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Slovis BH, Huang S, McArthur M, Martino C, Beers T, Labella M, Riggio JM, Pribitkin ED. Design and Implementation of an Opioid Scorecard for Hospital System-Wide Peer Comparison of Opioid Prescribing Habits: Observational Study. JMIR Hum Factors 2024; 11:e44662. [PMID: 39250214 PMCID: PMC11404392 DOI: 10.2196/44662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 05/05/2023] [Accepted: 06/02/2024] [Indexed: 09/10/2024] Open
Abstract
Background Reductions in opioid prescribing by health care providers can lead to a decreased risk of opioid dependence in patients. Peer comparison has been demonstrated to impact providers' prescribing habits, though its effect on opioid prescribing has predominantly been studied in the emergency department setting. Objective The purpose of this study is to describe the development of an enterprise-wide opioid scorecard, the architecture of its implementation, and plans for future research on its effects. Methods Using data generated by the author's enterprise vendor-based electronic health record, the enterprise analytics software, and expertise from a dedicated group of informaticists, physicians, and analysts, the authors developed an opioid scorecard that was released on a quarterly basis via email to all opioid prescribers at our institution. These scorecards compare providers' opioid prescribing habits on the basis of established metrics to those of their peers within their specialty throughout the enterprise. Results At the time of this study's completion, 2034 providers have received at least 1 scorecard over a 5-quarter period ending in September 2021. Poisson regression demonstrated a 1.6% quarterly reduction in opioid prescribing, and chi-square analysis demonstrated pre-post reductions in the proportion of prescriptions longer than 5 days' duration and a morphine equivalent daily dose of >50. Conclusions To our knowledge, this is the first peer comparison effort with high-quality evidence-based metrics of this scale published in the literature. By sharing this process for designing the metrics and the process of distribution, the authors hope to influence other health systems to attempt to curb the opioid pandemic through peer comparison. Future research examining the effects of this intervention could demonstrate significant reductions in opioid prescribing, thus potentially reducing the progression of individual patients to opioid use disorder and the associated increased risk of morbidity and mortality.
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Affiliation(s)
- Benjamin Heritier Slovis
- Office of Clinical Informatics, Thomas Jefferson University, 111 S 11th St, Philadelphia, PA, 19107, United States, 1 (215) 955-6000
- Department of Emergency Medicine, Jefferson Health Northeast, Thomas Jefferson University, Philadelphia, PA, United States
| | - Soonyip Huang
- Enterprise Analytics, Thomas Jefferson University, Philadelphia, PA, United States
| | - Melanie McArthur
- Enterprise Analytics, Thomas Jefferson University, Philadelphia, PA, United States
| | - Cara Martino
- Enterprise Analytics, Thomas Jefferson University, Philadelphia, PA, United States
- Office of Quality and Patient Safety, Thomas Jefferson University, Philadelphia, PA, United States
| | - Tasia Beers
- Enterprise Analytics, Thomas Jefferson University, Philadelphia, PA, United States
| | - Meghan Labella
- Enterprise Analytics, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jeffrey M Riggio
- Office of Clinical Informatics, Thomas Jefferson University, 111 S 11th St, Philadelphia, PA, 19107, United States, 1 (215) 955-6000
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, United States
| | - Edmund deAzevedo Pribitkin
- Office of the Chief Physician Executive, Thomas Jefferson University, Philadelphia, PA, United States
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, United States
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LoParco CR, Bone C, Berg CJ, Rossheim ME, Peeri NC, Tillett KK, Seo DC. Associations Between Opioid and Kratom Use in the USA: Differences by Race/Ethnicity and Sexual Orientation. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02142-6. [PMID: 39196491 DOI: 10.1007/s40615-024-02142-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 06/18/2024] [Accepted: 08/17/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND Kratom is federally unregulated and is marketed as an opioid alternative despite limited evidence and known negative effects. Disparities in associations between opioid and kratom use may be partly attributed to race/ethnicity and sexual orientation given differences in marketing, use motives, and prescriber practices. METHODS Data: 2021 nationally representative National Survey on Drug Use and Health among individuals aged 18 + . We used weighted logistic regression analyses to assess race/ethnicity and sexual orientation as moderators of associations between past-year opioid (1) use (total sample, n = 44,877) and (2) misuse and use disorder (among those with past-year opioid use, n = 10,398) and the outcome of kratom use (lifetime, past year). RESULTS 26.76% reported past-year opioid use, and among those, 12.20% and 7.54% reported past-year opioid misuse and use disorder, respectively; 1.72% and 0.67% had lifetime and past-year kratom use, respectively. Opioid use was positively associated with lifetime (aOR = 2.69, 95%CI = 1.98, 3.66) and past-year (aOR = 3.84, 95%CI = 2.50, 5.92) kratom use; associations among non-Hispanic Black and Hispanic (vs. non-Hispanic White) participants were weaker (p < 0.01). Among participants reporting past-year opioid use, misuse and use disorder were positively associated with lifetime (aORmisuse = 2.46, 95%CI = 1.60, 3.78; aORuse disorder = 5.58, 95%CI = 2.82, 11.04) and past-year (aORmisuse = 2.40, 95%CI = 1.26, 4.59; aORuse disorder = 3.08, 95%CI = 1.48, 6.41) kratom use; among bisexual (vs. heterosexual) participants, opioid use disorder was associated with a lower probability of lifetime kratom use (p < 0.01). DISCUSSION We observed positive associations between opioid and kratom use, with potential disparities among certain racial/ethnic and sexual orientation groups. Research should examine the mechanisms contributing to these differences to inform prevention and intervention efforts.
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Affiliation(s)
- Cassidy R LoParco
- Milken Institute School of Public Health, George Washington University, Washington, DC, USA.
| | - Carlton Bone
- College of Liberal Arts and Sciences, Portland State University, Portland, OR, USA
| | - Carla J Berg
- Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Matthew E Rossheim
- School of Public Health, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Noah C Peeri
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kayla K Tillett
- School of Public Health, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Dong-Chul Seo
- School of Public Health, Indiana University Bloomington, Bloomington, IN, USA
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3
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Strayer RJ, Friedman BW, Haroz R, Ketcham E, Klein L, LaPietra AM, Motov S, Repanshek Z, Taylor S, Weiner SG, Nelson LS. Emergency Department Management of Patients With Alcohol Intoxication, Alcohol Withdrawal, and Alcohol Use Disorder: A White Paper Prepared for the American Academy of Emergency Medicine. J Emerg Med 2023; 64:517-540. [PMID: 36997435 DOI: 10.1016/j.jemermed.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/06/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Reuben J Strayer
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York.
| | - Benjamin W Friedman
- Department of Emergency Medicine, Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Rachel Haroz
- Cooper Medical School of Rowan University, Cooper University Healthcare, Camden, New Jersey
| | - Eric Ketcham
- Department of Emergency Medicine, Department of Behavioral Health, Addiction Medicine, Presbyterian Healthcare System, Santa Fe & Española, New Mexico
| | - Lauren Klein
- Department of Emergency Medicine, Good Samaritan Hospital, West Islip, New York
| | - Alexis M LaPietra
- Department of Emergency Medicine, Saint Joseph's Regional Medical Center, Paterson, New Jersey
| | - Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Zachary Repanshek
- Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Scott Taylor
- Department of Emergency Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
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4
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Phinn K, Liu S, Patanwala AE, Penm J. Effectiveness of organizational interventions on appropriate opioid prescribing for noncancer pain upon hospital discharge: A systematic review. Br J Clin Pharmacol 2023; 89:982-1002. [PMID: 36495313 DOI: 10.1111/bcp.15633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 11/24/2022] [Accepted: 12/04/2022] [Indexed: 12/14/2022] Open
Abstract
This study aims to summarize the effectiveness of organizational interventions on appropriate opioid prescribing for noncancer pain upon hospital discharge. A systematic search was conducted on 6 electronic databases by 2 independent reviewers. We included original research articles reporting on quantitative outcomes of organizational interventions targeting appropriate opioid prescribing on hospital discharge. Quality assessment was performed by 2 independent reviewers. The protocol for this review was prospectively registered on PROSPERO (ID: CRD42020156104). Out of 173 full texts assessed for eligibility, 43 were included in this review. The majority of studies had a moderate to serious risk of bias (33 out of 43). Most of the studies implemented a multifaceted organizational intervention (16 studies). Other interventions included guideline implementation, prescriber education and default opioid-prescribing quantity changes in electronic medical records. Multiple studies found that the dissemination of patient-specific and procedure-specific guidelines reduced the quantity of opioids prescribed by 44 to 57%. Prescriber education provided with feedback was implemented in 4 studies and resulted in a 33 to 44% decrease in prescribing rates. Lowering the default quantities in the electronic medical records produced a 40% decrease in opioids prescribed in 1 study. Guideline implementation, prescriber education and default opioid-prescribing quantity changes all appear effective in improving the appropriate prescribing of opioids on hospital discharge. However, the extent of reduction of opioid prescribing upon hospital discharge after the implementation of multifaceted intervention strategies appears similar to that of simpler interventions which require fewer resources.
