Evaluating variation in opioid prescribing for emergency general surgery patients

Although procedure-specific guidelines have been established for postoperative opioid prescribing in the elective setting, it is unknown to what extent prescriptions in the emergency setting adhere to these standards. Variation in opioid prescribing for emergency general surgery patients may represent context-appropriate deviation or an opportunity for improved stewardship.

Leveraging data from a statewide Acute Care Surgery collaborative, we identified patients undergoing 4 common procedures in the emergency setting: laparoscopic appendectomy, laparoscopic cholecystectomy, emergency hernia repair, and open colectomy. We evaluated variation in discharge prescription size and adherence to elective opioid prescribing guidelines at the facility level using risk- and reliability-adjusted multilevel models. We also evaluated patient-level factors associated with non-guideline-concordant prescriptions.

This study included 10,155 patients across 10 hospitals. There was wide variation in opioid prescribing between facilities in terms of total oral morphine equivalents (1.5-3.7-fold) and opioid-free discharge (1.1-2.3-fold) for all procedures. Although most prescriptions were concordant with elective guidelines (75%-96%), colectomy prescriptions were 5 times less likely to be guideline concordant than appendectomy prescriptions (25% vs 4%). Increasing comorbidity burden (adjusted odds ratio 2.51, 95% confidence interval 1.55-4.05, P < .001) and American Society of Anesthesiologists physical status classification (adjusted odds ratio 1.77, 95% confidence interval 1.45-2.16, P < .001) were associated with non-guideline concordance.

Opioid-prescribing patterns in the emergency general surgery setting are widely variable and sometimes inconsistent with elective guidelines. Procedure- and patient-level factors unique to the emergency setting may inform postoperative pathways that improve opioid stewardship.