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Institutional and Regional Variation in Opioid Prescribing for Hospitalized Infants in the US
Olivia A Keane1, Shadassa Ourshalimian1, Ashwini Lakshmanan2
1Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California.
Insights
Opioid prescribing varies significantly among children's hospitals for high-risk infants. Standardizing opioid use in this vulnerable population is crucial for improving outcomes and reducing harm.
Area of Science:
- Neonatalogy
- Pediatric Pharmacology
- Health Services Research
Background:
- High-risk infants often experience prolonged opioid exposure due to medical complexities, linked to adverse outcomes.
- Understanding variations in opioid prescribing practices is essential for quality improvement initiatives.
Purpose of the Study:
- To investigate regional and institutional differences in opioid prescribing for high-risk infants.
- To analyze variation in the use of short- and long-acting opioid agents and methadone treatment.
Main Methods:
- Retrospective cohort study of 132,658 high-risk infants (<1 year) across 47 US children's hospitals (2016-2022).
- Data sourced from the Pediatric Health Information System (PHIS), stratified by US Census region.
- Hierarchical generalized linear models used to assess variation in cumulative days of opioid and methadone exposure.
Main Results:
- 76.5% of high-risk infants were exposed to opioids; 7.9% received methadone.
- Significant hospital-level variation observed in opioid and methadone exposure duration across all US regions.
- Hospitals accounted for 16% of variability in overall opioid prescribing and 20% in methadone treatment.
Conclusions:
- Institution-level variations in opioid and methadone exposure are prevalent among high-risk hospitalized infants nationwide.
- These findings underscore the critical need for standardized opioid prescribing guidelines in this vulnerable pediatric population.
- Standardization can mitigate risks associated with prolonged opioid exposure and improve patient outcomes.
Importance:
High-risk infants, defined as newborns with substantial neonatal-perinatal morbidities, often undergo multiple procedures and require prolonged intubation, resulting in extended opioid exposure that is associated with poor outcomes. Understanding variation in opioid prescribing can inform quality improvement and best-practice initiatives.
Objective:
To examine regional and institutional variation in opioid prescribing, including short- and long-acting agents, in high-risk hospitalized infants.
Design, Setting, And Participants:
This retrospective cohort study assessed high-risk infants younger than 1 year from January 1, 2016, to December 31, 2022, at 47 children's hospitals participating in the Pediatric Health Information System (PHIS). The cohort was stratified by US Census region (Northeast, South, Midwest, and West). Variation in cumulative days of opioid exposure and methadone treatment was examined among institutions using a hierarchical generalized linear model. High-risk infants were identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes for congenital heart disease surgery, medical and surgical necrotizing enterocolitis, extremely low birth weight, very low birth weight, hypoxemic ischemic encephalopathy, extracorporeal membrane oxygenation, and other abdominal surgery. Infants with neonatal opioid withdrawal syndrome, in utero substance exposure, or malignant tumors were excluded.
Exposure:
Any opioid exposure and methadone treatment.
Main Outcomes And Measures:
Regional and institutional variations in opioid exposure.
Results:
Overall, 132 658 high-risk infants were identified (median [IQR] gestational age, 34 [28-38] weeks; 54.5% male). Prematurity occurred in 30.3%, and 55.3% underwent surgery. During hospitalization, 76.5% of high-risk infants were exposed to opioids and 7.9% received methadone. Median (IQR) length of any opioid exposure was 5 (2-12) cumulative days, and median (IQR) length of methadone treatment was 19 (7-46) cumulative days. There was significant hospital-level variation in opioid and methadone exposure and cumulative days of exposure within each US region. The computed intraclass correlation coefficient estimated that 16% of the variability in overall opioid prescribing and 20% of the variability in methadone treatment was attributed to the individual hospital.
Conclusions And Relevance:
In this retrospective cohort study of high-risk hospitalized infants, institution-level variation in overall opioid exposure and methadone treatment persisted across the US. These findings highlight the need for standardization of opioid prescribing in this vulnerable population.
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