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Affiliation(s)
- Katelyn Phinn
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Camperdown, New South Wales, Australia
| | - Shania Liu
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Pharmacy, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Asad E Patanwala
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jonathan Penm
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Pharmacy, Prince of Wales Hospital, Randwick, New South Wales, Australia
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Daoust R, Paquet J, Marquis M, Chauny JM, Williamson D, Huard V, Arbour C, Émond M, Cournoyer A. Evaluation of Interventions to Reduce Opioid Prescribing for Patients Discharged From the Emergency Department: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2143425. [PMID: 35024834 PMCID: PMC8759006 DOI: 10.1001/jamanetworkopen.2021.43425] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/09/2021] [Indexed: 12/29/2022] Open
Abstract
Importance Limiting opioid overprescribing in the emergency department (ED) may be associated with decreases in diversion and misuse. Objective To review and analyze interventions designed to reduce the rate of opioid prescriptions or the quantity prescribed for pain in adults discharged from the ED. Data Sources MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane Controlled Register of Trials databases and the gray literature were searched from inception to May 15, 2020, with an updated search performed March 6, 2021. Study Selection Intervention studies aimed at reducing opioid prescribing at ED discharge were first screened using titles and abstracts. The full text of the remaining citations was then evaluated against inclusion and exclusion criteria by 2 independent reviewers. Data Extraction and Synthesis Data were extracted independently by 2 reviewers who also assessed the risk of bias. Authors were contacted for missing data. The main meta-analysis was accompanied by intervention category subgroup analyses. All meta-analyses used random-effects models, and heterogeneity was quantified using I2 values. Main Outcomes and Measures The primary outcome was the variation in opioid prescription rate and/or prescribed quantity associated with the interventions. Effect sizes were computed separately for interrupted time series (ITS) studies. Results Sixty-three unique studies were included in the review, and 45 studies had sufficient data to be included in the meta-analysis. A statistically significant reduction in the opioid prescription rate was observed for both ITS (6-month step change, -22.61%; 95% CI, -30.70% to -14.52%) and other (odds ratio, 0.56; 95% CI, 0.45-0.70) study designs. No statistically significant reduction in prescribed opioid quantities was observed for ITS studies (6-month step change, -8.64%; 95% CI, -17.48% to 0.20%), but a small, statistically significant reduction was observed for other study designs (standardized mean difference, -0.30; 95% CI, -0.51 to -0.09). For ITS studies, education, policies, and guideline interventions (6-month step change, -33.31%; 95% CI, -39.67% to -26.94%) were better at reducing the opioid prescription rate compared with prescription drug monitoring programs and laws (6-month step change, -11.18%; 95% CI, -22.34% to -0.03%). Most intervention categories did not reduce prescribed opioid quantities. Insufficient data were available on patient-centered outcomes such as pain relief or patients' satisfaction. Conclusions and Relevance This systematic review and meta-analysis found that most interventions reduced the opioid prescription rate but not the prescribed opioid quantity for ED-discharged patients. More studies on patient-centered outcomes and using novel approaches to reduce the opioid quantity per prescription are needed. Trial Registration PROSPERO Identifier: CRD42020187251.
