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Tai AMY, Kim JJ, Schmeckenbecher J, Kitchin V, Wang J, Kazemi A, Masoudi R, Fadakar H, Iorfino F, Krausz RM. Clinical decision support systems in addiction and concurrent disorders: A systematic review and meta-analysis. J Eval Clin Pract 2024. [PMID: 38979849 DOI: 10.1111/jep.14069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 07/10/2024]
Abstract
INTRODUCTION This review aims to synthesise the literature on the efficacy, evolution, and challenges of implementing Clincian Decision Support Systems (CDSS) in the realm of mental health, addiction, and concurrent disorders. METHODS Following PRISMA guidelines, a systematic review and meta-analysis were performed. Searches conducted in databases such as MEDLINE, Embase, CINAHL, PsycINFO, and Web of Science through 25 May 2023, yielded 27,344 records. After necessary exclusions, 69 records were allocated for detailed synthesis. In the examination of patient outcomes with a focus on metrics such as therapeutic efficacy, patient satisfaction, and treatment acceptance, meta-analytic techniques were employed to synthesise data from randomised controlled trials. RESULTS A total of 69 studies were included, revealing a shift from knowledge-based models pre-2017 to a rise in data-driven models post-2017. The majority of models were found to be in Stage 2 or 4 of maturity. The meta-analysis showed an effect size of -0.11 for addiction-related outcomes and a stronger effect size of -0.50 for patient satisfaction and acceptance of CDSS. DISCUSSION The results indicate a shift from knowledge-based to data-driven CDSS approaches, aligned with advances in machine learning and big data. Although the immediate impact on addiction outcomes is modest, higher patient satisfaction suggests promise for wider CDSS use. Identified challenges include alert fatigue and opaque AI models. CONCLUSION CDSS shows promise in mental health and addiction treatment but requires a nuanced approach for effective and ethical implementation. The results emphasise the need for continued research to ensure optimised and equitable use in healthcare settings.
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Affiliation(s)
- Andy Man Yeung Tai
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jane J Kim
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jim Schmeckenbecher
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Wien, Austria
| | - Vanessa Kitchin
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Johnston Wang
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alireza Kazemi
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Raha Masoudi
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hasti Fadakar
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Frank Iorfino
- Brain and Mind Centre, The University of Sydney, Sydney, Australia
| | - Reinhard Michael Krausz
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Erstad BL, Glenn MJ. Considerations and limitations of buprenorphine prescribing for opioid use disorder in the intensive care unit setting: A narrative review. Am J Health Syst Pharm 2024; 81:171-182. [PMID: 37979138 DOI: 10.1093/ajhp/zxad289] [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: 11/17/2023] [Indexed: 11/19/2023] Open
Abstract
PURPOSE The purpose of this review is to discuss important considerations when prescribing buprenorphine for opioid use disorder (OUD) in the intensive care unit (ICU) setting, recognizing the challenges of providing detailed recommendations in the setting of limited available evidence. SUMMARY Buprenorphine is a partial mu-opioid receptor agonist that is likely to be increasingly prescribed for OUD in the ICU setting due to the relaxation of prescribing regulations. The pharmacology and pharmacokinetics of buprenorphine are complicated by the availability of several formulations that can be given by different administration routes. There is no single optimal dosing strategy for buprenorphine induction, with regimens ranging from very low-dose to high dose regimens. Faster induction with higher doses of buprenorphine has been studied and is frequently utilized in the emergency department. In patients admitted to the ICU who were receiving opioids either medically or illicitly, analgesia will not occur until their baseline opioid requirements are covered when their preadmission opioid is either reversed or interrupted. For patients in the ICU who are not on buprenorphine at the time of admission but have possible OUD, there are no validated tools to diagnose OUD or the severity of opioid withdrawal in critically ill patients unable to provide the subjective components of instruments validated in outpatient settings. When prescribing buprenorphine in the ICU, important issues to consider include dosing, monitoring, pain management, use of adjunctive medications, and considerations to transition to outpatient therapy. Ideally, addiction and pain management specialists would be available when buprenorphine is prescribed for critically ill patients. CONCLUSION There are unique challenges when prescribing buprenorphine for OUD in critically ill patients, regardless of whether they were receiving buprenorphine when admitted to the ICU setting for OUD or are under consideration for buprenorphine initiation. There is a critical need for more research in this area.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Melody J Glenn
- Department of Emergency Medicine and Department of Psychiatry, University of Arizona College of Medicine/Banner University Medical Center, Tucson, AZ, USA
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Gao E, Melnick ER, Paek H, Nath B, Taylor RA, Loza AJ. Adoption of Emergency Department-Initiated Buprenorphine for Patients With Opioid Use Disorder: Secondary Analysis of a Cluster Randomized Trial. JAMA Netw Open 2023; 6:e2342786. [PMID: 37948075 PMCID: PMC10638655 DOI: 10.1001/jamanetworkopen.2023.42786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/02/2023] [Indexed: 11/12/2023] Open
Abstract
Importance Emergency department (ED) initiation of buprenorphine is safe and effective but underutilized in practice. Understanding the factors affecting adoption of this practice could inform more effective interventions. Objective To quantify the factors, including social contagion, associated with the adoption of the practice of ED initiation of buprenorphine for patients with opioid use disorder. Design, Setting, and Participants This is a secondary analysis of the EMBED (Emergency Department-Initiated Buprenorphine For Opioid Use Disorder) trial, a multicentered, cluster randomized trial of a clinical decision support intervention targeting ED initiation of buprenorphine. The trial occurred from November 2019 to May 2021. The study was conducted at ED clusters across health care systems from the northeast, southeast, and western regions of the US and included attending physicians, resident physicians, and advanced practice practitioners. Data analysis was performed from August 2022 to June 2023. Exposures This analysis included both the intervention and nonintervention groups of the EMBED trial. Graph methods were used to construct the network of clinicians who shared in the care of patients for whom buprenorphine was initiated during the trial before initiating the practice themselves, termed exposure. Main Outcomes and Measures Cox proportional hazard modeling with time-dependent covariates was performed to assess the association of the number of these exposures with self-adoption of the practice of ED initiation of buprenorphine while adjusting for clinician role, health care system, and intervention site status. Results A total of 1026 unique clinicians in 18 ED clusters across 5 health care systems were included. Analysis showed associations of the cumulative number of exposures to others initiating buprenorphine with the self-practice of buprenorphine initiation. This increased in a dose-dependent manner (1 exposure: hazard ratio [HR], 1.31; 95% CI, 1.16-1.48; 5 exposures: HR, 2.85; 95% CI, 1.66-4.89; 10 exposures: HR, 3.55; 95% CI, 1.47-8.58). Intervention site status was associated with practice adoption (HR, 1.50; 95% CI, 1.04-2.18). Health care system and clinician role were also associated with practice adoption. Conclusions and Relevance In this secondary analysis of a multicenter, cluster randomized trial of a clinical decision support tool for buprenorphine initiation, the number of exposures to ED initiation of buprenorphine and the trial intervention were associated with uptake of ED initiation of buprenorphine. Although systems-level approaches are necessary to increase the rate of buprenorphine initiation, individual clinicians may change practice of those around them. Trial Registration ClinicalTrials.gov Identifier: NCT03658642.
