"Hard" and "soft" patient cues that influence ED prescribing for potential opioid misusers

Implementation of Electronic Health Record Integration and Clinical Decision Support to Improve Emergency Department Prescription Drug Monitoring Program Use

STUDY OBJECTIVE(S)

To evaluate the implementation of 3 electronic health record (EHR)-based interventions to increase prescription drug monitoring program (PDMP) use in the emergency department (ED): EHR-PDMP integration, addition of a PDMP risk score, and addition of EHR-based clinical decision support alert to review the PDMP when prescribing an opioid.

METHODS

Three intervention stages were implemented using a prospective stepped-wedge design at 5 university-affiliated EDs split into 3 practice groups. The PDMP use and prescribing rates during the 3 stages were compared with baseline before EHR integration and a sustainability stage where the clinical decision support alert was removed, but EHR integration and risk score remained. Generalized linear mixed model with logit link function and a random intercept for clinicians was analyzed.

RESULTS

The ED provider PDMP review before opioid prescribing was low in all stages. The highest review rate occurred during interruptive clinical decision support alerts, 23.8% (interquartile range 10.6 to 37.5). Overall, opioid prescribing declined, and PDMP review was not associated with a decrease in opioid prescribing. PDMP review was associated with a reduction in the probability of prescribing an opioid as the number of prior opioid prescriptions increased (odds ratio: 0.92 [95% confidence interval: 0.91 to 0.94] for every additional prescription).

CONCLUSION

The EHR-PDMP integration did not increase PDMP use in the ED, but a PDMP risk score and a clinical decision support alert were associated with modest increases in the probability of PDMP review. When the PDMP is reviewed, ED clinicians are less likely to prescribe opioids to patients with a high number of prior opioid prescriptions.

Pilot Study of the Importance of Factors Affecting Emergency Department Opioid Analgesic Prescribing Decisions

INTRODUCTION

Little is known about the factors driving decision-making among emergency department (ED) providers when prescribing opioid analgesics (OA). The aim of this pilot study was to identify the importance of factors influencing OA-prescribing decisions and to determine how this varied among different types of providers.

METHODS

This was an observational cross-sectional survey study of 203 ED providers. The importance of decisional factors was rated on a 5-point Likert scale. Differences between provider groups were tested using Chi-squared or ANOVA tests where applicable.

RESULTS

Overall, 142/203 (69.9 %) potential respondents participated in the study. The five highest-rated factors were (mean ± SD) patient's opioid prescription history (4.4 ± 0.8), patient's history of substance abuse or dependence (4.4 ± 0.7), diagnosis thought to be the cause of patient's pain (4.2 ± 0.8), clinical gestalt (4.2 ± 0.7), and provider's concern about unsafe use of the medication (4.0 ± 0.9). The importance of 6 of 21 decisional factors varied significantly between different groups of providers.

CONCLUSION

In this pilot study of ED providers, the self-reported importance of several factors influencing OA-prescribing decisions were significantly different among attending physicians, resident physicians, and advanced practice providers. Further investigation into how ED providers make OA-prescribing decisions is needed to help guide interventions aimed at improving appropriate pain management.