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Affiliation(s)
- Raoul Daoust
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Le Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Nord-de-l’Île de-Montréal, Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d’Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche de l’Hôpital du Sacré-Coeur de Montréal, CIUSSS du Nord de-l’Île-de-Montréal, Montréal, Québec, Canada
| | - Jean Paquet
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Le Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Nord-de-l’Île de-Montréal, Montréal, Québec, Canada
| | - Martin Marquis
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Le Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Nord-de-l’Île de-Montréal, Montréal, Québec, Canada
| | - Jean-Marc Chauny
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Le Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Nord-de-l’Île de-Montréal, Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d’Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche de l’Hôpital du Sacré-Coeur de Montréal, CIUSSS du Nord de-l’Île-de-Montréal, Montréal, Québec, Canada
| | - David Williamson
- Centre de Recherche de l’Hôpital du Sacré-Coeur de Montréal, CIUSSS du Nord de-l’Île-de-Montréal, Montréal, Québec, Canada
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
| | - Vérilibe Huard
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Le Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Nord-de-l’Île de-Montréal, Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d’Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - Caroline Arbour
- Centre de Recherche de l’Hôpital du Sacré-Coeur de Montréal, CIUSSS du Nord de-l’Île-de-Montréal, Montréal, Québec, Canada
- Faculté des Sciences Infirmières, Université de Montréal, Montréal, Québec, Canada
| | - Marcel Émond
- Département de Médecine Familiale et de Médecine d’Urgence, Faculté de Médecine, Université Laval, Québec, Québec, Canada
| | - Alexis Cournoyer
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Le Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Nord-de-l’Île de-Montréal, Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d’Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche de l’Hôpital du Sacré-Coeur de Montréal, CIUSSS du Nord de-l’Île-de-Montréal, Montréal, Québec, Canada
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Oskvarek JJ, Aldeen A, Shawbell J, Venkat A, Zocchi MS, Pines JM. Opioid Prescription Reduction After Implementation of a Feedback Program in a National Emergency Department Group. Ann Emerg Med 2022; 79:420-432. [DOI: 10.1016/j.annemergmed.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/10/2021] [Accepted: 12/15/2021] [Indexed: 02/07/2023]
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7
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Lavingia R, Mondragon E, McFarlane-Johansson N, Shenoi RP. Improving Opioid Stewardship in Pediatric Emergency Medicine. Pediatrics 2021; 148:183393. [PMID: 34851415 DOI: 10.1542/peds.2020-039743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Poor opioid stewardship contributes to opioid misuse and adverse health outcomes. We sought to decrease opioid prescriptions in children 0 to 18 years treated for pain after fractures and cutaneous abscess drainage from 13.5% to 8%. Our secondary aims were to reduce opioid prescriptions written for >3 days from 41% to 10%, eliminate codeine prescriptions, increase safe opioid storage and disposal discharge instructions from 0% to 70%, and enroll all emergency department (ED) physicians in the state prescription drug monitoring program. METHODS We implemented an intervention bundle on the basis of 4 key drivers at a pediatric ED: ED-wide education, changes in the electronic medical record, discharge resources, and process standardization. Two plan-do-study-act cycles were performed. Interventions included provider feedback on prescribing, safe opioid storage and disposal instructions, and streamlined electronic medical record functions. Run charts were used to analyze the effect of interventions on outcomes. Our balance measure was return ED or clinic visits for inadequate analgesia within 3 days. RESULTS During the intervention period, 249 of 3402 (7.3%) patients with fractures and cutaneous abscesses were prescribed opioids. The percentage of opioid prescriptions >3 days decreased from 41% to 13.2% (P < .0001), codeine prescription dropped from 1.1% to 0% (P = .09), opioid discharge instructions increased 0% to 100% (P < .0001), and all physicians enrolled in the prescription drug monitoring program. There was no change in return visits for uncontrolled analgesia compared with the baseline (P = .79). CONCLUSIONS A comprehensive opioid stewardship program can improve opioid prescribing practices of ED physicians and deliver information on safe storage and disposal of prescription opioids with a negligible effect on return visits for uncontrolled pain.