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Affiliation(s)
- Evangeline Gao
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
| | - Hyung Paek
- Information Technology Services, Yale New Haven Health, Stratford, Connecticut
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - R. Andrew Taylor
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew J. Loza
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
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Barreveld AM, Mendelson A, Deiling B, Armstrong CA, Viscusi ER, Kohan LR. Caring for Our Patients With Opioid Use Disorder in the Perioperative Period: A Guide for the Anesthesiologist. Anesth Analg 2023; 137:488-507. [PMID: 37590794 DOI: 10.1213/ane.0000000000006280] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
Opioid use disorder (OUD) is a rising public health crisis, impacting millions of individuals and families worldwide. Anesthesiologists can play a key role in improving morbidity and mortality around the time of surgery by informing perioperative teams and guiding evidence-based care and access to life-saving treatment for patients with active OUD or in recovery. This article serves as an educational resource for the anesthesiologist caring for patients with OUD and is the second in a series of articles published in Anesthesia & Analgesia on the anesthetic and analgesic management of patients with substance use disorders. The article is divided into 4 sections: (1) background to OUD, treatment principles, and the anesthesiologist; (2) perioperative considerations for patients prescribed medications for OUD (MOUD); (3) perioperative considerations for patients with active, untreated OUD; and (4) nonopioid and nonpharmacologic principles of multimodal perioperative pain management for patients with untreated, active OUD, or in recovery. The article concludes with a stepwise approach for the anesthesiologist to support OUD treatment and recovery. The anesthesiologist is an important leader of the perioperative team to promote these suggested best practices and help save lives.
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Affiliation(s)
- Antje M Barreveld
- From the Department of Anesthesiology, Tufts University School of Medicine, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Andrew Mendelson
- Department of Anesthesiology, University of Virginia School of Medicine, University of Virginia Hospital, Charlottesville, Virginia
| | - Brittany Deiling
- Department of Anesthesiology, University of Virginia School of Medicine, University of Virginia Hospital, Charlottesville, Virginia
| | - Catharina A Armstrong
- Department of Medicine, Tufts University School of Medicine, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Lynn R Kohan
- Department of Anesthesiology, University of Virginia School of Medicine, University of Virginia Hospital, Charlottesville, Virginia
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Holland WC, Li F, Nath B, Jeffery MM, Stevens M, Melnick ER, Dziura JD, Khidir H, Skains RM, D’Onofrio G, Soares WE. Racial and ethnic disparities in emergency department-initiated buprenorphine across five health care systems. Acad Emerg Med 2023; 30:709-720. [PMID: 36660800 PMCID: PMC10467357 DOI: 10.1111/acem.14668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Opioid overdose deaths have disproportionately impacted Black and Hispanic populations, in part due to disparities in treatment access. Emergency departments (EDs) serve as a resource for patients with opioid use disorder (OUD), many of whom have difficulty accessing outpatient addiction programs. However, inequities in ED treatment for OUD remain poorly understood. METHODS This secondary analysis examined racial and ethnic differences in buprenorphine access using data from EMBED, a study of 21 EDs across five health care systems evaluating a clinical decision support system for initiating ED buprenorphine. The primary outcome was receipt of buprenorphine, ED administered or prescribed. Hospital type (academic vs. community) was evaluated as an effect modifier. Hierarchical models with cluster effects for site and clinician were used to assess buprenorphine receipt by race and ethnicity. RESULTS Black patients were less likely to receive buprenorphine (6.4% [51/801] vs. White patients 8.5% [268/3154], odds ratio [OR] 0.59, 95% confidence interval [CI] 0.45-0.78). This association persisted after adjusting for age, insurance, gender, clinician X-waiver, hospital type, and urbanicity (adjusted OR [aOR] 0.64, 95% CI 0.48-0.84) but not when discharge diagnosis was included (aOR 0.75, 95% CI 0.56-1.02). Hispanic patients were more likely to receive buprenorphine (14.8% [122/822] vs. non-Hispanic patients, 11.6% [475/4098]) in unadjusted (OR 1.57, 95% CI 1.09-1.83) and adjusted models (aOR 1.41, 95% CI 1.08-1.83) but not including discharge diagnosis (aOR 1.32, 95% CI 0.99-1.77). Odds of buprenorphine were similar in academic and community EDs by race (interaction p = 0.97) and ethnicity (interaction p = 0.64). CONCLUSIONS Black patients with OUD were less likely to receive buprenorphine whereas Hispanic patients were more likely to receive buprenorphine in academic and community EDs. Differences were attenuated with discharge diagnosis, as fewer Black and non-Hispanic patients were diagnosed with opioid withdrawal. Barriers to medication treatment are heterogenous among patients with OUD; research must continue to address the multiple drivers of health inequities at the patient, clinician, and community level.
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Affiliation(s)
| | - Fangyong Li
- Yale Center for Analytical Sciences, New Haven, Connecticut, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Molly M. Jeffery
- Department of Emergency Medicine and Department of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria Stevens
- Department of Emergency Medicine and Department of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota, USA
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James D. Dziura
- Yale Center for Analytical Sciences, New Haven, Connecticut, USA
| | - Hazar Khidir
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Rachel M. Skains
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - William E. Soares
- Department of Emergency Medicine, University of Massachusetts Chan Medical School–Baystate, Springfield, Massachusetts, USA
- Department of Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School–Baystate, Springfield, Massachusetts, USA
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Simpson MJ, Ritger C, Hoppe JA, Holland WC, Morris MA, Nath B, Melnick ER, Tietbohl C. Implementation strategies to address the determinants of adoption, implementation, and maintenance of a clinical decision support tool for emergency department buprenorphine initiation: a qualitative study. Implement Sci Commun 2023; 4:41. [PMID: 37081581 PMCID: PMC10117277 DOI: 10.1186/s43058-023-00421-7] [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: 11/17/2022] [Accepted: 03/22/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Untreated opioid use disorder (OUD) is a significant public health problem. Buprenorphine is an evidence-based treatment for OUD that can be initiated in and prescribed from emergency departments (EDs) and office settings. Adoption of buprenorphine initiation among ED clinicians is low. The EMBED pragmatic clinical trial investigated the effectiveness of a clinical decision support (CDS) tool to promote ED clinicians' behavior related to buprenorphine initiation in the ED. While the CDS intervention was not associated with increased rates of buprenorphine treatment for patients with OUD at intervention ED sites, attending physicians at intervention EDs were more likely to initiate buprenorphine at least once over the duration of the study compared to those in the usual care arms (44.4% vs 34.0%, P = 0.01). This suggests the CDS intervention may be associated with increased adoption of buprenorphine initiation. As a secondary aim, we sought to identify the determinants of CDS adoption, implementation, and maintenance in a variety of ED settings and geographic locations. METHODS We purposively sampled and conducted semi-structured, in-depth interviews with clinicians across EMBED trial sites randomized to the intervention arm from five healthcare systems. Interviews elicited clinician experiences regarding buprenorphine initiation and CDS use. Interviews were analyzed using directed content analysis informed by the Practical, Robust Implementation and Sustainability Model (PRISM). We used a hybrid approach (a priori codes informed by PRISM and emergent codes) for codebook development. ATLAS.ti (version 9.0) was used for data management. Coded data were analyzed within individual interview transcripts and across all interviews to identify major themes. This process involved (1) combining, comparing, and making connections between codes; (2) writing analytic memos about observed patterns; and (3) frequent team meetings to discuss emerging patterns. RESULTS Twenty-eight interviews were conducted. Major themes that influenced the successful adoption, implementation, and maintenance of the EMBED intervention and ED-initiated BUP were organizational culture and commitment, clinician training and support, the ability to connect patients to ongoing treatment, and the ability to tailor implementation to each ED. These findings informed the identification of implementation strategies (framed using PRISM domains) to enhance the ED initiation of buprenorphine. CONCLUSION The findings from this qualitative analysis can provide guidance to build better systems to promote the adoption of ED-initiated buprenorphine.
