A hospital discharge opioid taper support intervention to improve post-operative opioid prescribing

ABSTRACT This K23 application from Dr. Justina Groeger proposes a mentored research and career development plan that will advance her goal of becoming a leading physician-investigator who tests health systems strategies to minimize opioid-related harms, particularly among older adults (age ≥65). Post-operative care is a time when excessive opioid prescribing occurs which can result in unnecessary harms, particularly to older and frail adults. An EHR-embedded, provider-facing, patient-specific, discharge opioid taper support (DOTS) intervention may reduce excessive post-operative opioid prescribing, but has not been rigorously tested, and even if made available in the EHR, provider- and patient- factors are likely to influence whether providers use the intervention for patients. The overarching goal of the proposed research is to rigorously test DOTS, an intervention with three components: 1) a recommendation for a patient-specific opioid taper schedule based on patient opioid use prior to discharge, 2) an automated default discharge opioid prescription based on the recommended taper schedule, and 3) post-discharge enhanced telephonic support for patients. We will randomize 42 providers to DOTS or telephonic support alone (TS) for 15-months, collect electronic health record data for their 1890 patients having orthopedic surgery, collect patient-reported outcomes from a subset of 100 (50 from providers in each group), and conduct a qualitative study of 21 DOTS providers. The specific aims are to: 1) determine the effectiveness of DOTS for reducing excessive opioid prescribing after orthopedic surgery, 2) test the impact of DOTS on patient-reported post-operative outcomes including pain intensity, physical function, and emergency post-operative care; and 3) identify determinants of provider use of DOTS. We hypothesize that compared to patients of TS providers, patients of DOTS providers will have favorable outcomes including reduction in excessive opioid prescribing and improved pain and function after surgery. By completing the proposed research and career development plan, Dr. Groeger will gain skills in 1) design and conduct of randomized controlled trials, 2) development and implementation of EHR-embedded interventions, 3) qualitative research methods, and 4) advanced longitudinal data analysis. The proposed research will lead to an R01 application to rigorously test DOTS at other hospitals and future trials testing DOTS at hospital discharge for other (non-orthopedic) causes of acute pain. With the completion of these activities and with the guidance of a team of multi-disciplinary mentors, Dr. Groeger will obtain the skills necessary to achieve her career goal of become a leading physician-investigator who tests health systems strategies to minimize opioid- related harms, particularly among older adults.