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Affiliation(s)
| | | | - Nina McFarlane-Johansson
- Section of Emergency Medicine, Department of Pediatrics.,Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
| | - Rohit P Shenoi
- Section of Emergency Medicine, Department of Pediatrics.,Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
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8
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Smulowitz PB, O'Malley AJ, McWilliams JM, Zaborski L, Landon BE. Variation in Rates of Hospital Admission from the Emergency Department Among Medicare Patients at the Regional, Hospital, and Physician Levels. Ann Emerg Med 2021; 78:474-483. [PMID: 34148659 DOI: 10.1016/j.annemergmed.2021.03.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE Rates of admission from the emergency department (ED) vary widely across regions of the country, hospitals within regions, and physicians within hospitals. Our objective was to determine the extent to which variation in admission decisions was described by differences in admission rates at these 3 levels. This understanding will serve to better target interventions to modify rates of admission where appropriate. METHODS In this cross-sectional observational cohort study, we analyzed Medicare fee-for-service claims for ED visits from 2012 to 2015 in a 20% random sample of beneficiaries. We first estimated the total regional-, hospital-, and physician-level variations in rates of admission and their proportions of the total variation after adjusting for patient and each level's covariates. We then estimated the extent to which each level's characteristics accounted for variation at that respective level. RESULTS Our study sample included 5,778,218 visits with 45,491 physicians at 3,480 EDs across 306 hospital referral regions. The mean rate of admission was 38.9% and ranged from 21.4% to 53.0% for physicians at the 10th and 90th percentile of the distribution, respectively. The residual (unexplained) variations at the regional, hospital, and physician levels were 13.3% (95% confidence interval [CI], 11.2 to 15.5%), 60.1% (57.1 to 62.9%), and 26.7% (26.4 to 26.9%), respectively. Regional, hospital, and physician characteristics accounted for 9.1% (95% CI, -5.6 to 23.8%), 51.1% (48.8 to 53.5%), and 2.7% (1.3 to 4.1%), respectively, of the explained variation at their respective levels. CONCLUSION Within-area variation, both across hospitals within a region and across physicians within a hospital, is a more substantial component of observed variation in admission rates from the ED than regional level variation. These findings suggest that variation in admission rates is at least in part related to institutional norms and cultures as well as heterogeneity of physician decisionmaking within hospitals, both of which could be targets of interventions to modify rates of admission.
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Affiliation(s)
- Peter B Smulowitz
- Department of Emergency Medicine, Harvard Medical School, Boston, MA.
| | - A James O'Malley
- Department of Biomedical Data Science, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
| | | | - Lawrence Zaborski
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School and Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Suffoletto B, Landau A. Nudging Emergency Care Providers to Reduce Opioid Prescribing Using Peer Norm Comparison Feedback: A Pilot Randomized Trial. PAIN MEDICINE 2021; 21:1393-1399. [PMID: 31846029 DOI: 10.1093/pm/pnz314] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To determine the feasibility, acceptability, and potential impact of using audit and feedback (A&F) with or without peer norm comparison on opioid prescribing by emergency medicine providers. METHODS A convenience sample of 37 emergency medicine providers were recruited from 16 emergency departments in Western Pennsylvania for a pilot randomized controlled trial. Participants completed a baseline survey, were randomly allocated to A&F (N = 17) or A&F with peer norm comparison (N = 20), and were asked to complete a postintervention survey. We matched each participant 1:1 to a control who was not exposed to either intervention. RESULTS At baseline, 57% of participants perceived that they prescribed opioids at the same frequency as their peers, whereas 32% perceived prescribing less than and 11% perceived prescribing more than their peers. Most participants rated the interventions as helpful, with no differences between conditions. For the A&F with peer norm comparison condition, from pre- to postintervention, there was a relative increase of 20% in the percentage of participants who perceived that they prescribed more opioids than their peers but no change in the A&F condition (P = 0.02). 56.8% of controls, 52.9% of A&F participants, and 75.5% of A&F with peer norm comparison participants reduced their opioid prescribing (P = 0.33). The mean reduction in opioid prescriptions (SD) was 3.3. (9.6) for controls, 3.9 (10.5) for A&F, and 7.3 (7.8) for A&F with peer norm comparison (P = 0.31). CONCLUSIONS Audit and feedback interventions with peer norm comparisons are helpful to providers, can alter perceptions about prescribing norms, and are a potentially effective way to alter ED providers' opioid prescribing behavior.
