{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,31]],"date-time":"2026-10-31T00:07:54Z","timestamp":1793405274085,"version":"4.5.0"},"reference-count":29,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2022,7,12]],"date-time":"2022-07-12T00:00:00Z","timestamp":1657584000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2022,7,12]],"date-time":"2022-07-12T00:00:00Z","timestamp":1657584000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100003896","name":"Henry M. Jackson Foundation","doi-asserted-by":"publisher","award":["Henry Jackson Foundation"],"award-info":[{"award-number":["Henry Jackson Foundation"]}],"id":[{"id":"10.13039\/100003896","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Anesthesiol"],"published-print":{"date-parts":[[2022,12]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>To examine factors associated with post-Cesarean section analgesic prescription variation at hospital discharge in patients who are opioid na\u00efve; and examine relationships between pre-Cesarean section patient and care-level factors and discharge morphine equivalent dose (MED) on outcomes (e.g., probability of opioid refill within 30\u00a0days) across a large healthcare system.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>The Walter Reed Institutional Review Board provided an exempt determination, waiver of consent, and waiver of HIPAA authorization for research use in the present retrospective longitudinal cohort study. Patient records were included in analyses if: sex assigned in the medical record was \u201cfemale,\u201d age was 18\u00a0years of age or older, the Cesarean section occurred between January 2016 to December 2019 in the Military Health System, the listed TRICARE sponsor was an active duty service member, hospitalization began no more than three days prior to the Cesarean section, and the patient was discharged to home\u2009&lt;\u20094\u00a0days after the Cesarean section.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>Across 57 facilities, 32,757 adult patients had a single documented Cesarean section procedure in the study period; 24,538 met inclusion criteria and were used in analyses. Post-Cesarean section discharge MED varied by facility, with a median MED of 225\u00a0mg and median 5-day supply. Age, active duty status, hospitalization duration, mental health diagnosis, pain diagnosis, substance use disorder, alcohol use disorder, gestational diabetes, discharge opioid type (combined vs. opioid-only medication), concurrent tubal ligation procedure, single (vs. multiple) births, and discharge morphine equivalent dose were associated with the probability of an opioid prescription refill in bivariate analyses, and therefore were included as covariates in a generalized additive mixed model (GAMM). Generalized additive mixed model results indicated that non-active duty beneficiaries, those with mental health and pain conditions, those who received an opioid\/non-opioid combination medication, those with multiple births, and older patients were more likely to obtain an opioid refill, relative to their counterparts.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusion<\/jats:title>\n                <jats:p>Significant variation in discharge pain medication prescriptions, as well as the lack of association between discharge opioid MED and probability of refill, indicates that efforts are needed to optimize opioid prescribing and reduce unnecessary healthcare variation.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12871-022-01765-8","type":"journal-article","created":{"date-parts":[[2022,7,12]],"date-time":"2022-07-12T13:11:02Z","timestamp":1657631462000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Variation by default: cesarean section discharge opioid prescription patterns and outcomes in Military Health System hospitals: a retrospective longitudinal cohort study"],"prefix":"10.1186","volume":"22","author":[{"given":"Krista B.","family":"Highland","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ian","family":"Robertson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Monica","family":"Lutgendorf","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Germaine