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Affiliation(s)
- Matthew J Simpson
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, 12631 E. 17th Avenue, Box F496, Aurora, CO, 80045, USA.
| | - Carly Ritger
- Adult and Child Center for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 300, Aurora, CO, 80045, USA
| | - Jason A Hoppe
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, 12631 E. 17th Avenue, Box B215, Aurora, CO, 80045, USA
| | - Wesley C Holland
- Yale University School of Medicine, 333 Cedar St., New Haven, CT, 06510, USA
| | - Megan A Morris
- Adult and Child Center for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 300, Aurora, CO, 80045, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Ste 260, New Haven, CT, 06519, USA
| | - Edward R Melnick
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Ste 260, New Haven, CT, 06519, USA
| | - Caroline Tietbohl
- Adult and Child Center for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 300, Aurora, CO, 80045, USA
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Gettel CJ, Yiadom MYA, Bernstein SL, Grudzen CR, Nath B, Li F, Hwang U, Hess EP, Melnick ER. Pragmatic clinical trial design in emergency medicine: Study considerations and design types. Acad Emerg Med 2022; 29:1247-1257. [PMID: 35475533 PMCID: PMC9790188 DOI: 10.1111/acem.14513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/04/2022] [Accepted: 04/25/2022] [Indexed: 01/25/2023]
Abstract
Pragmatic clinical trials (PCTs) focus on correlation between treatment and outcomes in real-world clinical practice, yet a guide highlighting key study considerations and design types for emergency medicine investigators pursuing this important study type is not available. Investigators conducting emergency department (ED)-based PCTs face multiple decisions within the planning phase to ensure robust and meaningful study findings. The PRagmatic Explanatory Continuum Indicator Summary 2 (PRECIS-2) tool allows trialists to consider both pragmatic and explanatory components across nine domains, shaping the trial design to the purpose intended by the investigators. Aside from the PRECIS-2 tool domains, ED-based investigators conducting PCTs should also consider randomization techniques, human subjects concerns, and integration of trial components within the electronic health record. The authors additionally highlight the advantages, disadvantages, and rationale for the use of four common randomized study design types to be considered in PCTs: parallel, crossover, factorial, and stepped-wedge. With increasing emphasis on the conduct of PCTs, emergency medicine investigators will benefit from a rigorous approach to clinical trial design.
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Affiliation(s)
- Cameron J. Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, USA
| | - Maame Yaa A.B. Yiadom
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Erik P. Hess
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
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Melnick ER, Nath B, Dziura JD, Casey MF, Jeffery MM, Paek H, Soares WE, Hoppe JA, Rajeevan H, Li F, Skains RM, Walter LA, Patel MD, Chari SV, Platts-Mills TF, Hess EP, D'Onofrio G. User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial. BMJ 2022; 377:e069271. [PMID: 35760423 PMCID: PMC9231533 DOI: 10.1136/bmj-2021-069271] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder. DESIGN Pragmatic cluster randomized controlled trial (EMBED). SETTING 18 emergency department clusters across five healthcare systems in five states representing the north east, south east, and western regions of the US, ranging from community hospitals to tertiary care centers, using either the Epic or Cerner electronic health record platform. PARTICIPANTS 599 attending emergency physicians caring for 5047 adult patients presenting with opioid use disorder. INTERVENTION A user centered, physician facing clinical decision support system seamlessly integrated into user workflows in the electronic health record to support initiating buprenorphine in the emergency department by helping clinicians to diagnose opioid use disorder, assess the severity of withdrawal, motivate patients to accept treatment, and complete electronic health record tasks by automating clinical and after visit documentation, order entry, prescribing, and referral. MAIN OUTCOME MEASURES Rate of initiation of buprenorphine (administration or prescription of buprenorphine) in the emergency department among patients with opioid use disorder. Secondary implementation outcomes were measured with the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. RESULTS 1 413 693 visits to the emergency department (775 873 in the intervention arm and 637 820 in the usual care arm) from November 2019 to May 2021 were assessed for eligibility, resulting in 5047 patients with opioid use disorder (2787 intervention arm, 2260 usual care arm) under the care of 599 attending physicians (340 intervention arm, 259 usual care arm) for analysis. Buprenorphine was initiated in 347 (12.5%) patients in the intervention arm and in 271 (12.0%) patients in the usual care arm (adjusted generalized estimating equations odds ratio 1.22, 95% confidence interval 0.61 to 2.43, P=0.58). Buprenorphine was initiated at least once by 151 (44.4%) physicians in the intervention arm and by 88 (34.0%) in the usual care arm (1.83, 1.16 to 2.89, P=0.01). CONCLUSIONS User centered clinical decision support did not increase patient level rates of initiating buprenorphine in the emergency department. Although streamlining and automating electronic health record workflows can potentially increase adoption of complex, unfamiliar evidence based practices, more interventions are needed to look at other barriers to the treatment of addiction and increase the rate of initiating buprenorphine in the emergency department in patients with opioid use disorder. TRIAL REGISTRATION ClinicalTrials.gov NCT03658642.
