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Implementation of a Quality Improvement Initiative to Decrease Opioid Prescribing After Cesarean Delivery

Prabhu, Malavika, MD; Dubois, Heloise, BS; James, Kaitlyn, PhD, MPH; Leffert, Lisa R., MD; Riley, Laura E., MD; Bateman, Brian T., MD, MSc; Henderson, Marie, CNM, MSN

doi: 10.1097/AOG.0000000000002789
Contents: Cesarean Delivery: Clinical Practice and Quality

OBJECTIVE: To assess whether a multiphase, departmental quality improvement effort decreases opioid prescribing and increases multimodal analgesic use after cesarean delivery.

METHODS: This is a prospective quality improvement study. In phase 1 of the protocol, discharge providers implemented counseling regarding expectations for pain, typical need for opioids, and importance of multimodal nonopioid analgesic use and used shared decision-making to determine the number of opioids prescribed. Patients could select up to a maximum of 30 tablets of 5 mg oxycodone (or equivalent opioid), lower than the previous routine discharge prescription of 40 opioid tablets. The primary outcome was the mean (SD) number of opioid tablets prescribed on discharge with secondary outcomes including opioid refill rate within 30 days of discharge and rates of nonopioid analgesic prescriptions on discharge. In phase 2, using these results, we adjusted the protocol's maximum opioid prescription to 25 opioid tablets, but no other aspects of the protocol were changed. All data were analyzed with t test and χ2 analyses.

RESULTS: Data from 624 women who underwent cesarean deliveries were analyzed. Opioids, most commonly oxycodone, were prescribed after 95% of all cesarean deliveries. The mean (SD) number of opioid tablets prescribed decreased from 33.2 (9.3) to 26.5 (6.7; P<.01) with the implementation of phase 1 having no effect on the opioid refill rate, 8.9% vs 8.1% (P=.79). These results allowed adjustment of the maximum recommended prescription to 25 opioid tablets, introducing phase 2 of the study, during which the mean (SD) number of opioid tablets prescribed further decreased from 24.9 (7.5) to 21.5 (6.3; P<.01) with no effect on the opioid refill rate, 6.3% vs 5.1% (P=.72). Overall, this represents a 35% decrease in opioid prescribing (P<.01). Rates of ibuprofen prescribing were 98% or higher throughout the study, but rates of acetaminophen prescribing increased from 32.6% before phase 1 to 92.0% after phase 2 (P<.001).

CONCLUSION: Implementation of a multiphase quality improvement protocol to decrease opioid prescribing, combined with iterative review of discharge data, resulted in a significant decrease in the number of opioid tablets prescribed after cesarean delivery.

Decreasing the quantity of opioids prescribed after cesarean delivery is feasible with tailored discharge counseling incorporating shared decision-making and iterative analysis of discharge data.

Division of Maternal-Fetal Medicine, the Deborah Kelly Center for Outcomes Research, and the Division of Nurse-Midwifery, the Department of Obstetrics and Gynecology, and the Division of Obstetric Anesthesia, the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, and the Division of Obstetric Anesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

Corresponding author: Malavika Prabhu, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, 55 Fruit Street, Founders 460, Boston, MA 02114; email:

Financial Disclosure The authors did not report any potential conflicts of interest.

Each author has indicated that he or she has met the journal's requirements for authorship.

Received March 06, 2018

Received in revised form May 10, 2018

Accepted June 07, 2018

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.