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Affiliation(s)
- Brian Suffoletto
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Aaron Landau
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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10
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Bryl AW, Demartinis N, Etkin M, Hollenbach KA, Huang J, Shah S. Reducing Opioid Doses Prescribed From a Pediatric Emergency Department. Pediatrics 2021; 147:peds.2020-1180. [PMID: 33674462 DOI: 10.1542/peds.2020-1180] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Opioid overdose and abuse have reached epidemic rates in the United States. Medical prescriptions are a large source of opioid misuse. Our quality improvement initiative aimed to reduce opioid exposure from the pediatric emergency department (ED). Objective was to reduce opioid doses prescribed weekly from our ED by 50% within 4 months. METHODS Three categories of interventions were implemented in Plan-Do-Study-Act cycles: guidelines and education, electronic medical record optimization, and provider-specific feedback. Primary measures were opioid doses prescribed weekly from the ED and opioid doses per 100 ED visits. Process measures were opioid prescriptions, opioid doses per prescription, and opioid prescriptions for unspecified abdominal pain, headache, and viral upper respiratory infection. Balancing measures were phone calls and return visits for poor pain control in patients prescribed opioids and reports of poor pain control in call backs to orthopedic reduction patients. We used statistical process control to examine changes in measures over time. RESULTS Opioid doses decreased from 153 to 14 per week and from 8 to 0.7 doses per 100 ED visits in 10 months, sustained for 9 months. Opioid prescriptions, opioid doses per prescription, and prescriptions for unspecified abdominal pain, headache, and viral upper respiratory infection decreased. Phone calls and return visits in patients prescribed opioids did not increase. There were 2 reports of poor pain control among 152 orthopedic reduction patients called back. CONCLUSIONS We decreased opioid doses prescribed weekly from the pediatric ED by 91% while minimizing return visits and reports of poor pain control.
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Affiliation(s)
- Amy W Bryl
- Department of Pediatrics, School of Medicine and .,Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California
| | - Nicole Demartinis
- Department of Pediatrics, School of Medicine and.,Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California
| | - Marc Etkin
- Department of Pediatrics, School of Medicine and.,Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California
| | - Kathryn A Hollenbach
- Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California.,Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California; and
| | | | - Seema Shah
- Department of Pediatrics, School of Medicine and.,Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California
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11
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Raman R, Fleming L. We Need to Talk About Codeine: an Implementation Study to reduce the number of Emergency Department patients discharged on high-strength co-codamol using the Behaviour Change Wheel. Emerg Med J 2021; 38:895-900. [PMID: 33658270 DOI: 10.1136/emermed-2020-209479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/08/2021] [Accepted: 02/13/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The crisis of prescription opioid addiction in the USA is well-documented. Though opioid consumption per capita is lower in the UK, prescribing has increased dramatically in recent decades with an associated increase in deaths from prescription opioid overdose. At one Scottish Emergency Department high rates of prescribing of take-home co-codamol (30/500 mg) were observed, including for conditions where opioids are not recommended by national guidelines. An Implementation Science approach was adopted to investigate this. METHODS A Behaviour Change Wheel analysis suggested several factors contributing to high opioid prescribing: poor awareness of codeine addiction risk, poor knowledge of NICE (National Institute for Health and Care Excellence) guidelines on common painful conditions, mistaken assumptions about patient expectations and ready access to a large stock of take-home co-codamol. Based on this analysis a combined Education/Persuasion intervention was implemented over a 1-month period (January 2019) reaching 93% of prescribers. An Environmental Restructuring intervention was introduced at 4 months, and co-codamol prescriptions were monitored over a 12-month follow-up period. Unplanned re-attendances and complaints related to analgesia were monitored as balancing measures. RESULTS The Education/Persuasion intervention was associated with a 59% reduction in co-codamol prescribing that was maintained over 12 months. The Environmental Restructuring intervention was not associated with any further reduction in prescribing. No increase in unplanned re-attendances occurred during the study period and no complaints were received relating to pain control. CONCLUSIONS The increasing incidence of prescription opioid addiction in the UK suggests the need for all clinicians who write opioid prescriptions to re-evaluate their practice. This study suggests that knowledge of addiction risk and prescribing guidelines is poor among Emergency Department prescribers. We show that a rapid and sustained reduction in prescribing of take-home opioids is feasible in a UK Emergency Department, and that this reduction was not associated with any increase in unplanned re-attendances or complaints related to analgesia.