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Affiliation(s)
- Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - James D Dziura
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Martin F Casey
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Molly M Jeffery
- Department of Emergency Medicine and Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Hyung Paek
- Yale School of Public Health, New Haven, CT, USA
| | - William E Soares
- Department of Emergency Medicine, University of Massachusetts Medical School, Springfield, MA, USA
| | - Jason A Hoppe
- Department of Emergency Medicine, University of Colorado, Aurora, CO, USA
| | | | - Fangyong Li
- Yale School of Public Health, New Haven, CT, USA
| | - Rachel M Skains
- Department of Emergency Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Lauren A Walter
- Department of Emergency Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Srihari V Chari
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Erik P Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
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Federico CA, Heagerty PJ, Lantos J, O'Rourke P, Rahimzadeh V, Sugarman J, Weinfurt K, Wendler D, Wilfond BS, Magnus D. Ethical and epistemic issues in the design and conduct of pragmatic stepped-wedge cluster randomized clinical trials. Contemp Clin Trials 2022; 115:106703. [PMID: 35176501 PMCID: PMC9272561 DOI: 10.1016/j.cct.2022.106703] [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: 10/01/2021] [Revised: 01/27/2022] [Accepted: 02/02/2022] [Indexed: 11/27/2022]
Abstract
Stepped-wedge cluster randomized trial (SW-CRT) designs are increasingly employed in pragmatic research; they differ from traditional parallel cluster randomized trials in which an intervention is delivered to a subset of clusters, but not to all. In a SW-CRT, all clusters receive the intervention under investigation by the end of the study. This approach is thought to avoid ethical concerns about the denial of a desired intervention to participants in control groups. Such concerns have been cited in the literature as a primary motivation for choosing SW-CRT design, however SW-CRTs raise additional ethical concerns related to the delayed implementation of an intervention and consent. Yet, PCT investigators may choose SW-CRT designs simply because they are concerned that other study designs are infeasible. In this paper, we examine justifications for the use of SW-CRT study design, over other designs, by drawing on the experience of the National Institutes of Health's Health Care Systems Research Collaboratory (NIH Collaboratory) with five pragmatic SW-CRTs. We found that decisions to use SW-CRT design were justified by practical and epistemic reasons rather than ethical ones. These include concerns about feasibility, the heterogeneity of cluster characteristics, and the desire for simultaneous clinical evaluation and implementation. In this paper we compare the potential benefits of SW-CRTs against the ethical and epistemic challenges brought forth by the design and suggest that the choice of SW-CRT design must balance epistemic, feasibility and ethical justifications. Moreover, given their complexity, such studies need rigorous and informed ethical oversight.
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Affiliation(s)
- Carole A Federico
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA 98185, USA
| | - John Lantos
- Children's Mercy Hospital Bioethics Center, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | | | - Vasiliki Rahimzadeh
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Kevin Weinfurt
- Center for Health Measurement, Duke University, Durham, NC 27701, USA
| | - David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, MD 20892, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA 98185, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA.
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10
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Solberg LI, Hooker SA, Rossom RC, Bergdall A, Crabtree BF. Clinician Perceptions About a Decision Support System to Identify and Manage Opioid Use Disorder. J Am Board Fam Med 2021; 34:1096-1102. [PMID: 34772765 PMCID: PMC8759280 DOI: 10.3122/jabfm.2021.06.210126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Addressing the opioid epidemic would benefit from primary care clinicians identifying and managing opioid use disorder (OUD) during routine clinical encounters, but current rates are low. Clinical decision support (CDS) systems are a promising way to facilitate such interactions, but will clinicians use them? METHODS We iteratively conducted semi-structured interviews with 8 purposively sampled primary care clinicians participating in a pilot OUD-CDS study to identify attitudes toward discussing OUD and preferences for support in doing so. Five of them had used a pilot version of the CDS for 6 months, while the others were in comparison clinics. Interviews were recorded, transcribed, and analyzed by a multi-disciplinary group of experienced researchers, using an editing organizing style where the analysts independently highlighted relevant text and then discussed to reach a consensus on themes. RESULTS We identified five themes: 1. Primary care is the right place to address OUD. 2. Both clinician-patient and clinician-clinician relationships affect how and whether clinicians address OUD in a particular patient encounter. 3. The main challenges are limited time and competing priorities for these complex patients. 4. Although a CDS for OUD could be very helpful, it must meet different needs for different clinicians and clinical situations and be simple to use. 5. For optimal benefit, the CDS needs to be complemented by supportive organizational policies and systems as well as local clinician encouragement. CONCLUSIONS With the right design and a supportive organization, these primary care clinicians believe a CDS could help them regularly identify and address OUD among their patients as long as it incorporates their concerns about relationships, competing priorities, patient complexity, and user simplicity.
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Affiliation(s)
- Leif I Solberg
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC).
| | - Stephanie A Hooker
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC)
| | - Rebecca C Rossom
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC)
| | - Anna Bergdall
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC)
| | - Benjamin F Crabtree
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC)
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11
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Richesson RL, Marsolo KS, Douthit BJ, Staman K, Ho PM, Dailey D, Boyd AD, McTigue KM, Ezenwa MO, Schlaeger JM, Patil CL, Faurot KR, Tuzzio L, Larson EB, O'Brien EC, Zigler CK, Lakin JR, Pressman AR, Braciszewski JM, Grudzen C, Fiol GD. Enhancing the use of EHR systems for pragmatic embedded research: lessons from the NIH Health Care Systems Research Collaboratory. J Am Med Inform Assoc 2021; 28:2626-2640. [PMID: 34597383 PMCID: PMC8633608 DOI: 10.1093/jamia/ocab202] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/05/2021] [Accepted: 09/02/2021] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE We identified challenges and solutions to using electronic health record (EHR) systems for the design and conduct of pragmatic research. MATERIALS AND METHODS Since 2012, the Health Care Systems Research Collaboratory has served as the resource coordinating center for 21 pragmatic clinical trial demonstration projects. The EHR Core working group invited these demonstration projects to complete a written semistructured survey and used an inductive approach to review responses and identify EHR-related challenges and suggested EHR enhancements. RESULTS We received survey responses from 20 projects and identified 21 challenges that fell into 6 broad themes: (1) inadequate collection of patient-reported outcome data, (2) lack of structured data collection, (3) data standardization, (4) resources to support customization of EHRs, (5) difficulties aggregating data across sites, and (6) accessing EHR data. DISCUSSION Based on these findings, we formulated 6 prerequisites for PCTs that would enable the conduct of pragmatic research: (1) integrate the collection of patient-centered data into EHR systems, (2) facilitate structured research data collection by leveraging standard EHR functions, usable interfaces, and standard workflows, (3) support the creation of high-quality research data by using standards, (4) ensure adequate IT staff to support embedded research, (5) create aggregate, multidata type resources for multisite trials, and (6) create re-usable and automated queries. CONCLUSION We are hopeful our collection of specific EHR challenges and research needs will drive health system leaders, policymakers, and EHR designers to support these suggestions to improve our national capacity for generating real-world evidence.
