Protected: Qi15 – Large dispensations of opioids

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Operationalisation

Denominator

Population ( / 1,000) alive at the end of the year.

Numerator

All defined in the denominator who received a dispensation that contained at least 30 DDDs of opioid analgesics (ATC N02A single active ingredient products or combination products with ATC code (starting with) N02AA5*/ N02AA79/ N02AB5*/ N02AB7*/ N02AC54/ N02AC74/ N02AD5*/ N02AG /N02AJ /N02AX5*) excluding medications mainly used in treatment of addiction (buprenorphine (N02AE01) and methadone combinations (N02AC52) (1))

Exclusions

Numerator:

  • Individuals with opioid analgesic dispensations (N02A) during three preceding years (1,095 days preceding the first opioid purchase in the examined year).
  • Individuals with a secondary care contact with diagnosis of malignancy (ICD C00-99) included in the recorded diagnoses during three preceding years (1,095 days preceding the purchase the first opioid purchase in the examined year).

Denominator, numerator:

  • Individuals who die or emigrate during the examined year.

Notes

  • Amount dispensed is examined in Defined daily doses (DDDs). DDD is the assumed average maintenance dose per day for a medication used for its main indication in adults (1).

Sources of Data

  • Population register
  • Secondary care patient registers
  • Outpatient medication dispensations register

Information about the indicator set

Purpose

  • The quality indicator set is intended for comparison of effectiveness and/or safety aspects of prescribing across Nordic countries and subnational regions.
  • Further comparisons across population subgroups (e.g., socioeconomic position, immigration background) can inform equity considerations.
  • Further comparisons in relation to expenditures can inform efficiency considerations

Limitations

  • The indicators in the set use medication dispensings and/or sales data as a proxy for appropriate prescribing and medication use. This is to allow comparisons using register data, which have the advantage of being readily available and comprehensive in terms of population coverage and over time (5–7).
  • Register data are not without limitations. Medications may have been prescribed, but not collected from the pharmacy by the user. Collected medications may not have been (appropriately) used by the patient. Sales data may not be fully comparable across countries.
  • Register data are collected primarily for other purposes than quality assessment. Thus, discontinuities over time due to, e.g., legislative changes and administrative reforms need to be acknowledged in the interpretation of the results.
  • Indicators need to be updated regularly because clinical guidelines and the range of available medications change over time.
  • ATC-codes are based on WHO Collaborating Centre for Drug Statistics Methodology ATC/DDD Index version 2024

Background and literature related to the proposed indicator

Similar or related indicators in Nordic or European quality assessment guidelines or databases

Swedish Association of Local Authorities and Regions quality indicators (Vården i siffror/Primärvårdskvalitet)

  • Share of listed patients (primary care) who had been treated with opioids during the year (15)
  • Share of listed patients (primary care) who had been treated with opioids during the year, excluding cancer patients (16)
  • Share of patients treated with opioids who were prescribed a large quantity of opioids (> 0,25 DDD per day during the past 365 days) (17)
  • Share of patients treated with opioids who were prescribed a large quantity of opioids, excluding cancer patients (18)

OECD Health Care Quality Indicators (1)

  • Overall volume of opioids (N02A, excluding N02AC52, N02AE01) prescribed (DDDs per 1,000 adult population per day)
  • Proportion of chronic opioid users in the adult population (2 or more prescriptions of opioids (N02A, excluding N02AC52, N02AE01) prescribed for ≥ 90 days in the year≥ 90 day’s supply in a year)

Similar or related indicators in international scientific literature

  • The amount of discharge opioids after different types of surgery (19–27)
  • Average days-supply of first-fill opioids (acute pain) (28)
  • Overall opioid prescriptions per 100 patients, use of opioids at high dosage / primary care unit (29)
  • Prescribing patterns among patients with chronic non-cancer pain (30–32)
  • The proportion of patients (age 18 years or over) diagnosed with chronic non-cancer pain dispensed an opioid at a dose less than the equivalent of 100mg per day of morphine. (33)
  • Potential prescription misuse measured as receipt of two or more early refills of an opioid medication in the past year. Early refill defined as a prescription written 7–25 days after the previous prescription for the same medication (typical refill cycle: 28 days) (34)

