 
template will be populated with the individual surgeon data and sent as emailed push reports to 
surgeons eligible to receive the intervention.  
 
D4A Description of the Push Report 
Surgeons receiving provider-level push report notifications will receive an email displaying their 
personal prescribing performance compared to OPEN prescribing guidelines and their de-identified 
peers. Because no case information except opioid prescribing will be included in the push report, the 
push report will also include a link to the existing, secure MSQC data platform that displays more 
information about the case so the surgeon can further investigate their prescribing if desired. The 
email will also contain contact information for the study team so as to help any surgeons troubleshoot, 
learn more, request to stop receiving reports, etc.   
D4B Sending the Push Reports 
The push reports will be sent to surgeons at sites who have signed the Exhibit B-1 over the course of 
four weeks. This will include all surgeons at sites who have signed Exhibit B-1s before the initiation of 
the push report launch for whom the study team has contact information. Sites who did not sign the 
Exhibit B-1 and/or surgeons for whom the team was unable to gather updated email addresses for 
push reporting and/or for whom the email address was no longer valid will be excluded from the 
intervention arm and moved to the control arm.  
 
The push report will be sent via using a secure email client. The email will be sent to the email the 
surgeon has provided to MSQC as their official email.  In the case of multiple email addresses, the 
study team will send the email to the most secure account available (e.g. .edu, .gov, .org rather than 
Yahoo, Gmail, etc). 
 
All surgeons who practice at hospitals and for whom we have a current email address who have 
signed the Exhibit B-1 will receive a push report email from the study team. Read receipts will be 
embedded in each push report email to see if surgeons have opened the push report. If they have 
not, the study team will follow-up with the same email on a weekly basis for a total of 4 weeks or until 
they open the email, whichever comes first. Emails will be sent to prescribers in this fashion unless 
they directly contact the study team to request otherwise and/or their hospital/health system revokes 
permission. 
 

D4C Push Report Data Collection 
We will collect prescribing data reported through the existing MSQC mechanism for five months from 
the date of the first push report In addition to the standard variables reported to MSQC, the study 
team will collect data on surgeon interaction with the email push report.  We will collect information 
such as who opens the email, who logs into the MSQC platform after receiving the email, and who 
directly contacts the study team and why. This information will be used to inform who needs to 
continue receiving push reports, be used in research analyses, and inform quality improvement 
opportunities based on this methodology. 
 
D5 Feedback Surveys 
Following receipt of the push report(s), the study team will send up to two surveys to all prescribers 
who received the push report to collect information about usability and acceptability of the email push 
reports. Surgeons who open the push report will be sent a survey invitation the following day and 
another two weeks later. The first survey will ask about their reactions to the push report and ask 
surgeons for permission to contacted again regarding a qualitative interview whereas the second will 
ask about any actions taken after receiving the push report.  Surgeons who do not open any of the 
push reports will be sent a different survey invitation. These surgeons will be asked a single question 
regarding what could be improved. Each invitation will contain a link to the appropriate survey 
programmed in University of Michigan secure Qualtrics and will be preceded by the approved consent 
form. 
Figure 2: Push Report Feedback Timeline  
 
 
 
D7 Qualitative Interview  
In addition to receiving up to two surveys, surgeons who indicate in the first survey that they are 
interested in scheduling or learning more about scheduling a qualitative interview will be emailed by 
the study team with the appropriate information. The purpose of this fifteen minute interview is to 
examine the preferences and experiences of surgeons who have received this feedback. The study 

team will reach out to the surgeon individually and work with them to schedule a time to conduct the 
interview.  
 
 
 
The interview will take place via Zoom or on the phone at the mutually agreeable time. A trained 
member of the study team will obtain consent from the participant prior to the interview. The 
participant must consent to having audio from the interview recorded in order to participate and 
language indicating this will be included in the consent. The interview will be recorded on an 
encrypted recorder or directly in the Zoom platform and then saved directly to an encrypted study 
drive. Once the audio recording is obtained and saved a study team member or third party who have 
an agreement with the University of Michigan will transcribe the interview. The transcription will also 
be saved to an encrypted study drive with the participant’s study ID.  
 
E. Statistical Design 
E1 Primary Outcome 
The primary outcome will be the average opioid prescribed (measured in oral morphine equivalents 
[OMEs] adjusted for the surgery type following the intervention. Only cases with valid prescribing data 
and surgeon NPI will be included for analysis. Prescribing data will be collected for five months 
following the first push report.  
E2 Exploratory Outcomes 
Exploratory outcomes will be the rate of prescribing within the MSQC guidelines over the same year 
following the intervention. We will also evaluate the survey and interview items collected on 
acceptability, ease of use, relevance, utility, and appearance. 
 
References: 
1.) CDC/NCHS, National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: 
US Department of Health and Human Services, CDC; 2018. https://wonder.cdc.gov 
2.) Opioid Summaries by State. National Institute of Drug Abuse. May 2019. 
https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state 
3.) Ivers N, Jamtvedt G, Flottorp S, et al. Audit and Feedback: Effects on professional 
practice and healthcare outcomes. Cochrane Database of Systematic Reviews. June 
13, 2012.  
4.) Brehaut, JC, Colquhoun HL, Eva KW, et al. Feedback interventions: 15 suggestions for 
optimizing effectiveness. Annals of Internal Medicine. March 15, 2016: 164:435-41. 
5.) Foy R, Eccles MP, Jamtvedt G, Young J, Grimshaw HM, Baker R. What do we know 
about how to do audit and feedback? Pitfalls in applying evidence from a systematic 
review. BMC Health Services Research. July 13, 2005; 5(50).