F.","family":"Herrera","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander G.","family":"Velosky","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ryan C.","family":"Costantino","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael S.","family":"Patzkowski","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2022,7,12]]},"reference":[{"issue":"10155","key":"1765_CR1","doi-asserted-by":"publisher","first-page":"1341","DOI":"10.1016\/S0140-6736(18)31928-7","volume":"392","author":"T Boerma","year":"2018","unstructured":"Boerma T, Ronsmans C, Melesse DY, Barros AJD, Barros FC, Juan L, Moller AB, Say L, Hosseinpoor AR, Yi M, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018;392(10155):1341\u20138.","journal-title":"Lancet"},{"issue":"4","key":"1765_CR2","doi-asserted-by":"publisher","first-page":"829","DOI":"10.1097\/GRF.0000000000000325","volume":"60","author":"MA Clapp","year":"2017","unstructured":"Clapp MA, Barth WH. The future of cesarean delivery rates in the United States. Clin Obstet Gynecol. 2017;60(4):829\u201339.","journal-title":"Clin Obstet Gynecol"},{"issue":"5","key":"1765_CR3","doi-asserted-by":"publisher","first-page":"665","DOI":"10.1111\/anae.15339","volume":"76","author":"E Roofthooft","year":"2021","unstructured":"Roofthooft E, Joshi GP, Rawal N, Van de Velde M. Anaesthesia tPWGotESoR, Therapy P, Association sbtOA: PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2021;76(5):665\u201380.","journal-title":"Anaesthesia"},{"issue":"7","key":"1765_CR4","doi-asserted-by":"publisher","first-page":"e197863","DOI":"10.1001\/jamanetworkopen.2019.7863","volume":"2","author":"AF Peahl","year":"2019","unstructured":"Peahl AF, Dalton VK, Montgomery JR, Lai Y-L, Hu HM, Waljee JF. Rates of new persistent opioid use after vaginal or cesarean birth among US women. JAMA Netw Open. 2019;2(7):e197863\u2013e197863.","journal-title":"JAMA Netw Open"},{"issue":"11","key":"1765_CR5","doi-asserted-by":"publisher","first-page":"853","DOI":"10.1097\/EJA.0000000000000535","volume":"33","author":"S Weibel","year":"2016","unstructured":"Weibel S, Neubert K, Jelting Y, Meissner W, W\u00f6ckel A, Roewer N, Kranke P. Incidence and severity of chronic pain after caesarean section: a systematic review with meta-analysis. Eur J Anaesthesiol. 2016;33(11):853\u201365.","journal-title":"Eur J Anaesthesiol"},{"key":"1765_CR6","unstructured":"ACOG Committee Opinion No.742. Postpartum Pain Management. 2018;132:135\u201343."},{"issue":"5","key":"1765_CR7","doi-asserted-by":"publisher","first-page":"665","DOI":"10.1111\/anae.15339","volume":"76","author":"E Roofthooft","year":"2021","unstructured":"Roofthooft E, Joshi GP, Rawal N, Van de Velde M. PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2021;76(5):665\u201380.","journal-title":"Anaesthesia"},{"issue":"1","key":"1765_CR8","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1097\/AOG.0000000000002093","volume":"130","author":"BT Bateman","year":"2017","unstructured":"Bateman BT, Cole NM, Maeda A, Burns SM, Houle TT, Huybrechts KF, Clancy CR, Hopp SB, Ecker JL, Ende H, et al. Patterns of opioid prescription and use after cesarean delivery. Obstet Gynecol. 2017;130(1):29\u201335.","journal-title":"Obstet Gynecol"},{"issue":"3","key":"1765_CR9","doi-asserted-by":"publisher","first-page":"353. e351-353.","DOI":"10.1016\/j.ajog.2016.03.016","volume":"215","author":"BT Bateman","year":"2016","unstructured":"Bateman BT, Franklin JM, Bykov K, Avorn J, Shrank WH, Brennan TA, Landon JE, Rathmell JP, Huybrechts KF, Fischer MA. Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naive women. Am J Obstet Gynecol. 2016;215(3):353. e351-353. e318.","journal-title":"Am J Obstet Gynecol"},{"issue":"6","key":"1765_CR10","doi-asserted-by":"publisher","first-page":"763","DOI":"10.1097\/AAP.0000000000000460","volume":"41","author":"AM Zeng","year":"2016","unstructured":"Zeng AM, Nami NF, Wu CL, Murphy JD. The analgesic efficacy of nonsteroidal anti-inflammatory agents (NSAIDs) in patients undergoing cesarean deliveries: a meta-analysis. Reg Anesth Pain Med. 2016;41(6):763\u201372.","journal-title":"Reg Anesth Pain Med"},{"issue":"2","key":"1765_CR11","first-page":"2014","volume":"1","author":"I Subirana","year":"2014","unstructured":"Subirana I, Sanz H, Vila J. Building Bivariate Tables: the comparegroups package for r. j stat soft. 2014;1(2):2014.","journal-title":"j stat soft"},{"key":"1765_CR12","first-page":"339","volume":"45","author":"S Wood","year":"2017","unstructured":"Wood S, Scheipl F, Wood MS. Package \u2018gamm4.