References

  1. Healthcare Quality and Outcomes Indicators – OECD [Internet]. [cited 2024 Feb 29]. Available from: https://www.oecd.org/health/health-care-quality-outcomes-indicators.htm
  2. ATCDDD – Definition and general considerations [Internet]. [cited 2024 May 2]. Available from: https://atcddd.fhi.no/ddd/definition_and_general_considera/
  3. Humphreys K, Shover CL, Andrews CM, Bohnert ASB, Brandeau ML, Caulkins JP, et al. Responding to the opioid crisis in North America and beyond: recommendations of the Stanford–Lancet Commission. The Lancet. 2022 Feb 5;399(10324):555–604.
  4. Degenhardt L, Grebely J, Stone J, Hickman M, Vickerman P, Marshall BDL, et al. Global patterns of opioid use and dependence: harms to populations, interventions, and future action. The Lancet. 2019 Oct 26;394(10208):1560–79.
  5. Higgins C, Smith BH, Matthews K. Incidence of iatrogenic opioid dependence or abuse in patients with pain who were exposed to opioid analgesic therapy: a systematic review and meta-analysis. Br J Anaesth. 2018 Jun 1;120(6):1335–44.
  6. Kendler KS, Lönn SL, Ektor-Andersen J, Sundquist J, Sundquist K. Risk factors for the development of opioid use disorder after first opioid prescription: a Swedish national study. Psychol Med. 2023 Oct;53(13):6223–31.
  7. Suggested Paths to Fixing the Opioid Crisis: Directions and Misdirections | Substance Use and Addiction Medicine | JAMA Network Open | JAMA Network [Internet]. [cited 2024 Aug 26]. Available from: https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2682874
  8. OECD [Internet]. 2019 [cited 2024 Aug 26]. Addressing Problematic Opioid Use in OECD Countries. Available from: https://www.oecd.org/en/publications/2019/06/addressing-problematic-opioid-use-in-oecd-countries_351ed846.html
  9. Shah A, Hayes CJ, Martin BC. Factors Influencing Long-Term Opioid Use Among Opioid Naive Patients: An Examination of Initial Prescription Characteristics and Pain Etiologies. J Pain. 2017 Nov 1;18(11):1374–83.
  10. Barnett ML, Olenski AR, Jena AB. Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use. N Engl J Med. 2017 Feb 16;376(7):663–73.
  11. Ahomäki I, Pitkänen V, Soppi A, Saastamoinen L. Impact of a physician-targeted letter on opioid prescribing. J Health Econ. 2020 Jul 1;72:102344.
  12. Laugesen K, Ludvigsson JF, Schmidt M, Gissler M, Valdimarsdottir UA, Lunde A, et al. Nordic Health Registry-Based Research: A Review of Health Care Systems and Key Registries. Clin Epidemiol. 2021 Dec 31;13:533–54.
  13. Furu K, Wettermark B, Andersen M, Martikainen JE, Almarsdottir AB, Sørensen HT. The Nordic countries as a cohort for pharmacoepidemiological research. Basic Clin Pharmacol Toxicol. 2010 Feb;106(2):86–94.
  14. Rasmussen L, Wettermark B, Steinke D, Pottegård A. Core concepts in pharmacoepidemiology: Measures of drug utilization based on individual-level drug dispensing data. Pharmacoepidemiol Drug Saf. 2022;31(10):1015–26.
  15. PVQ Läkemedel Lm11alla: Andel patienter som behandlas med opioider – KIK [Internet]. [cited 2024 Aug 26]. Available from: https://kvalitetsindikatorkatalog.se/#/measure/c06297bd-3475-4719-94c1-a4d0ed91a819
  16. PVQ Läkemedel Lm11ejCa: Andel patienter som behandlas med opioider, exklusive patienter med cancerdiagnoser – KIK [Internet]. [cited 2024 Aug 26]. Available from: https://kvalitetsindikatorkatalog.se/#/measure/c113b9c5-1381-4f29-aabe-c91361ba0a8c
  17. PVQ Läkemedel Lm12alla: Andel opioidbehandlade patienter med stor förskrivning av opioider – KIK [Internet]. [cited 2024 Aug 26]. Available from: https://kvalitetsindikatorkatalog.se/#/measure/40a931f8-b205-4639-afa0-e46e08598103
  18. PVQ Läkemedel Lm12ejCa: Andel opioidbehandlade patienter med stor förskrivning av opioider, exklusive patienter med cancerdiagnoser – KIK [Internet]. [cited 2024 Aug 26]. Available from: https://kvalitetsindikatorkatalog.se/#/measure/d6d4108b-7c97-4409-9195-7ade289261f3
