Peri-Operative Opioid Prescribing Practices of Resident Trainees Compared with Staff Surgeons

Abstract

<h3>Study Objective</h3> To evaluate the opioid prescribing practices of resident trainees compared to academic and community staff surgeons following elective hysterectomy. We also sought to identify surgeon characteristics associated with high-dose opioid prescriptions. <h3>Design</h3> A retrospective population-based cohort study. <h3>Setting</h3> We used linked administrative data in Ontario, Canada where all legally dispensed opioids in the province are recorded, regardless of insurance status. <h3>Patients or Participants</h3> We included opioid-naïve adult women (age≥18 years) who underwent elective hysterectomy, by any route, between 2013-2019. We excluded emergency surgeries and patients with malignancy. We limited the cohort to patients who filled at least one opioid prescription in the perioperative period (on the day of, to 7-days after hysterectomy). <h3>Interventions</h3> The main exposure was the opioid prescriber (trainee versus academic or community surgeon). <h3>Measurements and Main Results</h3> To account for confounding, we used inverse-probability of exposure weighting where we generated a propensity score for being in a given prescriber group regressed on baseline covariates. Observations were weighted according to the inverse of the calculated probability of being in a particular prescriber group. We included 20,352 patient-prescriptions (4,362 by trainees, 1,727 by academic surgeons, 14,263 by community surgeons). After weighting, baseline covariates were balanced between prescriber groups. Primary outcome: Trainees prescribed less perioperative opioids (oral morphine equivalent) compared to academic surgeons (MD 13.01mg, 95% CI 1.85 to 25.77) and community surgeons (MD 16.75mg, 95% CI 6.99 to 26.21). In a subset of 15,990 patients with prescription written by a staff surgeon, 1841 (11.5%) received a high-dose opioid prescription (>225mg OME). Surgeons with >25 years' experience (adjRR 1.38, 95%CI 1.03-1.81) and higher hysterectomy case volumes (adjRR_{highest-quintile} 1.59, 95% CI 1.07-2.36) were most likely to write high-dose opioid prescriptions. <h3>Conclusion</h3> Resident trainees prescribed less perioperative opioids compared to staff surgeons. Prudent opioid prescribing education should target experienced, high-volume staff surgeons, with a focus on community hospitals, where majority of hysterectomies are performed.