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Affiliation(s)
- Rachel L Richesson
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Keith S Marsolo
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brian J Douthit
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,US Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Karen Staman
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - P Michael Ho
- Department of Medicine, University of Colorado Medicine, Denver, Colorado, USA
| | - Dana Dailey
- Center for Health Sciences, St. Ambrose University, Davenport, Iowa and Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, Iowa, USA
| | - Andrew D Boyd
- Department of Biomedical and Health Information Sciences University of Illinois Chicago, Chicago, Illinois, USA
| | - Kathleen M McTigue
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Miriam O Ezenwa
- Department of Biobehavioral Nursing Science, University of Florida, College of Nursing, Gainesville, Florida, USA
| | - Judith M Schlaeger
- Department of Human Development Nursing Science, University of Illinois Chicago, College of Nursing, Chicago, Illinois, USA
| | - Crystal L Patil
- Department of Human Development Nursing Science, University of Illinois Chicago, College of Nursing, Chicago, Illinois, USA
| | - Keturah R Faurot
- Department of Physical Medicine and Rehabilitation, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Leah Tuzzio
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christina K Zigler
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joshua R Lakin
- Palliative Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Alice R Pressman
- Center for Health Systems Research, Sutter Health Center for Health Systems Research, Walnut Creek, California, USA
| | - Jordan M Braciszewski
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan, USA
| | - Corita Grudzen
- Department of Emergency Medicine, New York University School of Medicine, New York, New York, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
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12
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Stewart MT, Coulibaly N, Schwartz D, Dey J, Thomas CP. Emergency department-based efforts to offer medication treatment for opioid use disorder: What can we learn from current approaches? J Subst Abuse Treat 2021; 129:108479. [PMID: 34080563 PMCID: PMC8380665 DOI: 10.1016/j.jsat.2021.108479] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/17/2020] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The opioid epidemic remains a public health crisis and most people with opioid use disorder (OUD) do not receive effective treatment. The emergency department (ED) can be a critical entry point for treatment. EDs are developing and implementing ED-based efforts to address OUD to improve access to OUD treatment. This study's objective is to identify features of ED-based OUD treatment programs that relate to program implementation, effectiveness, and sustainability. METHODS We obtained data through literature review and semistructured interviews with ED physicians and leaders. The study analyzed these data to develop a framework of key components of ED-based efforts and highlight barriers and facilitators to implementation and program effectiveness. RESULTS We identify five key features of ED-based opioid treatment programs that vary across programs and may influence effectiveness and impact: patient identification methods; treatment approaches; program structure; relationship with community partners; and financing and sustainability. Successful implementation of ED-based OUD treatment includes having a champion, a reliable referral network, and systematic tracking and reporting of data for monitoring and feedback. CONCLUSION Going forward, attention to these features may help to improve effectiveness. As researchers conduct studies of ED-based care models, they should assess the impact of variation in key features to improve program effectiveness.
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Affiliation(s)
- Maureen T Stewart
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, 415 South St., Waltham, MA, USA.
| | - Neto Coulibaly
- Global Health Policy & Management, The Heller School for Social Policy and Management, Brandeis University, 415 South St., Waltham, MA, USA.
| | - Daniel Schwartz
- Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, DC, USA.
| | - Judith Dey
- Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, DC, USA.
| | - Cindy Parks Thomas
- Schneider Institutes for Health Policy, The Heller School for Social Policy and Management, Brandeis University, 415 South St., Waltham, MA, USA.
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13
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Mospan GA, Chaplin M. Initiation of buprenorphine for opioid use disorder in the hospital setting: Practice models, challenges, and legal considerations. Am J Health Syst Pharm 2021; 79:140-146. [PMID: 34554207 DOI: 10.1093/ajhp/zxab373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To provide health-system pharmacists with published examples of strategies utilized to offer buprenorphine to inpatients with opioid use disorder (OUD) along with information on challenges and legal considerations. SUMMARY Hospitals and emergency departments (EDs) are a constant source of healthcare for patients with OUD. As a result, hospital practitioners can screen, diagnose, begin treatment, and facilitate transfer of care to the outpatient setting. Offering sublingual buprenorphine in the hospital can bridge the gap before outpatient care is established. Multiple studies have shown that initiating treatment in the ED or during inpatient hospitalization results in 47% to 74% of patients utilizing medication-assisted treatment at day 30 of follow-up, statistically superior to the rates achieved with brief interventions or referral alone. Moreover, initiating buprenorphine treatment in the ED has been shown to decrease healthcare costs. Despite the benefits of offering buprenorphine in the inpatient setting, several challenges must be solved by hospital administration, such as achieving clinician readiness to prescribe buprenorphine, developing relationships with outpatient providers of buprenorphine, and creating an efficient workflow. Treatment of OUD with buprenorphine is heavily regulated on the federal level. Pharmacists can participate in the development of these programs and ensure compliance with applicable laws. CONCLUSION As health systems continue to care for patients with OUD, starting buprenorphine in the inpatient setting can improve the transition to outpatient treatment. Several institutions have developed programs with positive results. With an understanding of the typical barriers and relevant laws when initiating buprenorphine in the hospital setting, health-system pharmacists can assist in the development and operation of these initiatives.
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14
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Wake DT, Smith DM, Kazi S, Dunnenberger HM. Pharmacogenomic Clinical Decision Support: A Review, How-to Guide, and Future Vision. Clin Pharmacol Ther 2021; 112:44-57. [PMID: 34365648 PMCID: PMC9291515 DOI: 10.1002/cpt.2387] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/28/2021] [Indexed: 02/06/2023]
Abstract
Clinical decision support (CDS) is an essential part of any pharmacogenomics (PGx) implementation. Increasingly, institutions have implemented CDS tools in the clinical setting to bring PGx data into patient care, and several have published their experiences with these implementations. However, barriers remain that limit the ability of some programs to create CDS tools to fit their PGx needs. Therefore, the purpose of this review is to summarize the types, functions, and limitations of PGx CDS currently in practice. Then, we provide an approachable step‐by‐step how‐to guide with a case example to help implementers bring PGx to the front lines of care regardless of their setting. Particular focus is paid to the five “rights” of CDS as a core around designing PGx CDS tools. Finally, we conclude with a discussion of opportunities and areas of growth for PGx CDS.
