Cover: Peer Comparison or Guideline-Based Feedback and Postsurgery Opioid Prescriptions

Peer Comparison or Guideline-Based Feedback and Postsurgery Opioid Prescriptions

A Randomized Clinical Trial

Published in: JAMA Health Forum, Volume 5, No. 3, e240077 (March 2024). DOI: 10.1001/jamahealthforum.2024.0077

Posted on Mar 18, 2024

by Zachary Wagner, Allison Kirkegaard, Louis T. Mariano, Jason N. Doctor, Xiaowei Sherry Yan, Stephen D. Persell, Noah J. Goldstein, Craig Fox, Chad M. Brummett, Robert J. Romanelli, et al.


Excess opioid prescribing after surgery can result in prolonged use and diversion. Email feedback based on social norms may reduce the number of pills prescribed.


To assess the effectiveness of 2 social norm-based interventions on reducing guideline-discordant opioid prescribing after surgery.

Design, Setting, and Participants

This cluster randomized clinical trial conducted at a large health care delivery system in northern California between October 2021 and October 2022 included general, obstetric/gynecologic, and orthopedic surgeons with patients aged 18 years or older discharged to home with an oral opioid prescription.


In 19 hospitals, 3 surgical specialties (general, orthopedic, and obstetric/gynecologic) were randomly assigned to a control group or 1 of 2 interventions. The guidelines intervention provided email feedback to surgeons on opioid prescribing relative to institutionally endorsed guidelines; the peer comparison intervention provided email feedback on opioid prescribing relative to that of peer surgeons. Emails were sent to surgeons with at least 2 guideline-discordant prescriptions in the previous month. The control group had no intervention.

Main Outcome and Measures

The probability that a discharged patient was prescribed a quantity of opioids above the guideline for the respective procedure during the 12 intervention months.


There were 38,235 patients discharged from 640 surgeons during the 12-month intervention period. Control-group surgeons prescribed above guidelines 36.8% of the time during the intervention period compared with 27.5% and 25.4% among surgeons in the peer comparison and guidelines arms, respectively. In adjusted models, the peer comparison intervention reduced guideline-discordant prescribing by 5.8 percentage points (95% CI, -10.5 to -1.1; P=.03) and the guidelines intervention reduced it by 4.7 percentage points (95% CI, -9.4 to -0.1; P=.05). Effects were driven by surgeons who performed more surgeries and had more guideline-discordant prescribing at baseline. There was no significant difference between interventions.

Conclusions and Relevance

In this cluster randomized clinical trial, email feedback based on either guidelines or peer comparison reduced opioid prescribing after surgery. Guideline-based feedback was as effective as peer comparison-based feedback. These interventions are simple, low-cost, and scalable, and may reduce downstream opioid misuse.

Research conducted by

This report is part of the RAND external publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

RAND is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.