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Lauffenburger JC, DiFrancesco MF, Bhatkhande G, Crum KL, Kim E, Robertson T, Oran R, Hanken KE, Haff N, Coll MD, Avorn J, Choudhry NK. Pragmatic trial evaluating the impact of simulation training on high-risk prescribing to older adults by junior physicians. J Am Geriatr Soc 2024; 72:1420-1430. [PMID: 38456561 PMCID: PMC11090740 DOI: 10.1111/jgs.18862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/13/2024] [Accepted: 02/09/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND High-risk medications like benzodiazepines, sedative hypnotics, and antipsychotics are commonly prescribed for hospitalized older adults, despite guidelines recommending avoidance. Prior interventions have not fully addressed how physicians make such prescribing decisions, particularly when experiencing stress or cognitive overload. Simulation training may help improve prescribing decision-making but has not been evaluated for overprescribing. METHODS In this two-arm pragmatic trial, we randomized 40 first-year medical resident physicians (i.e., interns) on inpatient general medicine services at an academic medical center to either intervention (a 40-minute immersive simulation training) or control (online educational training) groups. The primary outcome was the number of new benzodiazepine, sedative hypnotic, or antipsychotic orders for treatment-naïve older adults during hospitalization. Secondary outcomes included the same outcome by all providers, being discharged on one of the medications, and orders for related or control medications. Outcomes were measured using electronic health record data over each intern's service period (~2 weeks). Outcomes were evaluated using generalized estimating equations, adjusting for clustering. RESULTS In total, 522 treatment-naïve older adult patients were included in analyses. Over follow-up, interns prescribed ≥1 high-risk medication for 13 (4.9%) intervention patients and 13 (5.0%) control patients. The intervention led to no difference in the number of new prescriptions (Rate Ratio [RR]: 0.85, 95%CI: 0.31-2.35) versus control and no difference in secondary outcomes. In secondary analyses, intervention interns wrote significantly fewer "as-needed" ("PRN") order types for the high-risk medications (RR: 0.29, 95%CI: 0.08-0.99), and instead tended to write more "one-time" orders than control interns, though this difference was not statistically significant (RR: 2.20, 95%CI: 0.60-7.99). CONCLUSIONS Although this simulation intervention did not impact total high-risk prescribing for hospitalized older adults, it did influence how the interns prescribed, resulting in fewer PRN orders, suggesting possibly greater ownership of care. Future interventions should consider this insight and implementation lessons raised. TRIAL REGISTRATION Clinicaltrials.gov(NCT04668248).
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Affiliation(s)
- Julie C. Lauffenburger
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Matthew F. DiFrancesco
- Division of Internal Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Gauri Bhatkhande
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Katherine L. Crum
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Erin Kim
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Kaitlin E. Hanken
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Nancy Haff
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Maxwell D. Coll
- Division of Internal Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Jerry Avorn
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Niteesh K. Choudhry
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
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Lauffenburger JC, Coll M, Kim E, Robertson T, Oran R, Haff N, Hanken K, Avorn J, Choudhry NK. Prescribing decision making by medical residents on night shifts: A qualitative study. MEDICAL EDUCATION 2022; 56:1032-1041. [PMID: 35611564 PMCID: PMC9474569 DOI: 10.1111/medu.14845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Prescribing of medications with well-known adverse effects, like antipsychotics or benzodiazepines, during hospitalisation is extremely common despite guideline recommendations against their use. Barriers to optimal prescribing, including perceived pressure from allied health professionals and fatigue, may be particularly pronounced for less experienced medical residents, especially during night shifts when these medications are often prescribed. Under these circumstances, physicians may be more likely to use 'quick', often referred to as System 1 choices, rather than 'considered' System 2 strategies for decisions. Understanding how medical residents use, these different cognitive approaches could help develop interventions to improve prescribing. METHODS To understand decision-making and contextual contributors that influence suboptimal prescribing during night coverage by medical residents, we conducted semi-structured qualitative interviews with residents in general medicine inpatient settings. The interviews elicited perspectives on shift routines, stressful situations, factors influencing prescribing decision making and hypothetical measures that could improve prescribing. Interviews were audio-recorded and transcribed. Data were analysed using codes developed by the team to generate themes using immersion/crystallisation approaches. RESULTS We conducted interviews with 21 medical residents; 47% were female, 43% were White, and 43% were Asian. We identified five key themes: (i) time pressures affecting prescribing decisions, (ii) fears of judgement by senior physicians and peers and being responsible for patient outcomes, (iii) perceived pressure from nursing staff, amplified by nurses' greater experience, (iv) clinical acuity as a key factor influencing prescribing, and (v) strategies to improve communication between members of the care team, like ensuring adequate hand-off by day teams. CONCLUSION Medical residents highlighted numerous contextual factors that promote quick thinking rather than slower thinking when prescribing on night shifts, particularly time constraints, perceived pressure and patient clinical acuity. Interventions aimed at reducing prescribing should address how to manage stress and perceived pressure in decision making.