\u2019 Am Stat. 2017;45:339.","journal-title":"Am Stat"},{"issue":"26","key":"1765_CR13","doi-asserted-by":"publisher","first-page":"772","DOI":"10.21105\/joss.00772","volume":"3","author":"D Ludecke","year":"2018","unstructured":"Ludecke D. ggeffects: Tidy data frames of marginal effects from regression models. J Open Source Softw. 2018;3(26):772.","journal-title":"J Open Source Softw"},{"key":"1765_CR14","unstructured":"Gelman A, Su Y-S, Yajima M, Hill J, Pittau MG, Kerman J, et al. Data Analysis Using Regression and Multilevel\/hierarchical Models. Cambridge: Cambridge University Press; 2007. Print."},{"key":"1765_CR15","doi-asserted-by":"publisher","DOI":"10.1007\/978-3-319-24277-4","volume-title":"ggplot2: Elegent Graphics for Data Analysis","author":"H Wickham","year":"2016","unstructured":"Wickham H. ggplot2: Elegent Graphics for Data Analysis. New York, New York: Springer-Verlag; 2016."},{"key":"1765_CR16","unstructured":"Package \u2018ggpubr\u2019 [https:\/\/cran.r-project.org\/web\/packages\/ggpubr\/index.html]"},{"issue":"8","key":"1765_CR17","doi-asserted-by":"publisher","first-page":"e035126","DOI":"10.1136\/bmjopen-2019-035126","volume":"10","author":"B Ukert","year":"2020","unstructured":"Ukert B, Huang Y, Sennett B, Delgado K. State-level variation in opioid prescribing after knee arthroscopy among the opioid-na\u00efve in the USA: 2015\u20132019. BMJ Open. 2020;10(8):e035126.","journal-title":"BMJ Open"},{"issue":"10180","key":"1765_CR18","doi-asserted-by":"publisher","first-page":"1547","DOI":"10.1016\/S0140-6736(19)30428-3","volume":"393","author":"MD Neuman","year":"2019","unstructured":"Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. The Lancet. 2019;393(10180):1547\u201357.","journal-title":"The Lancet"},{"issue":"1","key":"1765_CR19","doi-asserted-by":"publisher","first-page":"42","DOI":"10.1097\/AOG.0000000000002094","volume":"130","author":"M Prabhu","year":"2017","unstructured":"Prabhu M, McQuaid-Hanson E, Hopp S, Burns SM, Leffert LR, Landau R, Lauffenburger JC, Choudhry NK, Kaimal A, Bateman BT. A shared decision-making intervention to guide opioid prescribing after cesarean delivery. Obstet Gynecol. 2017;130(1):42.","journal-title":"Obstet Gynecol"},{"issue":"11","key":"1765_CR20","doi-asserted-by":"publisher","first-page":"1012","DOI":"10.1001\/jamasurg.2018.2083","volume":"153","author":"AS Chiu","year":"2018","unstructured":"Chiu AS, Jean RA, Hoag JR, Freedman-Weiss M, Healy JM, Pei KY. Association of lowering default pill counts in electronic medical record systems with postoperative opioid prescribing. JAMA Surg. 2018;153(11):1012\u20139.","journal-title":"JAMA Surg"},{"issue":"3","key":"1765_CR21","first-page":"217","volume":"26","author":"TD Geracioti","year":"2014","unstructured":"Geracioti TD. Tramadol treatment of combat-related posttraumatic stress disorder. Ann Clin Psychiatry. 2014;26(3):217\u201321.","journal-title":"Ann Clin Psychiatry"},{"issue":"2","key":"1765_CR22","doi-asserted-by":"publisher","first-page":"136","DOI":"10.1007\/s40140-021-00442-9","volume":"11","author":"K Patel","year":"2021","unstructured":"Patel K, Zakowski M. Enhanced recovery after cesarean: current and emerging trends. Curr Anesthesiol Rep. 2021;11(2):136\u201344.","journal-title":"Curr Anesthesiol Rep."},{"issue":"4","key":"1765_CR23","doi-asserted-by":"publisher","first-page":"685","DOI":"10.1097\/AOG.0000000000004023","volume":"136","author":"L Mullman","year":"2020","unstructured":"Mullman L, Hilden P, Goral J, Gwacham N, Tauro C, Spinola K, Rosales K, Collier S, Holmes L, Maccione J, et al. Improved outcomes with an enhanced recovery approach to cesarean delivery. Obstet Gynecol. 