A qualitative analysis on the implementation of a nudge intervention to reduce post-surgical opioid prescribing

Reducing above-guideline opioid prescribing is one approach to reducing the availability of unused opioids. We describe contextual factors affecting the implementation and outcomes of a successful email 'nudge' aimed at reducing post-operative opioid prescribing, with the goal of informing future implementation and dissemination efforts.

Between October 2021-September 2022, we sent email nudges to general, orthopedic, and obstetrics/gynecology surgeons at 19 hospitals in a large integrated healthcare system in California whose patients had post-operative opioid prescriptions that exceeded guideline-recommended quantities. We then interviewed 36 surgeons between September 2022-January 2023 and coded and themed transcripts and implementation process documents from the study. We used the Consolidated Framework for Implementation Research (CFIR) to understand the contextual factors impacting nudge design, implementation, and effectiveness.

Factors across all five CFIR domains were found to be important in understanding the acceptability, feasibility, and sustainability of the intervention. In the Innovation Domain, key factors included the method of nudge delivery, the validity of comparators, and the design and layout of the nudge itself. The interaction between the nudges and existing state regulations (Outer Setting Domain) caused confusion, while the size, structure, and centralization of hospitals (Inner Setting Domain) influenced communication and leadership engagement, underscoring the need for local champions (Individuals Domain). In the Implementation Process Domain, workflow considerations emerged, e.g., the fact that the surgeon performing the procedure was at times not the discharge prescriber, the need for pre-intervention education, and the importance of ensuring surgeons have a clear process to access additional information when questions arise about nudge content.

Contextual factors related to how the nudges were implemented influenced their acceptability among surgeons. Future dissemination efforts of similar interventions to curb opioid overprescribing should take these design considerations into account, including how to account for variations in prescribing workflows, the amount of information provided in the nudge, how information is construed, and how the rest of the hospital system can adjust to encourage guideline-supported opioid prescribing at the point of post-surgical discharge. These types of considerations may also apply to other clinician-directed, nudge-based interventions beyond the subject of opioid prescribing.

Clinicaltrials.gov, Identifier: NCT05070338, Registration Date: October 19, 2021.