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Affiliation(s)
- Dyson T Wake
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - D Max Smith
- MedStar Health, Columbia, Maryland, USA.,Georgetown University Medical Center, Washington, DC, USA
| | - Sadaf Kazi
- Georgetown University Medical Center, Washington, DC, USA.,National Center for Human Factors in Healthcare, MedStar Health Research Institute Washington, Washington, DC, USA
| | - Henry M Dunnenberger
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
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15
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Agarwal S, Glenton C, Tamrat T, Henschke N, Maayan N, Fønhus MS, Mehl GL, Lewin S. Decision-support tools via mobile devices to improve quality of care in primary healthcare settings. Cochrane Database Syst Rev 2021; 7:CD012944. [PMID: 34314020 PMCID: PMC8406991 DOI: 10.1002/14651858.cd012944.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The ubiquity of mobile devices has made it possible for clinical decision-support systems (CDSS) to become available to healthcare providers on handheld devices at the point-of-care, including in low- and middle-income countries. The use of CDSS by providers can potentially improve adherence to treatment protocols and patient outcomes. However, the evidence on the effect of the use of CDSS on mobile devices needs to be synthesized. This review was carried out to support a World Health Organization (WHO) guideline that aimed to inform investments on the use of decision-support tools on digital devices to strengthen primary healthcare. OBJECTIVES To assess the effects of digital clinical decision-support systems (CDSS) accessible via mobile devices by primary healthcare providers in the context of primary care settings. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Global Index Medicus, POPLINE, and two trial registries from 1 January 2000 to 9 October 2020. We conducted a grey literature search using mHealthevidence.org and issued a call for papers through popular digital health communities of practice. Finally, we conducted citation searches of included studies. SELECTION CRITERIA Study design: we included randomized trials, including full-text studies, conference abstracts, and unpublished data irrespective of publication status or language of publication. Types of participants: we included studies of all cadres of healthcare providers, including lay health workers and other individuals (administrative, managerial, and supervisory staff) involved in the delivery of primary healthcare services using clinical decision-support tools; and studies of clients or patients receiving care from primary healthcare providers using digital decision-support tools. Types of interventions: we included studies comparing digital CDSS accessible via mobile devices with non-digital CDSS or no intervention, in the context of primary care. CDSS could include clinical protocols, checklists, and other job-aids which supported risk prioritization of patients. Mobile devices included mobile phones of any type (but not analogue landline telephones), as well as tablets, personal digital assistants, and smartphones. We excluded studies where digital CDSS were used on laptops or integrated with electronic medical records or other types of longitudinal tracking of clients. DATA COLLECTION AND ANALYSIS A machine learning classifier that gave each record a probability score of being a randomized trial screened all search results. Two review authors screened titles and abstracts of studies with more than 10% probability of being a randomized trial, and one review author screened those with less than 10% probability of being a randomized trial. We followed standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care group. We used the GRADE approach to assess the certainty of the evidence for the most important outcomes. MAIN RESULTS Eight randomized trials across varying healthcare contexts in the USA,. India, China, Guatemala, Ghana, and Kenya, met our inclusion criteria. A range of healthcare providers (facility and community-based, formally trained, and lay workers) used digital CDSS. Care was provided for the management of specific conditions such as cardiovascular disease, gastrointestinal risk assessment, and maternal and child health. The certainty of evidence ranged from very low to moderate, and we often downgraded evidence for risk of bias and imprecision. We are uncertain of the effect of this intervention on providers' adherence to recommended practice due to the very low certainty evidence (2 studies, 185 participants). The effect of the intervention on patients' and clients' health behaviours such as smoking and treatment adherence is mixed, with substantial variation across outcomes for similar types of behaviour (2 studies, 2262 participants). The intervention probably makes little or no difference to smoking rates among people at risk of cardiovascular disease but probably increases other types of desired behaviour among patients, such as adherence to treatment. The effect of the intervention on patients'/clients' health status and well-being is also mixed (5 studies, 69,767 participants). It probably makes little or no difference to some types of health outcomes, but we are uncertain about other health outcomes, including maternal and neonatal deaths, due to very low-certainty evidence. The intervention may slightly improve patient or client acceptability and satisfaction (1 study, 187 participants). We found no studies that reported the time between the presentation of an illness and appropriate management, provider acceptability or satisfaction, resource use, or unintended consequences. AUTHORS' CONCLUSIONS We are uncertain about the effectiveness of mobile phone-based decision-support tools on several outcomes, including adherence to recommended practice. None of the studies had a quality of care framework and focused only on specific health areas. We need well-designed research that takes a systems lens to assess these issues.
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Affiliation(s)
- Smisha Agarwal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, Maryland (MD), USA
| | | | - Tigest Tamrat
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
| | | | | | | | - Garrett L Mehl
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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16
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Accounting for quality improvement during the conduct of embedded pragmatic clinical trials within healthcare systems: NIH Collaboratory case studies. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 8 Suppl 1:100432. [PMID: 34175091 PMCID: PMC8900087 DOI: 10.1016/j.hjdsi.2020.100432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 04/23/2020] [Accepted: 05/14/2020] [Indexed: 11/21/2022]
Abstract
Embedded pragmatic clinical trials (ePCTs) and quality improvement (QI) activities often occur simultaneously within healthcare systems (HCSs). Embedded PCTs within HCSs are conducted to test interventions and provide evidence that may impact public health, health system operations, and quality of care. They are larger and more broadly generalizable than QI initiatives, and may generate what is considered high-quality evidence for potential use in care and clinical practice guidelines. QI initiatives often co-occur with ePCTs and address the same high-impact health questions, and this co-occurrence may dilute or confound the ability to detect change as a result of the ePCT intervention. During the design, pilot, and conduct phases of the large-scale NIH Collaboratory Demonstration ePCTs, many QI initiatives occurred at the same time within the HCSs. Although the challenges varied across the projects, some common, generalizable strategies and solutions emerged, and we share these as case studies.
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17
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Huntley K, Einstein E, Postma T, Thomas A, Ling S, Compton W. Advancing emergency department-initiated buprenorphine. J Am Coll Emerg Physicians Open 2021; 2:e12451. [PMID: 34179878 PMCID: PMC8208651 DOI: 10.1002/emp2.12451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/01/2021] [Accepted: 04/23/2021] [Indexed: 01/10/2023] Open
Abstract
Opioids are the main driver of drug overdose deaths in the United States, and there has been a marked increase in opioid-related overdoses during the COVID-19 public health emergency. Many emergency departments (EDs) across the country are implementing ED-initiated buprenorphine programs, and this is a method to address and prevent opioid overdoses. Resources are available to overcome barriers and take action.
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Affiliation(s)
- Kristen Huntley
- Center for the Clinical Trials NetworkThe National Institute on Drug AbuseBethesdaMarylandUSA
| | - Emily Einstein
- Office of Science Policy and CommunicationsThe National Institute on Drug AbuseBethesdaMarylandUSA
| | - Terri Postma
- Center for MedicareCenters for Medicare & Medicaid ServicesBaltimoreMarylandUSA
| | - Anita Thomas
- Center for Clinical Standards and QualityCenters for Medicare & Medicaid ServicesBaltimoreMarylandUSA
| | - Shari Ling
- Center for Clinical Standards and QualityCenters for Medicare & Medicaid ServicesBaltimoreMarylandUSA
| | - Wilson Compton
- Office of the DirectorThe National Institute on Drug AbuseBethesdaMarylandUSA
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18
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Emergency Department Visits for Nonfatal Opioid Overdose During the COVID-19 Pandemic Across Six US Health Care Systems. Ann Emerg Med 2021; 79:158-167. [PMID: 34119326 PMCID: PMC8449788 DOI: 10.1016/j.annemergmed.2021.03.013] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/02/2021] [Accepted: 03/11/2021] [Indexed: 01/28/2023]
Abstract
Study objective People with opioid use disorder are vulnerable to disruptions in access to addiction treatment and social support during the COVID-19 pandemic. Our study objective was to understand changes in emergency department (ED) utilization following a nonfatal opioid overdose during COVID-19 compared to historical controls in 6 healthcare systems across the United States. Methods Opioid overdoses were retrospectively identified among adult visits to 25 EDs in Alabama, Colorado, Connecticut, North Carolina, Massachusetts, and Rhode Island from January 2018 to December 2020. Overdose visit counts and rates per 100 all-cause ED visits during the COVID-19 pandemic were compared with the levels predicted based on 2018 and 2019 visits using graphical analysis and an epidemiologic outbreak detection cumulative sum algorithm. Results Overdose visit counts increased by 10.5% (n=3486; 95% confidence interval [CI] 4.18% to 17.0%) in 2020 compared with the counts in 2018 and 2019 (n=3020 and n=3285, respectively), despite a 14% decline in all-cause ED visits. Opioid overdose rates increased by 28.5% (95% CI 23.3% to 34.0%) from 0.25 per 100 ED visits in 2018 to 2019 to 0.32 per 100 ED visits in 2020. Although all 6 studied health care systems experienced overdose ED visit rates more than the 95th percentile prediction in 6 or more weeks of 2020 (compared with 2.6 weeks as expected by chance), 2 health care systems experienced sustained outbreaks during the COVID-19 pandemic. Conclusion Despite decreases in ED visits for other medical emergencies, the numbers and rates of opioid overdose-related ED visits in 6 health care systems increased during 2020, suggesting a widespread increase in opioid-related complications during the COVID-19 pandemic. Expanded community- and hospital-based interventions are needed to support people with opioid use disorder and save lives during the COVID-19 pandemic.
