First EDition: Emergency Physicians’ Rates of Opioid Prescribing, more

BY JEFF BAUER

A large retrospective analysis found a wide variation in opioid prescribing among emergency physicians (EPs) working within the same ED. The study also found that Medicare patients treated by EPs who wrote the most prescriptions for opioids were more likely to use opioids for 6 months after their ED visit than were those treated by EPs who wrote fewer opioid prescriptions.

Researchers evaluated initial visits to an ED by approximately 378,000 Medicare beneficiaries (average age: 68 years) from 2008 through 2011. None of these patients had received a prescription for an opioid in the 6 months before the ED visit, and none of the visits resulted in a hospital admission. Prescriptions for opioids (excluding methadone) were identified by the national drug code in the Medicare Part D database. An opioid prescription was attributed to the treating EP if the patient filled the prescription within 3 days after the ED visit.

Investigators categorized the treating EPs in this study as “high-intensity” or “low-intensity” opioid prescribers by calculating the proportion of all ED visits that resulted in an opioid prescription being filled. They then grouped the EPs into quartiles of opioid prescribing within each hospital. High-intensity prescribers were those in the top quartile of opioid prescribing rates, and low-intensity prescribers were those in the bottom quartile.

The primary outcome was long-term opioid use, defined as 6 months or more of opioids supplied in the 12 months after the initial ED visit. This did not include prescriptions filled within 30 days of the initial visit.

Overall, approximately 215,700 patients were treated by low-intensity prescribers and 162,000 by high-intensity prescribers. In general, the patient characteristics and diagnoses were similar in both groups. The rate of opioid prescribing of high-intensity prescribers was approximately triple the rate of low-intensity prescribers. High-intensity prescribers provided an opioid prescription for 21.4% of ED visits, compared to 7.3% among low-intensity prescribers.

Long-term opioid use at 12 months was significantly higher among patients who had been initially treated by high-intensity prescribers compared to those who had been treated by low-intensity prescribers (1.51% vs 1.16%; unadjusted odds ratio [OR], 1.31). There was minimal change in this difference after the results were adjusted for the patients’ age, race, sex, disability status, and presence of chronic conditions (OR, 1.30). The number needed to harm was calculated as 49, meaning theoretically, for every 49 patients who received a new opioid prescription in the ED, one would become a long-term user. The authors noted, however, that “…prescriptions provided by other physicians in the months after an [ED] visit are necessary for long-term opioid use to take hold.”

Researchers pointed out several limitations to their study. Because the study was observational, it could not establish causality. Researchers were not able to directly attribute opioid prescriptions to the treating EPs, but instead used prescriptions filled within 3 days of an ED visits as a surrogate; some opioid prescriptions could have been written by another clinician, such as the patient’s primary care physician during a follow-up visit. Because the study focused on Medicare patients, the results may not be applicable to younger patients. Based on their analysis, researchers could not determine whether an opioid prescription was appropriate, and therefore they could not quantify the extent of opioid overprescribing.

For more on EPs and opioid prescribing, see “The New Opioid Epidemic and the Law of Unintended Consequences” by Emergency Medicine Editor in Chief Neal Flomenbaum, MD (Emergency Medicine. 2017;49[2]:52) and “The New Opioid Epidemic: Prescriptions, Synthetics, and Street Drugs” by Rama B. Rao, MD and Emergency Medicine Associate Editor, Toxicology Lewis S. Nelson, MD (Emergency Medicine. 2017;49[2]:64-70).

Barnett ML, Olenski AR, Jena AB. Opioid-prescribing patterns of emergency physicians and risk of long-term use. N Engl J Med. 2017;376(7):663-673. doi:10.1056/NEJMsa1610524.

Lower Admission Rates, Other Factors Tied to High Rate of Death Soon After ED Discharge Among Older Adults

BY JEFF BAUER

Each year, approximately 10,000 older adult patients die within 7 days of discharge from an ED in the United States, despite having no obvious life-threatening illness, according to a large retrospective study. Emergency departments with lower rates of inpatient admission from the ED, lower patient volumes, and lower charges had significantly higher rates of death after discharge.

Researchers evaluated Medicare claims data related to slightly more than 10 million ED visits from 2007 to 2012. Because the goal was to study generally healthy patients, the following patients were excluded: individuals who were age 90 years and older; were receiving palliative or hospice care; or had received a life-limiting diagnosis, such as a myocardial infarction (MI) or a malignancy, either in the ED or in the year prior to the ED visit. The primary outcome was death within 7 days after discharge from an ED. The cause of death was determined by linking claims to death certificates; this information was available only for a subset of patients who visited an ED in 2007 or 2008.

Overall, during the 6-year study, 0.12% of discharged patients died within 7 days of discharge; this translates to more than 10,000 early deaths per year nationally. The leading causes of death were atherosclerotic heart disease (13.6%), MI (10.3%), and chronic obstructive pulmonary disease (9.6%).

Emergency departments ranked in the lowest fifth for admission rates admitted 15% of patients, compared to 56% of patients at EDs with the highest admission rates. The early death rate of patients treated at EDs with the lowest rates of inpatient admissions from the ED was 3.4 times higher than the death rate seen in EDs with the highest inpatient admission rates (0.27% vs 0.08%, respectively). This was true despite the fact that EDs with low-admission rates treated healthier patients, as evidenced by the overall 7-day mortality rate of all patients treated in the ED, whether they were admitted or discharged. Emergency departments that saw higher volumes of patients and had higher charges for visits had significantly fewer deaths.