Postoperative Nudges to Reduce Opioid Prescribing

Study Overview
=================
Brief Summary
-----------------
This study tests the effectiveness of two email-based behavioral nudges, one based on peer behavior and one based on best practice guidelines, in reducing excessive opioid prescriptions after surgery. It will be conducted in three surgical specialties (general surgery, orthopedic surgery, and obstetric/gynecological surgery) at 19 hospitals within one healthcare system. These specialties will each be randomized to a control group or one of two nudge groups. Each month for one year, surgeons in the nudge groups will receive emails comparing their opioid prescribing either to their peers' prescribing or to prescribing guidelines. Both types of email-based nudges are expected to reduce opioid prescribing after surgery.

Official Title
-----------------
Reducing Inappropriate Prescription Opioid Prescribing at Hospital Discharge

Conditions
-----------------
Opioid Prescribing

Intervention / Treatment
-----------------
* Behavioral: Guideline-Based (Injunctive Norm) Nudges
* Behavioral: Peer-Based (Social Norm) Nudges


Participation Criteria
=================
Eligibility Criteria
-----------------
The nudges that a surgeon in either intervention arm will receive are based on that surgeon's eligible discharge opioid prescriptions in the previous month. Eligible prescriptions meet all of the following criteria: the patient is at least 18 years old at the date of surgery the patient is discharged to their home the surgical procedure has an applicable post-operative opioid prescribing guideline the surgical procedure is the only surgical procedure performed during the patient's hospital stay the prescription is for an opioid taken orally (tablets, capsules, or liquid solution) To avoid contamination between the intervention arms, surgeons who operate across multiple surgical specialties (defined as surgeons who performed less than 90% of their total procedures in one specialty between June 2020 and May 2021) will not be eligible.

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Guideline-Based Nudges<br> | Behavioral: Guideline-Based (Injunctive Norm) Nudges<br>* Surgeons in this arm will receive an email with the following content at the end of each month in which at least two of their patients are discharged with an opioid prescription that exceeds the prescribing guideline for the procedure performed. Dear Dr. [Name], In [month], at least XX of your patients were discharged with opioid prescriptions exceeding the amounts recommended by safety guidelines for these procedures. For patient safety, Sutter Health recommends prescribing within the ranges below for these procedures. Doing so will also meet best-practice safety guidelines for post-operative opioid prescribing. We will continue to send you opioid prescribing safety reports. Sincerely, [Signature] [Table displaying recommended ranges of 5mg oxycodone tablets for each procedure]<br>|
| Experimental: Peer-Based Nudges<br> | Behavioral: Peer-Based (Social Norm) Nudges<br>* Surgeons in this arm will receive an email with the following content at the end of each month in which at least two of their patients are discharged with an opioid prescription that exceeds the prescribing guideline for the procedure performed. Dear Dr. [Name], In [month], at least XX of your patients were discharged with opioid prescriptions exceeding the amount prescribed by YY% of your peers for these procedures. YY% of [specialty] surgeons at Sutter Health prescribe within the ranges below for these procedures. We will continue to send you opioid prescribing safety reports. Sincerely, [Signature] [Table displaying recommended ranges of 5mg oxycodone tablets for each procedure] The ranges of 5mg oxycodone tablets displayed will be the same as the ranges stipulated by the prescribing guidelines, but this nudge will not mention guidelines.<br>|
| No Intervention: Control<br> | |

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Share of discharge opioid prescriptions above prescribing guidelines | Prescriptions will be compared to prescribing guidelines via morphine milligram equivalents (MMEs) and coded as within or above guidelines. If no opioid is prescribed at discharge, this will be coded as within guidelines. | 12 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Morphine milligram equivalents (MMEs) prescribed at discharge | Continuous measure of the total morphine milligram equivalents prescribed at discharge | 12 months | 
| Days' supply of opioids prescribed at discharge | Continuous variable indicating the number of days' supply of opioids prescribed at discharge | 12 months | 
| Share of discharges where any opioid was prescribed | Derived from binary variable indicating if any opioid was prescribed at discharge | 12 months | 
| Share of patients on opioids for greater than 3 months post-discharge | Derived from binary variable indicating if the patient has any opioid prescriptions between 3 and 6 months after surgery | 3-6 months post-discharge | 
| Number of 30-day all-cause emergency department visits | Number of emergency department visits the post-operative patient has in the 30 days after the initial procedure | 0-30 days post-discharge | 
| Number of 30-day all-cause hospitalizations | Number of hospital admissions the post-operative patient has in the 30 days after the initial procedure | 0-30 days post-discharge | 
| Share of discharge opioid prescriptions above prescribing guidelines in the year after the intervention ends | Prescriptions will be compared to prescribing guidelines via morphine milligram equivalents (MMEs) and coded as within or above guidelines. If no opioid is prescribed at discharge, this will be coded as within guidelines. | 12 months | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Opioid Epidemic, Inappropriate Prescribing, Opioid-Related Disorders, Practice Guideline, Peer Influence, Nudges