Postoperative opioid prescribing is not my job: A qualitative analysis of care transitions

Abstract

Background: Persistent opioid use is common after surgical procedures, and postoperative opioid prescribing often transitions from surgeons to primary care physicians in the months after surgery. It is unknown how surgeons currently transition these patients or the preferred approach to successful coordination of care. This qualitative study aimed to describe transitions of care for postoperative opioid prescribing and identify barriers and facilitators of ideal transitions for potential intervention targets.

Methods: We conducted a qualitative study of surgeons and primary care physicians at a large academic healthcare system using a semi-structured interview guide. Transcripts were independently coded using the Theoretical Domains Framework to identify underlying determinants of physician behaviors. We mapped dominant themes to the Behavior Change Wheel to propose potential interventions targeting these behaiors.

Results: Physicians were interviewed between July 2017 and December 2017 beyond thematic saturation (n = 20). Surgeons report passive transitions to primary care physicians after ruling out surgical complications, and these patients often bounce back to the surgeon when primary care physicians are uncertain of the cause of ongoing pain. Ideal practices were identified as setting preoperative expectations and engaging in active transition for postoperative opioid prescribing. We identified 3 behavioral targets for multidisciplinary intervention: knowledge (guidelines for coordination of care), barriers (utilizing support staff for active transition), and professional role (incentive for multidisciplinary collaboration).

Conclusion: This qualitative study identifies potential interventions aimed at changing physician behaviors regarding transitions of care for postoperative opioid prescribing. Implementation of these interventions could improve coordination of care for patients with persistent postoperative opioid use.

Fig I.. Behavior Change Wheel

At the center of the Behavior Change Wheel are the COM-B components (green) that interact with underlying behaviors. TDF domains (yellow) are listed and illustrated how these are linked to COM-B components. Intervention functions (red) and policy categories (gray) are shown on the outside portions of the wheel. It is important to note that COM-B components and TDF domains are directly linked, but their connection to interventions and policies is nonlinear and previously described in referenced literature.

Fig II.. Current and ideal process for transitioning care of postoperative opioid prescribing

After ruling out surgical complications, most surgeons report telling patients to follow-up with their primary care physician for additional opioid medications. Many primary care physicians report sending patients back to surgeons if they request postoperative opioid medications. Ideal practices included preoperative expectations from surgeons on surgical pain and opioid use. Active transition for patients with persistent postoperative opioid use was also noted as an ideal practice for multidisciplinary collaboration on if opioids should be continued or tapered.

Fig III.. Potential interventions for transitions of care of postoperative opioid prescribing

Three theoretical domains, specific constructs, and beliefs were determined to be most relevant and actionable. Potential targeted intervention functions and examples are depicted for each.