Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use
Michael L. Barnett, M.D., Andrew R. Olenski, B.S., and Anupam B. Jena, M.D., Ph.D.
N Engl J Med 2017; 376:663-673February 16, 2017
Increasing overuse of opioids in the United States may be driven in part by physician prescribing. However, the extent to which individual physicians vary in opioid prescribing and the implications of that variation for long-term opioid use and adverse outcomes in patients are unknown.
We performed a retrospective analysis involving Medicare beneficiaries who had an index emergency department visit in the period from 2008 through 2011 and had not received prescriptions for opioids within 6 months before that visit. After identifying the emergency physicians within a hospital who cared for the patients, we categorized the physicians as being high-intensity or low-intensity opioid prescribers according to relative quartiles of prescribing rates within the same hospital. We compared rates of long-term opioid use, defined as 6 months of days supplied, in the 12 months after a visit to the emergency department among patients treated by high-intensity or low-intensity prescribers, with adjustment for patient characteristics.
Our sample consisted of 215,678 patients who received treatment from low-intensity prescribers and 161,951 patients who received treatment from high-intensity prescribers. Patient characteristics, including diagnoses in the emergency department, were similar in the two treatment groups. Within individual hospitals, rates of opioid prescribing varied widely between low-intensity and high-intensity prescribers (7.3% vs. 24.1%). Long-term opioid use was significantly higher among patients treated by high-intensity prescribers than among patients treated by low-intensity prescribers (adjusted odds ratio, 1.30; 95% confidence interval, 1.23 to 1.37; P<0.001); these findings were consistent across multiple sensitivity analyses.
Wide variation in rates of opioid prescribing existed among physicians practicing within the same emergency department, and rates of long-term opioid use were increased among patients who had not previously received opioids and received treatment from high-intensity opioid prescribers. (Funded by the National Institutes of Health.).
NEJM Journal Watch:
Are Antibiotics Useful for Small Skin Abscesses? Now There’s an Answer
Comments from Dr. Paolo:
Some initial thoughts on this study:
- Even taken at face value this is one study in a vast sea of
literature that has found no distinction between antibiotic therapy versus
simple incision and drainage. If we are to assume the 7% difference in
rate of cure as defined in the article (more to come) then difference in
cure rate is a solitary data point that will be summated within the larger
body of literature currently demonstrating no significant first pass cure
rate (rates of subsequent skin and soft tissue infections aside). This may
move the summated needle and change the end point of the combined
literature but it is not, in and of itself against a backdrop of negative
studies, compelling on its own.
- Primary outcome was defined by a clinical test of cure assessment at
7-14 days via a non-validated internally developed outcome measure. This
instrument has never been studied, externally validated, or assessed to
determine the secondary generalizability and inter-rater reliability of the
assessment tool. Though the study mentions a “good inter-rater
reliability” there is no external means to assess this instrument and it is
the (very) subjective crux upon which the whole study rests.
- 34 of the total cohort was lost to follow-up and not included in an
intention to treat analysis. 69 individuals were never assessed at the
test of cure visit (or were excluded prior to the test of cure visit) and
were included in the mITT-2 population.
- The secondary outcomes are nonsense and there are 12 of them and they
should be dismissed out of hand and ignored. There is no reason to include
multiple uncontrolled, nonsensical secondary outcomes that cannot possibly
be controlled for and will, defintionally, have significant differences
discovered simply by the volume of the parsing of the initial dataset.
- The point estimate of this study offers a NNT of 14 to (and this is
important) demonstrate clinical cure as assessed by a non-validated
instrument at 7-10 days post incision and drainage (with no standardization
of the I&D techniques). This means that at best 13 people will receive no
benefit whatsoever from the exposure to high dose antibiotics and will
demonstrate no changes in a (non-validated) clinical assessment
instrument. Further if the lower bound of the confidence interval were
true this would yield an NNT of 50 in order to achieve a benefit on the
(non-validated) clinical assessment instrument. There were no harms found
in this study (NNH) to counterbalance the NNT for us to determine the
likelihood of harm from the prescription of antimicrobials. I am not sure
why this occurred but we are aware of high rates of allergic reactions,
c-diff, antimicrobial resistance, and diarrhea to counterbalance to alleged
benefit of antimicrobial prescriptions.
- There were no distinctions between invasive disease between each group
or other severe outcomes that would bias towards the treatment with
antimicrobials. If you believe this study and the point estimated
difference then this study does not (as it alleges using a non-validated
instrument) argue for treatment of all comers to the ED with initial
antimicrobials rather than I&D alone (which cured the vast majority of
patients)—in fact it argues that the initial treatment SHOULD be I&D alone
followed by a return visit (or PCP follow-up) in 7-10 days for
reassessment. At the return visit antimicrobial therapy can be added to
the small and select group who are deemed treatment failures rather than
the wanton and inappropriate prescription of antibiotics to all comers
(based upon this study and its non-validated clinical assessment
Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage.
Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, Moy CS, Silbergleit R, Steiner T, Suarez JI, Toyoda K, Wang Y, Yamamoto H, Yoon BW; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network.
N Engl J Med. 2016 Sep 15;375(11):1033-43. doi: 10.1056/NEJMoa1603460. Epub 2016 Jun 8.
Full Text PDF
Computed Tomography Use for Adults with Head Injury: Describing Likely Avoidable ED Imaging based on the Canadian CT Head Rule.
Sharp AL, Nagaraj G, Rippberger EJ, Shen E, Swap CJ, Silver MA, McCormick T, Vinson DR, Hoffman JR.
Acad Emerg Med. 2016 Jul 30. doi: 10.1111/acem.13061. [Epub ahead of print]
Full Text PDF
Via Dr. Paolo:
“For every hour a physician sees a patient…he/she spends 2 filling out paperwork.”
Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties
Ann Intern Med. Published online 6 September 2016 doi:10.7326/M16-0961
Full text PDF: http://annals.org/data/Journals/AIM/0/AIME201612060-M160961.pdf
Via Louise Prince:
“Dr. Johnson sends the scientific and NY Times articles. I wanted to send this “feel good” article about patient experience. What we do matters. It’s a quick read.”