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19
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Whiteside LK, Vrablik MC, Russo J, Bulger EM, Nehra D, Moloney K, Zatzick DF. Leveraging a health information exchange to examine the accuracy of self-report emergency department utilization data among hospitalized injury survivors. Trauma Surg Acute Care Open 2021; 6:e000550. [PMID: 33553651 PMCID: PMC7845668 DOI: 10.1136/tsaco-2020-000550] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/07/2020] [Accepted: 01/05/2021] [Indexed: 11/09/2022] Open
Abstract
Background Accurate acute care medical utilization history is an important outcome for clinicians and investigators concerned with improving trauma center care. The objective of this study was to examine the accuracy of self-report emergency department (ED) utilization compared with utilization obtained from the Emergency Department Information Exchange (EDIE) in admitted trauma surgery patients with comorbid mental health and substance use problems. Methods This is a retrospective cohort study of 169 injured patients admitted to the University of Washington’s Harborview Level I Trauma Center. Patients had high levels of post-traumatic stress disorder and depressive symptoms, suicidal ideation and alcohol comorbidity. The investigation used EDIE, a novel health technology tool that collects information at the time a patient checks into any ED in Washington and other US states. Patterns of EDIE-documented visits were described, and the accuracy of injured patients’ self-report visits was compared with EDIE-recorded visits during the course of the 12 months prior to the index trauma center admission. Results Overall, 45% of the sample (n=76) inaccurately recalled their ED visits during the past year, with 36 participants (21%) reporting less ED visits than EDIE indicated and 40 (24%) reporting more ED visits than EDIE indicated. Patients with histories of alcohol use problems and major psychiatric illness were more likely to either under-report or over-report ED health service use. Discussion Nearly half of all patients were unable to accurately recall ED visits in the previous 12 months compared with EDIE, with almost one-quarter of patients demonstrating high levels of disagreement. The improved accuracy and ease of use when compared with self-report make EDIE an important tool for both clinical and pragmatic trial longitudinal outcome assessments. Orchestrated investigative and policy efforts could further examine the benefits of introducing EDIE and other information exchanges into routine acute care clinical workflows. Level of evidence II/III. Trial registration number ClinicalTrials.gov NCT02274688.
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Affiliation(s)
- Lauren K Whiteside
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Marie C Vrablik
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Joan Russo
- Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Deepika Nehra
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kathleen Moloney
- Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Douglas F Zatzick
- Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
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20
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Salter H, Hutton J, Cantwell K, Dietze P, Higgs P, Straub A, Zordan R, Lloyd‐Jones M. Review article: Rapid review of the emergencydepartment‐initiatedbuprenorphine for opioid use disorder. Emerg Med Australas 2020; 32:924-934. [DOI: 10.1111/1742-6723.13654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/13/2020] [Accepted: 09/18/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Helen Salter
- Emergency Department St Vincent's Hospital Melbourne Melbourne Victoria Australia
- Department of Medicine The University of Melbourne Melbourne Victoria Australia
| | - Jennie Hutton
- Emergency Department St Vincent's Hospital Melbourne Melbourne Victoria Australia
- Department of Medicine The University of Melbourne Melbourne Victoria Australia
| | - Kate Cantwell
- Ambulance Victoria Melbourne Victoria Australia
- Department of Community Emergency Health and Paramedic Practice, Monash University Melbourne Victoria Australia
| | - Paul Dietze
- Behaviours and Health Risks Program Burnet Institute Melbourne Victoria Australia
- National Drug Research Institute Curtin University Perth Western Australia Australia
| | - Peter Higgs
- Department of Public Health La Trobe University Melbourne Victoria Australia
| | - Adam Straub
- Department of Addiction Medicine St Vincent's Hospital Melbourne Melbourne Victoria Australia
| | - Rachel Zordan
- Department of Medicine The University of Melbourne Melbourne Victoria Australia
- Department of Education and Learning St Vincent's Hospital Melbourne Melbourne Victoria Australia
| | - Martyn Lloyd‐Jones
- Department of Addiction Medicine St Vincent's Hospital Melbourne Melbourne Victoria Australia
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21
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Cao SS, Dunham SI, Simpson SA. Prescribing Buprenorphine for Opioid Use Disorders in the ED: A Review of Best Practices, Barriers, and Future Directions. Open Access Emerg Med 2020; 12:261-274. [PMID: 33116962 PMCID: PMC7569244 DOI: 10.2147/oaem.s267416] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/18/2020] [Indexed: 01/14/2023] Open
Abstract
ED-initiated addiction treatment holds promise for enhancing access to treatment for those with opioid use disorder (OUD). We present a literature review summarizing the evidence for buprenorphine induction in the ED including best practices for dosing, follow-up care, and reducing implementation barriers. A literature search of Pubmed, PsychInfo, and Embase identified articles studying OUD treatment in the ED published after 1980. Twenty-five studies were identified including eleven scientific abstracts. Multiple studies suggest that buprenorphine induction improves engagement in substance treatment up to 30 days after ED treatment. Many different induction protocols were presented, but no particular approach was best supported as criteria for induction and initial dosing vary widely. Similarly, transition of care models focused on either a "hub and spoke" model or "warm hand-offs" model, but no studies compared these approaches. Common barriers to implementing induction programs were provider inexperience, discomfort with addiction treatment, and limited time during the ED visit. No studies described the number of EDs offering induction. While ED buprenorphine induction is safe and enhances adherence to addiction treatment, uncertainty persists in how to best identify patients needing treatment, how to initiate buprenorphine, and how to enhance follow-up after ED-initiated treatment.
