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March 10, 2017

How Dartmouth-Hitchcock dramatically cut opioid prescription for some surgeries

Daily Briefing

A new study found that simple opioid prescribing guidelines for surgeons may significantly reduce the number of opioid pills prescribed to patients, Lenny Bernstein reports for Washington Post's "To Your Health."

In recent years, providers, insurers, and policymakers have launched a number of programs to help fight overprescribing of opioids. For instance, every state but Missouri now asks or requires providers to check databases that help doctors determine whether a patient is "doctor shopping" for an opioid prescription, Bernstein writes. Many ED doctors are working to minimize the number of pills they prescribe, and some insurers are notifying heavy prescribers of opioids to nudge them back within prescribing norms.

But "few if any of these projects are as simple as the effort undertaken by" Richard Barth, chief of general surgery at Dartmouth-Hitchcock Medical Center, Bernstein writes.

A simple solution

According to Bernstein, Barth thought that surgeons might reduce opioid prescriptions if they were given simple guidelines for the number of pills they should prescribe after certain surgeries. According to Barth, "There weren't really operation-specific guidelines out there." And he hypothesized that "doctors are very data-driven, and if there are specific guidelines, people are going to follow them."

Barth started the project by surveying 642 patients who underwent five outpatient surgeries:

  • Partial mastectomy;
  • Partial mastectomy with a lymph-node biopsy;
  • Gallbladder removal; and
  • Two types of hernia repair.

According to Bernstein, Barth and colleagues found physicians' prescribing habits varied widely and that the patients took only 28 percent of opioids that doctors prescribed.

Based on the survey, they suggested to surgeons orally and in writing that they limit the number of prescribed pills to five and 10 for the two breast operations and 15 for the other three procedures. Patients were also told that nonnarcotic painkillers such as acetaminophen or non-steroidal anti-inflammatory drugs could likely effectively manage their pain.

The goal was to discourage long-term use of opioids and curb the diversion of drugs to illegal users. According to Barth and his colleagues, illegal users consume as much as 71 percent of legitimately prescribed opioids.

8 resources to jump-start your care variation reduction strategy


Richard Barth and colleagues recently published the results of their intervention in Annals of Surgery. In a follow-up survey of 224 patients, they found that the number of prescribed opioid pills dropped 53 percent, from 6,170 to 2,932. The average proportional decrease was even greater for partial mastectomies, for which prescribed pills dropped from 19.8 to 5.1 pills, and partial mastectomies with a lymph-node biopsy, for which prescribed pills dropped from 23.7 to 9.6. "Only one patient came back for a prescription refill," Bernstein writes.

In addition, in a survey of 148 of the patients in the study, the researchers found that patients consumed only 656 of the 1,913 pills they had been prescribed.

The researchers are now investigating whether providing similar data for inpatient surgeries can help cut overprescribing when those patients are released from the hospital. "I think (the idea) has potential to have a big impact," Barth said. "This could easily be done by other general surgeons all across the country" (Bernstein, "Too Your Health," Washington Post, 3/7; Dartmouth-Hitchcock Medical Center release, 9/19/16).

One key to improving your hospital's quality: Identify clinical variation

There are many opportunities to reduce care variation in hospitals today—but how should you prioritize those opportunities?

You should start by examining variation in two ways: "horizontal" and "vertical." A horizontal approach focuses on the use of costly resources across multiple conditions, while a vertical approach analyzes performance within a particular condition or patient population to develop a consensus-based standard.

Our infographic gives an example of each approach and explains the challenges of a horizontal approach versus the benefits of a vertical one.


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