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Affiliation(s)
- Rajendra Raman
- Accident and Emergency, Victoria Hospital, Kirkcaldy, UK
| | - Laura Fleming
- Accident and Emergency, Victoria Hospital, Kirkcaldy, UK
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Embry J, Reis MD, Couchman G, Ledbetter TG, Zolfaghari K. Quality improvement initiative for pain management practices in primary care. Proc AMIA Symp 2020; 33:513-519. [PMID: 33100518 PMCID: PMC7549893 DOI: 10.1080/08998280.2020.1814181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/20/2020] [Accepted: 08/20/2020] [Indexed: 10/23/2022] Open
Abstract
In the context of both chronic pain and opioid crises, this large-system quality improvement project sought to increase use of evidence-based multimodal pain management strategies. Primary care providers (PCPs) in internal medicine and family medicine identified as above-median prescribers of 30-day opioid supplies were selected for intervention. PCPs received individualized email letters showing their opioid prescribing patterns relative to peers and urging them to view an internal pain/opioid educational video and related system guidelines. The median number of patients receiving 30-day opioid supplies from our target PCPs decreased over a 24-month period. For cohort patients identified at baseline and remaining in treatment over time, those receiving opioid prescriptions decreased, and those receiving nonopioid prescriptions increased. Percentages of PCPs prescribing nonopioids for cohort patients increased over the first year and nonpharmacologic referrals increased in range. Our evidence suggests that PCPs who are higher opioid prescribers will change their practices voluntarily when given feedback about their opioid prescribing patterns relative to their peers, as well as education regarding evidence-based pain management and opioid prescribing.
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Affiliation(s)
- Judy Embry
- Department of Family Medicine, Baylor Scott & White Health, Temple, Texas
- Pain Management and Opioid Prescribing Ambulatory Taskforce, Baylor Scott & White Health, Temple, Texas
| | - Michael D. Reis
- Department of Family Medicine, Baylor Scott & White Health, Temple, Texas
- Pain Management and Opioid Prescribing Ambulatory Taskforce, Baylor Scott & White Health, Temple, Texas
| | - Glen Couchman
- Pain Management and Opioid Prescribing Ambulatory Taskforce, Baylor Scott & White Health, Temple, Texas
- Chief Medical Officer of Clinical Operations, Baylor Scott & White Health, Dallas, Texas
| | - T. Glenn Ledbetter
- Pain Management and Opioid Prescribing Ambulatory Taskforce, Baylor Scott & White Health, Temple, Texas
- Quality Alliance Board of Managers, Baylor Scott & White Health, Dallas, Texas
| | - Kiumars Zolfaghari
- Center for Applied Health Research, Baylor Scott & White Health, Temple, Texas
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Strayer RJ, Hawk K, Hayes BD, Herring AA, Ketcham E, LaPietra AM, Lynch JJ, Motov S, Repanshek Z, Weiner SG, Nelson LS. Management of Opioid Use Disorder in the Emergency Department: A White Paper Prepared for the American Academy of Emergency Medicine. J Emerg Med 2020; 58:522-546. [DOI: 10.1016/j.jemermed.2019.12.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/19/2019] [Accepted: 12/24/2019] [Indexed: 11/28/2022]
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