Opioid disposal, medication cost alerts, and more

Summaries from ACP Hospitalist Weekly.

Many patients do not use or discard prescription opioids after surgery, review finds

Patients commonly do not use, lock, or discard their postoperative prescription opioids, according to a recent systematic review.

Researchers reviewed six studies of 810 unique patients (range, 30 to 250 patients) undergoing seven different types of surgical procedures to assessed opioid oversupply. They defined the primary outcome, opioid oversupply, as the number of patients who did not fill their opioid prescriptions or filled but did not use them.

Results were published online on Aug. 2 by JAMA Surgery.

Overall, 67% to 92% of patients in the studies reported unused opioids. Of the opioids that patients did obtain, 42% to 71% were not used. Most patients who stopped or did not use opioids (71% to 83%) reported doing so because their pain was adequately controlled. About 16% to 29% of patients reported concerns about opioid-induced adverse effects.

Two studies that looked at storage safety found that 73% to 77% of patients reported that their prescription opioids were not stored in locked containers. Only 4% to 9% of patients considered or used FDA-recommended disposal methods.

The study authors noted limitations to their analysis, such as the intermediate rather than high methodological quality of the studies they reviewed and heterogeneity among the studies. They added that the studies did not report leftover morphine equivalents or more granular data on unused opioid pill counts.

“Increased efforts are needed to develop and disseminate best practices to reduce the oversupply of opioids after surgery, especially given how commonly opioid analgesics prescribed by clinicians are diverted for nonmedical use and may contribute to opioid-associated injuries and deaths,” the study authors wrote.

Alerts about high medication costs did not affect inpatient prescribing

Displaying the costs of medications to inpatient prescribers did not significantly change their ordering patterns, a recent study found.

Photo by Thinkstock
Photo by Thinkstock.

The retrospective analysis looked at inpatient orders for nine expensive medications before and after Johns Hopkins Hospital in Baltimore implemented a cost-transparency initiative. From April 10 to Oct. 5, 2015, the hospital's computerized provider order entry system displayed the cost of the medications. For seven of the medications, there were also alerts such as “Levothyroxine injection cost: $55 per 100 mcg dose vs $0.80 per 200 mcg oral dose. Consider enteral therapy at a 50% dose conversion unless clinically contraindicated.” Medication orders during the intervention period were compared to a baseline period from Jan. 1, 2013, to April 9, 2015.

No significant changes were seen in orders for seven of the medications: IV eculizumab, calcitonin, levetiracetam, linezolid, mycophenolate, ribavirin, and levothyroxine. There were immediate and sustained reductions in use of two drugs. However, both of those drugs were affected by policy changes during the study. IV pantoprazole was restricted due to a national shortage and required approval from the pharmacy (−985 orders per 10,000 patient-days; 73% decrease), and oral voriconazole was replaced by another drug in several oncology order sets (−110 orders per 10,000 patient-days; 46% decrease). The study was published in the August Journal of Hospital Medicine.

The findings “suggest that the passive strategy of displaying cost alone was not effective in altering prescriber ordering patterns for the selected medications,” the authors said. The significant reduction in prescriptions for the two medications affected by policy changes suggests that more active strategies might be more successful at changing prescribing patterns, they added.

Previous research at the same hospital has shown that notifying clinicians about the costs of tests did affect their ordering of lab tests, but not imaging. “One might speculate that ordering fewer laboratory tests is viewed by providers as eliminating waste rather than choosing a less expensive option to accomplish the same diagnostic task at hand,” the authors wrote. They noted that the effects of cost transparency might also differ in situations where the clinician entering the orders has more autonomy (e.g., lab vs. medication orders or community vs. academic hospitals). The intervention might also be more effective in institutions that offer incentives to clinicians for practicing cost-conscious care, the authors said.

Decreased hospital readmission rates not linked to increased postdischarge mortality, study finds

Decreased hospital readmission rates among Medicare fee-for-service beneficiaries are not linked to increased postdischarge mortality rates, according to a recent study.

Researchers performed a retrospective study of Medicare patients ages 65 years and older who were hospitalized with heart failure, acute myocardial infarction, or pneumonia from Jan. 1, 2008, through Dec. 31, 2014. The goal of the study was to determine whether national reductions in readmission rates for these three conditions due to the Affordable Care Act (ACA) were related to increased 30-day mortality rates postdischarge.

The researchers calculated 30-day risk-adjusted readmission rates (RARRs) and 30-day risk-adjusted mortality rates (RAMRs) after discharge monthly for each condition at each hospital and looked for monthly trends. The study results were published July 18 by JAMA.

During the study period, 2,962,554 hospitalizations were identified for heart failure at 5,016 hospitals, 1,229,939 hospitalizations were identified for acute myocardial infarction at 4,772 hospitals, and 2,544,530 hospitalizations were identified for pneumonia at 5,057 hospitals. The mean hospital 30-day RARRs and 30-day RAMRs after discharge in January 2008 were 24.6% and 8.4%, respectively, for heart failure, 19.3% and 7.6% for acute myocardial infarction, and 18.3% and 8.5% for pneumonia.