  19. Chambers L, Jaynstein J, Parry JA, Mauffrey C. The effect of the orthopaedic trauma association’s (OTA) pain management guidelines on opioid prescriptions, pain control, and refills in outpatient orthopaedic trauma surgery. Eur J Orthop Surg Traumatol. 2022 Feb;32(2):237–42.
  20. Acebedo C. Discharge Opioid Prescribing Guideline for the Urologic Surgery Patient Population. Urol Nurs. 2020 Jan;40(1):23–33.
  21. Krauss WE, Habermann EB, Goyal A, Ubl DS, Alvi MA, Whipple DC, et al. Impact of Opioid Prescribing Guidelines on Postoperative Opioid Prescriptions Following Elective Spine Surgery: Results From an Institutional Quality Improvement Initiative. Neurosurgery. 2021 Aug 16;89(3):460–70.
  22. Lee JS, Howard RA, Klueh MP, Englesbe MJ, Waljee JF, Brummett CM, et al. The Impact of Education and Prescribing Guidelines on Opioid Prescribing for Breast and Melanoma Procedures. Ann Surg Oncol. 2019 Jan;26(1):17–24.
  23. Opioid Consumption Patterns After Anorectal Operations: Development of an Institutional Prescribing Guideline. Vol. 64. United States; 2021.
  24. Pullman A, Syrowatka A, Businger A, Sainlaire M, Lipsitz S, Thai T, et al. Development and Alpha Testing of Specifications for a Prolonged Opioid Prescribing Electronic Clinical Quality Measure (eCQM). AMIA Annu Symp Proc AMIA Symp. 2020;2020:1022–30.
  25. Reiter A, Huang R, Iroz C, Slocum JD, Johnson JK, Stulberg J. Adherence to Opioid Prescribing Guidelines in a Statewide Surgical Quality Improvement Collaborative. J Am Coll Surg. 2023 May;236(5, 3):S56.
  26. Sutherland TN, Wunsch H, Pinto R, Newcomb C, Brensinger C, Gaskins L, et al. Association of the 2016 US Centers for Disease Control and Prevention Opioid Prescribing Guideline With Changes in Opioid Dispensing After Surgery. JAMA Netw Open. 2021 Jun 11;4(6):e2111826.
  27. Langnas E, Bishara A, Croci R, Rodriguez-Monguio R, Wick EC, Chen CL, et al. Opioid prescribing practices at hospital discharge for surgical patients before and after the Centers for Disease Control and Prevention’s 2016 opioid prescribing guideline. BMC Anesthesiol. 2022 May;22(1):1–8.
  28. Phillips AL, Thiese MS, Freeman M, Kartchner R, Hegmann KT. Implementation of an Opioid Guideline Impacts on Opioid Prescriptions, Adverse Outcomes, and an Association with a State Opioid-Related Fatalities. J Occup Environ Med. 2019 Aug;61(8):653–8.
  29. Milner KA, DeNisco SM, Greer AE. Opioid Prescribing for Chronic Pain in Federally Qualified Health Centers Post–Centers for Disease Control and Prevention Guidelines. J Nurse Pract. 2021 Nov;17(10):1243–9.
  30. Zgierska AE, Robinson JM, Lennon RP, Smith PD, Nisbet K, Ales MW, et al. Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project. BMC Fam Pract. 2020 Nov 28;21(1):245.
  31. Shoemaker-Hunt S, Sargent WJ, Swan H, Mikosz C, Cobb K, McDonald D, et al. Developing Clinical Quality Improvement Measures Aligned With the CDC Guideline for Prescribing Opioids for Chronic Pain: An Important Strategy to Support Safer Prescribing in Primary Care. Am J Med Qual Off J Am Coll Med Qual. 2021 Apr 1;36(2):125–8.
  32. Navis A, George MC, Nmashie A, ra, Hoang E, Cedillo G, et al. Validation of the Safer Opioid Prescribing Evaluation Tool (SOPET) for Assessing Adherence to the Centers for Disease Control Opioid Prescribing Guidelines. Pain Med. 2020 Dec;21(12):3655–9.
  33. Spackman E, Clement F, Allan GM, Bell CM, Bjerre LM, Blackburn DF, et al. Developing key performance indicators for prescription medication systems. PloS One. 2019;14(1):e0210794.
  34. Khalid L, Liebschutz JM, Xuan Z, Dossabhoy S, Kim Y, Crooks D, et al. Adherence to Prescription Opioid Monitoring Guidelines among Residents and Attending Physicians in the Primary Care Setting. Pain Med. 2015 Mar;16(3):480–7.