Substantial Variation in Opioid Prescribing Rates among ED Providers in the Same VA Healthcare Facility
BACKGROUND:
Among the Medicare population, a study of opioid-naïve patients (without opioid prescriptions in the prior 6 months) found that a higher likelihood of receiving a short-term opioid prescription in the emergency department (ED) was associated with higher rates of subsequent long-term opioid use. To replicate this in VA, the study team examined the extent to which variation in individual ED physicians' opioid prescribing was independently associated with long-term opioid use in Veterans. Using VA data, investigators identified Veterans with an index ED visit at any VA facility in 2012 – and who were opioid naïve. The primary outcome was long-term opioid use, defined as >180 days of opioids supplied in the 12 months after an index ED visit, excluding prescriptions within 30 days after the index visit since the likelihood of getting an opioid in that period is directly related to the ED provider's opioid prescribing rate. The study cohort included 304,601 opioid-naïve Veterans treated by 1,607 ED physicians in 105 VA facilities. Among these Veterans, 57,738 (19%) were treated by physicians classified as low-intensity opioid prescribers, while 86,393 (28%) were treated by high-intensity opioid prescribers.
FINDINGS:
- There was a three-fold variation in the rates of opioid prescribing by ED physicians within the same VA facility (21% vs. 6%), regardless of patients' severity of pain or primary diagnosis.
- The frequency of long-term opioid use was higher among opioid-naïve Veterans treated by high vs. low-quartile ED prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%).
- Though the increase in long-term opioid use among Veterans treated by the highest-prescribing ED providers was not significant in the overall sample, it was significant among important patient subgroups, including those with back pain, musculoskeletal pain, or depression.
- High-intensity prescribers were more likely to prescribe opioids across the spectrum of pain intensity, while low-intensity prescribers were less likely to prescribe opioids across the spectrum.
LIMITATIONS:
- The data were several years old, which could limit relevance to prescribing in 2018 and beyond, as dates were chosen to match the Medicare study.
- Investigators were unable to capture prescriptions filled by Veterans outside VA, which could impact their definition of "opioid naïve."
AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D (IIR 14-297). All authors, except Dr. Barnett, are part of HSR&D's Center for the Study Health Equity Research and Promotion (CHERP) located in Pittsburgh and Philadelphia, PA.
Barnett M, Zhao X, Fine M, Thorpe C, Sileanu F, Cashy P, Mor M, Radomski T, Hausmann L, Good C, and Gellad WF. Emergency Physician Opioid Prescribing and Risk of Long-Term Use in the Veterans Health Administration: An Observational Analysis. Journal of General Internal Medicine. May 29, 2019; Epub ahead of print.
