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Variation in Opioid Prescribing After Vaginal and Cesarean Birth: A Statewide Analysis

Published:September 20, 2022DOI:https://doi.org/10.1016/j.whi.2022.08.007

      Abstract

      Introduction

      Our aim was to evaluate variation in opioid prescribing rates and prescription size following childbirth across providers and hospitals.

      Methods

      This retrospective cohort study analyzed claims data from a single-payer Preferred Provider Organization from June 2014 to May 2019 in 84 hospitals in a statewide quality collaborative. All patients aged 12–55 years, undergoing childbirth, with continuous enrollment in pregnancy were included. The primary outcome was the predicted rate of postpartum opioid fills from 7 days before birth to 3 days after discharge. Secondary outcomes included postpartum opioid prescription size in oral morphine equivalents, a standardized measure that includes the number of pills prescribed times the strength of the medication. Multilevel regression models accounted for clustering. We calculated attributable variation in opioid fills using the intraclass correlation coefficient.

      Results

      Of 41,427 births, 15,459 patients (37.2%) filled a postpartum opioid prescription (vaginal, 4,624/27,536 [16.8%]; cesarean, 10,835/13,891 [78.0%]). The median postpartum prescription size was 150 oral morphine equivalents (interquartile range [IQR], 30) (vaginal, 135; [IQR, 45]; cesarean, 150 [IQR, 75]). In adjusted models, the rates of opioid prescribing after vaginal birth differed from cesarean birth (vaginal median, 12.1% [range, 1.1%–60.0%]; cesarean median, 80.4% [range, 43.6%–90.2%]). More variation in postpartum opioid fills was attributable to providers and hospitals for vaginal (provider, 29%; hospital, 24%) than cesarean birth (provider, 8%; hospital, 6%). Variation in prescription size was driven by providers for vaginal birth (provider, 27%; hospital, 6%) and providers and hospitals for cesarean birth (provider, 29%; hospital, 21%).

      Conclusions

      Across a statewide quality collaborative, variation in postpartum opioid prescribing is attributable to providers and hospitals. Future efforts at the provider and hospital levels are needed to implement best practices for postpartum opioid prescribing.
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      Biography

      Alex F. Peahl, MD, MSc, is Assistant Professor, University of Michigan Department of Obstetrics and Gynecology and the Chair of the American College of Obstetricians and Gynecologists' Prenatal Care Initiative. Her research focuses on improving the effectiveness, efficiency, and equity of reproductive health care.

      Biography

      Daniel M. Morgan, MD, is Professor, University of Michigan Department of Obstetrics and Gynecology. His research focuses on clinical outcomes of treatment for pelvic floor disorders, health care services research, and quality improvement efforts.

      Biography

      Elizabeth S. Langen, MD, is Associate Professor, University of Michigan Department of Obstetrics and Gynecology and Co-Director of the Obstetrics Initiative. Her research interests include labor abnormalities in term and preterm birth, as well as maternal cardiac disease in pregnancy.

      Biography

      Lisa Kane Low, PhD, CNM, is Professor, University of Michigan Department of Obstetrics and Gynecology and School of Nursing, and Co-Director of the Obstetrics Initiative. Her research focuses on evidence-based childbirth practices that promote optimal outcomes for childbearing women and their families.

      Biography

      Chad M. Brummett, MD, is Professor, University of Michigan Department of Anesthesiology and Co-Director of the Michigan Opioid Prescribing Engagement Network. His research interests include predictors of acute and chronic post-surgical pain and failure to derive benefit from surgical interventions.

      Biography

      Yen-Ling Lai, MS, is Clinical Information Analyst, Michigan Opioid Prescribing Engagement Network, Department of Surgery at the University of Michigan.

      Biography

      Hsou-Mei Hu, PhD, is Clinical Information Analyst, Michigan Opioid Prescribing Engagement Network, Department of Surgery at the University of Michigan.

      Biography

      Melissa Bauer, DO, is Associate Professor, Duke University Department of Anesthesiology. Her research interests are focused on early identification and improving treatment for maternal infection and sepsis, and she is passionate about providing patient-centered care to meet each patient's needs.

      Biography

      Jennifer Waljee, MD, MPH, is Associate Professor, University of Michigan Department of Surgery; Co-Director, Michigan Opioid Prescribing Engagement Network; and Director, Center for Healthcare Outcomes & Policy. Her research interests include the development and implementation of patient-reported outcomes as quality measures.