2020;136(4):685\u201391.","journal-title":"Obstet Gynecol"},{"key":"1765_CR24","doi-asserted-by":"crossref","unstructured":"Patzkowski MS, Hammond KL, Herrera G, Highland KB. Factors Associated With Postoperative Opioid Prescribing After Primary Elective Cesarean Section. Mil Med. 2021:usab263.","DOI":"10.1093\/milmed\/usab263"},{"issue":"6","key":"1765_CR25","doi-asserted-by":"publisher","first-page":"879","DOI":"10.1097\/SLA.0000000000004225","volume":"272","author":"HMA Kaafarani","year":"2020","unstructured":"Kaafarani HMA, Han K, El Moheb M, Kongkaewpaisan N, Jia Z, El Hechi MW, van Wijck S, Breen K, Eid A, Rodriguez G, et al. Opioids After Surgery in the United States Versus the Rest of the World: The International Patterns of Opioid Prescribing (iPOP) Multicenter Study. Ann Surg. 2020;272(6):879\u201386.","journal-title":"Ann Surg"},{"issue":"5","key":"1765_CR26","doi-asserted-by":"publisher","first-page":"729","DOI":"10.1111\/1475-6773.13319","volume":"55","author":"JM Snowden","year":"2020","unstructured":"Snowden JM, Osmundson SS, Kaufman M, Blauer Peterson C, Kozhimannil KB. Cesarean birth and maternal morbidity among Black women and White women after implementation of a blended payment policy. Health Serv Res. 2020;55(5):729\u201340.","journal-title":"Health Serv Res"},{"issue":"5","key":"1765_CR27","doi-asserted-by":"publisher","first-page":"512","DOI":"10.1016\/j.ajog.2021.02.036","volume":"224","author":"JL Hamilton","year":"2021","unstructured":"Hamilton JL, Shumbusho D, Cooper D, Fletcher T, Aden J, Weir L, Keyser E. Race matters: maternal morbidity in the Military Health System. Am J Obstet Gynecol. 2021;224(5):512.","journal-title":"Am J Obstet Gynecol"},{"issue":"10","key":"1765_CR28","doi-asserted-by":"publisher","first-page":"2088","DOI":"10.1097\/j.pain.0000000000001313","volume":"159","author":"JL Booth","year":"2018","unstructured":"Booth JL, Sharpe EE, Houle TT, Harris L, Curry RS, Aschenbrenner CA, et al. Patterns of recovery from pain after cesarean delivery. Pain. 2018;159(10):2088\u201396.","journal-title":"Pain."},{"issue":"7","key":"1765_CR29","doi-asserted-by":"publisher","first-page":"e0253990","DOI":"10.1371\/journal.pone.0253990","volume":"16","author":"HB Ende","year":"2021","unstructured":"Ende HB, Landau R, Cole NM, Burns SM, Bateman BT, Bauer ME, Booth JL, Flood P, Leffert LR, Houle TT, et al. Labor prior to cesarean delivery associated with higher post-discharge opioid consumption. PLoS One. 2021;16(7):e0253990.","journal-title":"PLoS One"}],"container-title":["BMC Anesthesiology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12871-022-01765-8.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12871-022-01765-8\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12871-022-01765-8.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,7,12]],"date-time":"2022-07-12T13:13:04Z","timestamp":1657631584000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcanesthesiol.biomedcentral.com\/articles\/10.1186\/s12871-022-01765-8"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,7,12]]},"references-count":29,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2022,12]]}},"alternative-id":["1765"],"URL":"https:\/\/doi.org\/10.1186\/s12871-022-01765-8","relation":{},"ISSN":["1471-2253"],"issn-type":[{"value":"1471-2253","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,7,12]]},"assertion":[{"value":"7 April 2022","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"4 July 2022","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"12 July 2022","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This research qualifies as minimal risk to subjects and is exempt from most of the requirements of the Federal Policy for the Protection of Human Subjects, but is still considered research requiring an IRB review for an exemption determination. The study was approved by the Walter Reed National Military Medical Center Institutional Review Board (WRNMMC-EDO-2020\u20130560). The Walter Reed National Military Medical Center Institutional Review board provided an exempt determination, waiver of informed consent, and waiver of HIPAA authorization. All methods, as described in the abstract and in the appropriate manuscript section, were performed in accordance with the relevant guidelines and regulations.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors report no conflicts of interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"218"}}