From 2008 to 2014, 30-day RARRs declined in the aggregate across hospitals from 2008 through 2014, with monthly changes in RARRs of −0.053% for heart failure, −0.044% for acute myocardial infarction, and −0.033% for pneumonia. Monthly aggregate changes across hospitals in 30-day RAMRs after discharge, however, varied by condition, with 0.008% for heart failure, −0.003% for acute myocardial infarction, and 0.001% for pneumonia. The correlation coefficients for hospitals' paired monthly changes in 30-day RARRs and 30-day RAMRs after discharge were weakly positive, with 0.066 for heart failure, 0.067 for acute myocardial infarction, and 0.108 for pneumonia. Secondary analyses yielded similar findings.

The authors acknowledged that their study was observational, involved only three conditions, and may not apply to younger patients. However, they concluded that a weak but significant correlation exists between reductions in 30-day readmissions and reductions in 30-day mortality rates postdischarge. “These findings do not support increasing postdischarge mortality related to reducing hospital readmissions,” the authors wrote. The results also suggest that preventing deaths in patients with severe illness does not necessarily contribute to high readmission rates, they added.

An accompanying editorial noted that while the study addresses one way in which the ACA's Hospital Readmissions Reduction Program (HRRP) could increase mortality rates, namely “by adopting or implementing approaches that are ultimately harmful to patients,” such as sending patients home from the ED who warrant admission, it does not examine the possibility that reducing readmissions has been prioritized over reducing mortality rates.

“Perhaps it is time to reexamine and reengineer the HRRP to avoid unintended consequences and to ensure that its incentives are fully aligned with the ultimate goal of improving the health outcomes of patients,” the editorialist wrote. She called for increased focus on risk adjustment and the structure of the HRRP penalty program.

Facility-level antibiotic use associated with C. difficile rates in long-term care

Facility-level antibiotic use and transfers of infected patients from acute care are drivers of Clostridium difficile infection in long-term care facilities, a study found.

Researchers sought to obtain a comprehensive picture of C. difficile incidence and risk factors in acute and long-term care using a case-cohort study of patients spending at least three days in one of 131 acute care or 120 long-term Veterans Health Administration facilities between 2006 and 2012.

Eight individual-level risk factors were assessed: sex, age, Charlson comorbidity count, acute care stay, long-term care stay, antibiotic exposure, antibiotic risk index, and proton-pump inhibitor (PPI) exposure. Facility factors included mean antibiotic use, mean PPI use, mean patient age, mean facility census, and importation (i.e., colonized or infected patients moved from outpatient settings). The study outcome was facility-onset, laboratory-identified C. difficile infection, defined as a person with a positive C. difficile test without a positive test in the previous eight weeks. Results were published by Clinical Infectious Diseases on June 8 and appeared in the Oct. 15 issue.

The study included 35,754 case-days of C. difficile, of which 28,615 (80%) were diagnosed during acute care stays and 7,139 (20%) were diagnosed during long-term care stays. Most of the studied individual-level variables, including male sex, comorbidity count, and pharmaceutical risk factors, were associated with C. difficile infection in both acute and long-term care, but the magnitude tended to be larger in long-term care, the study found.

A recent history of acute care exposure was a common (64.5% of cases and 27.3% of controls) and strong risk factor for C. difficile among long-term care patients (relative risk [RR], 4.84; 95% CI, 4.34 to 5.41). Among acute care patients, a history of long-term care exposure was a relatively rare (7.4% of cases and 4.0% of controls) and moderate risk factor for infection (RR, 1.89; 95% CI, 1.75 to 2.05).

C. difficile infection incidence was five times higher in acute care than in long-term care (median, 15.6 vs. 3.2 per 10,000 person-days). History of antibiotic use was greater in acute care compared to long-term care (median, 739 vs. 513 per 1,000 person-days) and explained 72% of the variation in C. difficile rates. Individual-level antibiotic use in acute care and in long-term care was strongly associated with risk (incidence rate ratios [IRR], 3.16 and 4.40, respectively).

In long-term care, facility-level importation of acute care cases (IRR, 1.35 per increase of 100; 95% CI, 1.18 to 1.53) and facility-level antibiotic use (IRR, 1.20 per increase of 100; 95% CI, 1.02 to 1.41) contributed to C. difficile infection risk. In the acute care model, facility-level importation of long-term care cases was associated with risk (IRR, 1.88 per increase of 100; 95% CI, 1.19 to 2.96) while facility-level antibiotic use was not (IRR, 0.88 per increase of 100; 95% CI, 0.70 to 1.12). Importation of C. difficile cases was three times higher in long-term care than in acute care (median, 52.3 vs. 16.2 per 10,000 person-days).

“We have shown the potential for inter-facility transmission of C. difficile infection, and that long-term care facilities disproportionately shoulder the burden of dealing with C. difficile cases from acute care, rather than vice versa,” the authors wrote. “This suggests that it may be wise for health care systems to coordinate infection control practices, so that appropriate infection prevention and control strategies are put into place for incoming patients and long-term care residents with histories of C. difficile infection.”