Default setting in EMRs “nudged” emergency department physicians to limit opioid prescriptions to 10 tablets

Jan. 18, 2018

For patients who have never been prescribed opioids, larger numbers of tablets given with the initial prescription is associated with long-term use and more tablets leftover that could be diverted for misuse or abuse. Patients may receive 30 or more opioid tablets in an initial prescription, for example, when a much lesser quantity, such as 10-12 tablets as recommended by current emergency department prescribing guidelines, would suffice. Implementing a default option for a lower quantity of tablets in the electronic medical records (EMR) discharge orders may help combat the issue by “nudging” physicians to prescribe smaller quantities consistent with prescribing guidelines Penn Medicine researchers show in a new study published in the Journal of General Internal Medicine.

The research team found that physicians from two Penn Medicine emergency departments prescribed a fewer number of opioid pills to their patients when the EMR default setting was set to 10 tablets. Initial prescriptions for that amount shot up by 22%, from a pre-default rate of 21% to 43% after the default option had been introduced. Conversely, the number of prescriptions written for 20 tablets decreased by almost 7%, and prescriptions for 11 to 19 tablets decreased by over 13%.

The number of people in the U.S. who die from prescription opioid overdoses has continued to rise in 2016 according to the U.S. Centers for Disease Control and Prevention (CDC).  Recent research by the CDC has shown that even small increases in the number of tablets prescribed is associated with long-term use among those who had never been prescribed opioids before.

In the new study, researchers analyzed prescription data from the emergency departments of the Hospital of the University of Pennsylvania (HUP) and Penn Presbyterian Medical Center (PPMC) between late 2014 and mid-2015, before and after the default was in place.

In 2015, both departments replaced an EMR that required clinicians to enter the number of tablets for opioid prescriptions with an EMR that now includes a default quantity of 10 tablets. The clinician could also “opt-out” by selecting a quantity of 20 tablets, which was displayed second, or they could modify their orders. The researchers compared weekly prescribing patterns for oxycodone 5mg/acetaminophen (325 mg) for 41 weeks. In all, physicians wrote over 3,200 prescriptions.

After the default implementation, the median number of opioid tablets supplied per prescription decreased by a small amount from an already low baseline of 11.3 to 10 at HUP and 12.6 to 10.9 at PPMC. However, across the two emergency departments there was a marked increase in the proportion of prescriptions written for 10 tablets, from 20.6% to 43.3%, whereas prescriptions for larger quantities dropped.

With implementation of the default of 10 tablets, there was a small unintended decrease in prescriptions written for less than 10 tablets. “This suggests that future efforts to set default quantities should provide a default option for the lowest baseline prescription,” the authors wrote.

Many studies have shown how default options can positively influence physician behavior and prescriptions. Last year, Penn researchers found that a change to default options increased generic drug prescribing rates from 75% to 98%. Using generic instead of brand name medications saves money for both patients and health system. That default has now been implemented across the University of Pennsylvania Health System.

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