O3291: National Assessment of Procedure-Specific Opioid Use in Children’s Surgery

Background: Surgery remains a key source of opioid exposure for children in the United States. This study evaluates the utilization of the National Surgical Quality Improvement Program - Pediatric (NSQIP-Ped) registry to explore aggregate data on postoperative opioid prescribing practices for children undergoing surgery. A data-driven approach based on procedure group is proposed for action plan development to reduce potentially harmful opioid utilization.

Methods: Postoperative opioid prescriptions at discharge for non-neonate pediatric surgical patients aged 0-18 years were collected from 157 NSQIP-Ped hospitals from January 1, 2023, to June 30, 2023. Surgical cases were categorized by Current Procedural Terminology codes into procedural groups. The top 20 procedure group contributors to opioid prescriptions at discharge for non-neonate patients were analyzed. The primary outcomes assessed were the proportion of patients with an opioid prescription at discharge within procedure groups and hospital-based practice pattern variation (PPV). To assess PPV for each hospital, the proportion of a procedure group prescribed opioids at discharge and the interquartile range (IQR) of these hospital-level prescribing proportions were calculated. We divided the procedure groups into four quadrants based on prescribing rates and PPV.

Results: The 44 procedure groups were ranked based on their percent contribution to the overall volume of opioid prescriptions at discharge. Of all cases in the cohort, 64% (45,907/71,456) were captured in the top 20 procedure groups (Figure 1). These 20 procedure groups contributed to 92% (20,384/22,239) of opioid prescriptions at discharge. Spinal procedures (in the “bottom-right” quadrant) had opioid prescriptions at discharge in 88% (3,431/3,908) of cases, demonstrated low PPV with an IQR of 0.15, and contributed 15% (3,431/22,239) of the total opioid volume prescribed at discharge. Appendectomy procedures (in the “bottom-left” quadrant) had opioid prescriptions in 6% (699/11,536) of cases, demonstrated low PPV with an IQR of 0.06, and contributed 3% (699/22,239) of the total opioid volume prescribed at discharge. Cleft Lip-Palate and Fracture Repair (in the “top-right” quadrant) displayed wide PPV with IQRs of 0.70 and 0.57, respectively.

Conclusion: This study demonstrates the feasibility of leveraging an existing national quality improvement registry as a tool to improve surgical opioid stewardship in children. Procedure groups with high prescribing proportions and low PPV may benefit from optimization of multimodal pain control strategies to reduce, but not eliminate, opioid prescriptions. Procedure groups with low prescribing proportions and low PPV may be targets for elimination of opioid prescribing at discharge. Procedure groups with high PPV may benefit from further investigation to assess clinical drivers of opioid prescription such as heterogeneity in anticipated postoperative pain based on procedure complexity or invasiveness. In summary, procedure group-targeted interventions that account for current opioid prescribing patterns offer relevant and timely direction to mitigate the risks of harmful opioid prescriptions within pediatric surgical care.