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Affiliation(s)
- Julie C. Lauffenburger
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Maxwell Coll
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Erin Kim
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Nancy Haff
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Kaitlin Hanken
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Jerry Avorn
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Niteesh K. Choudhry
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
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Lauffenburger JC, DiFrancesco MF, Barlev RA, Robertson T, Kim E, Coll MD, Haff N, Fontanet CP, Hanken K, Oran R, Avorn J, Choudhry NK. Overcoming Decisional Gaps in High-Risk Prescribing by Junior Physicians Using Simulation-Based Training: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2022; 11:e31464. [PMID: 35475982 PMCID: PMC9096643 DOI: 10.2196/31464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 02/03/2022] [Accepted: 02/05/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Gaps between rational thought and actual decisions are increasingly recognized as a reason why people make suboptimal choices in states of heightened emotion, such as stress. These observations may help explain why high-risk medications continue to be prescribed to acutely ill hospitalized older adults despite widely accepted recommendations against these practices. Role playing and other efforts, such as simulation training, have demonstrated benefits to help people avoid decisional gaps but have not been tested to reduce overprescribing of high-risk medications. OBJECTIVE This study aims to evaluate the impact of a simulation-based training program designed to address decisional gaps on prescribing of high-risk medications compared with control. METHODS In this 2-arm pragmatic trial, we are randomizing at least 36 first-year medical resident physicians (ie, interns) who provide care on inpatient general medicine services at a large academic medical center to either intervention (simulation-based training) or control (online educational training). The intervention comprises a 40-minute immersive individual simulation training consisting of a reality-based patient care scenario in a simulated environment at the beginning of their inpatient service rotation. The simulation focuses on 3 types of high-risk medications, including benzodiazepines, antipsychotics, and sedative hypnotics (Z-drugs), in older adults, and is specifically designed to help the physicians identify their reactions and prescribing decisions in stressful situations that are common in the inpatient setting. The simulation scenario is followed by a semistructured debriefing with an expert facilitator. The trial's primary outcome is the number of medication doses for any of the high-risk medications prescribed by the interns to patients aged 65 years or older who were not taking one of the medications upon admission. Secondary outcomes include prescribing by all providers on the care team, being discharged on 1 of the medications, and prescribing of related medications (eg, melatonin, trazodone), or the medications of interest for the control intervention. These outcomes will be measured using electronic health record data. RESULTS Recruitment of interns began on March 29, 2021. Recruitment for the trial ended in Q42021, with follow-up completed by Q12022. CONCLUSIONS This trial will evaluate the impact of a simulation-based training program designed using behavioral science principles on prescribing of high-risk medications by junior physicians. If the intervention is shown to be effective, this approach could potentially be reproducible by others and for a broader set of behaviors. TRIAL REGISTRATION ClinicalTrials.gov NCT04668248; https://clinicaltrials.gov/ct2/show/NCT04668248. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/31464.
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Affiliation(s)
| | | | - Renee A Barlev
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Erin Kim
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Maxwell D Coll
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Nancy Haff
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Kaitlin Hanken
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Jerry Avorn
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Niteesh K Choudhry
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
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Bhashyam AR, Young J, Qudsi RA, Parisien RL, Dyer GSM. Opioid Prescribing Patterns of Orthopedic Surgery Residents After Open Reduction Internal Fixation of Distal Radius Fractures. J Hand Surg Am 2019; 44:201-207.e2. [PMID: 30635200 DOI: 10.1016/j.jhsa.2018.11.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 09/27/2018] [Accepted: 11/08/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE In many academic medical centers, resident physicians typically write initial opioid prescriptions, but little is known about their prescribing practices. We hypothesized that lower resident postgraduate year, residency-training program, and noncompletion of an opioid prescribing training would be factors associated with increased opioid prescribing by orthopedic residents after open reduction and internal fixation of distal radius fractures. METHODS A survey was administered to all 135 residents from 4 orthopedic residency programs in a state located in the northeastern United States between August 2017 and November 2017. Respondents were asked to indicate the initial analgesia (quantity and duration) they would prescribe for a younger and older, otherwise healthy, opiate-naïve female patient after open reduction and internal fixation of a distal radius fracture. We analyzed the quantity of initial opioids prescribed in morphine milligram equivalents (MME) and number of days supplied. Three different measures of overprescribing were assessed: prescribing over 150 MME, 225 MME, or 7 days of opioids. RESULTS The response rate was 63% (85 of 135 residents). Of all respondents, 36.5% of residents reported completion of an opioid training in the past. In terms of overprescribing by duration, 19% of residents prescribed more than 7 days of opioids. For overprescribing by quantity, 36% to 59% (depending on patient age) of residents prescribed more than 20 tablets of 5 mg oxycodone (150 MME) and 16% to 25% (depending on patient age) prescribed more than 30 tablets of 5 mg oxycodone (225 MME). In comparison with junior residents, senior residents were more likely to prescribe over 225 MME. CONCLUSIONS After open reduction and internal fixation of distal radius fractures, 19% of orthopedic surgery residents would prescribe more than 7 days of prescription opioids, which is beyond the state law maximum. In addition, we found that less than half of residents had participated in an opioid training program. Our results highlight the need for continued resident guidance when prescribing. Enrollment in opioid prescribing training programs that have been shown to decrease prescribed opioid quantities while still effectively managing patient pain is probably important. CLINICAL RELEVANCE This study describes the opioid prescribing practices and prior training of orthopedic residents. It highlights an opportunity for increased involvement in educational programs on opioid prescribing that better align with published recommendations/guidelines.
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Affiliation(s)
- Abhiram R Bhashyam
- Department of Orthopaedic Surgery, Harvard Combined Orthopaedics Residency Program, Boston, MA.
| | - Jason Young
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA
| | - Rameez A Qudsi
- Department of Orthopaedic Surgery, Harvard Combined Orthopaedics Residency Program, Boston, MA
| | - Robert L Parisien
- Department of Orthopaedic Surgery, Boston University Orthopaedic Surgery Residency Program, Boston, MA
| | - George S M Dyer
- Department of Orthopaedic Surgery, Harvard Combined Orthopaedics Residency Program, Boston, MA
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