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Affiliation(s)
- Scott S Cao
- University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
| | - Samuel I Dunham
- University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
| | - Scott A Simpson
- University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
- Psychiatric Emergency Services, Denver Health Medical Center, Denver, CO, USA
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22
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Jeffery MM, D'Onofrio G, Paek H, Platts-Mills TF, Soares WE, Hoppe JA, Genes N, Nath B, Melnick ER. Trends in Emergency Department Visits and Hospital Admissions in Health Care Systems in 5 States in the First Months of the COVID-19 Pandemic in the US. JAMA Intern Med 2020; 180:1328-1333. [PMID: 32744612 PMCID: PMC7400214 DOI: 10.1001/jamainternmed.2020.3288] [Citation(s) in RCA: 346] [Impact Index Per Article: 86.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
IMPORTANCE As coronavirus disease 2019 (COVID-19) spread throughout the US in the early months of 2020, acute care delivery changed to accommodate an influx of patients with a highly contagious infection about which little was known. OBJECTIVE To examine trends in emergency department (ED) visits and visits that led to hospitalizations covering a 4-month period leading up to and during the COVID-19 outbreak in the US. DESIGN, SETTING, AND PARTICIPANTS This retrospective, observational, cross-sectional study of 24 EDs in 5 large health care systems in Colorado (n = 4), Connecticut (n = 5), Massachusetts (n = 5), New York (n = 5), and North Carolina (n = 5) examined daily ED visit and hospital admission rates from January 1 to April 30, 2020, in relation to national and the 5 states' COVID-19 case counts. EXPOSURES Time (day) as a continuous variable. MAIN OUTCOMES AND MEASURES Daily counts of ED visits, hospital admissions, and COVID-19 cases. RESULTS A total of 24 EDs were studied. The annual ED volume before the COVID-19 pandemic ranged from 13 000 to 115 000 visits per year; the decrease in ED visits ranged from 41.5% in Colorado to 63.5% in New York. The weeks with the most rapid rates of decrease in visits were in March 2020, which corresponded with national public health messaging about COVID-19. Hospital admission rates from the ED were stable until new COVID-19 case rates began to increase locally; the largest relative increase in admission rates was 149.0% in New York, followed by 51.7% in Massachusetts, 36.2% in Connecticut, 29.4% in Colorado, and 22.0% in North Carolina. CONCLUSIONS AND RELEVANCE From January through April 2020, as the COVID-19 pandemic intensified in the US, temporal associations were observed with a decrease in ED visits and an increase in hospital admission rates in 5 health care systems in 5 states. These findings suggest that practitioners and public health officials should emphasize the importance of visiting the ED during the COVID-19 pandemic for serious symptoms, illnesses, and injuries that cannot be managed in other settings.
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Affiliation(s)
- Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota.,Department of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Hyung Paek
- Information Technology Services, Yale New Haven Health System, New Haven, Connecticut
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - William E Soares
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Jason A Hoppe
- Department of Emergency Medicine, University of Colorado, School of Medicine, Aurora
| | - Nicholas Genes
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
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23
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Jeffery MM, D'Onofrio G, Paek H, Platts-Mills TF, Soares WE, Hoppe JA, Genes N, Nath B, Melnick ER. Trends in Emergency Department Visits and Hospital Admissions in Health Care Systems in 5 States in the First Months of the COVID-19 Pandemic in the US. JAMA Intern Med 2020. [PMID: 32744612 DOI: 10.1101/2020.04.24.20078584] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
IMPORTANCE As coronavirus disease 2019 (COVID-19) spread throughout the US in the early months of 2020, acute care delivery changed to accommodate an influx of patients with a highly contagious infection about which little was known. OBJECTIVE To examine trends in emergency department (ED) visits and visits that led to hospitalizations covering a 4-month period leading up to and during the COVID-19 outbreak in the US. DESIGN, SETTING, AND PARTICIPANTS This retrospective, observational, cross-sectional study of 24 EDs in 5 large health care systems in Colorado (n = 4), Connecticut (n = 5), Massachusetts (n = 5), New York (n = 5), and North Carolina (n = 5) examined daily ED visit and hospital admission rates from January 1 to April 30, 2020, in relation to national and the 5 states' COVID-19 case counts. EXPOSURES Time (day) as a continuous variable. MAIN OUTCOMES AND MEASURES Daily counts of ED visits, hospital admissions, and COVID-19 cases. RESULTS A total of 24 EDs were studied. The annual ED volume before the COVID-19 pandemic ranged from 13 000 to 115 000 visits per year; the decrease in ED visits ranged from 41.5% in Colorado to 63.5% in New York. The weeks with the most rapid rates of decrease in visits were in March 2020, which corresponded with national public health messaging about COVID-19. Hospital admission rates from the ED were stable until new COVID-19 case rates began to increase locally; the largest relative increase in admission rates was 149.0% in New York, followed by 51.7% in Massachusetts, 36.2% in Connecticut, 29.4% in Colorado, and 22.0% in North Carolina. CONCLUSIONS AND RELEVANCE From January through April 2020, as the COVID-19 pandemic intensified in the US, temporal associations were observed with a decrease in ED visits and an increase in hospital admission rates in 5 health care systems in 5 states. These findings suggest that practitioners and public health officials should emphasize the importance of visiting the ED during the COVID-19 pandemic for serious symptoms, illnesses, and injuries that cannot be managed in other settings.
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Affiliation(s)
- Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Hyung Paek
- Information Technology Services, Yale New Haven Health System, New Haven, Connecticut
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - William E Soares
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Jason A Hoppe
- Department of Emergency Medicine, University of Colorado, School of Medicine, Aurora
| | - Nicholas Genes
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
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24
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Holland WC, Nath B, Li F, Maciejewski K, Paek H, Dziura J, Rajeevan H, Lu CC, Katsovich L, D'Onofrio G, Melnick ER. Interrupted Time Series of User-centered Clinical Decision Support Implementation for Emergency Department-initiated Buprenorphine for Opioid Use Disorder. Acad Emerg Med 2020; 27:753-763. [PMID: 32352206 PMCID: PMC7496559 DOI: 10.1111/acem.14002] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/08/2020] [Accepted: 04/23/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Adoption of emergency department (ED) initiation of buprenorphine (BUP) for opioid use disorder (OUD) into routine emergency care has been slow, partly due to clinicians' unfamiliarity with this practice and perceptions that it is complicated and time-consuming. To address these barriers and guide emergency clinicians through the process of BUP initiation, we implemented a user-centered computerized clinical decision support system (CDS). This study was conducted to assess the feasibility of implementation and to evaluate the preliminary efficacy of the intervention to increase the rate of ED-initiated BUP. METHODS An interrupted time series study was conducted in an urban, academic ED from April 2018 to February 2019 (preimplementation phase), March 2019 to August 2019 (implementation phase), and September 2019 to December 2019 (maintenance phase) to study the effect of the intervention on adult ED patients identified by a validated electronic health record (EHR)-based computable phenotype consisting of structured data consistent with potential cases of OUD who would benefit from BUP treatment. The intervention offers flexible CDS for identification of OUD, assessment of opioid withdrawal, and motivation of readiness to start treatment and automates EHR activities related to ED initiation of BUP (including documentation, orders, prescribing, and referral). The primary outcome was the rate of ED-initiated BUP. Secondary outcomes were launch of the intervention, prescription for naloxone at ED discharge, and referral for ongoing addiction treatment. RESULTS Of the 141,041 unique patients presenting to the ED over the preimplementation and implementation phases (i.e., the phases used in primary analysis), 906 (574 preimplementation and 332 implementation) met OUD phenotype and inclusion criteria. The rate of BUP initiation increased from 3.5% (20/574) in the preimplementation phase to 6.6% (22/332) in the implementation phase (p = 0.03). After the temporal trend of the number of physician's with X-waiver training and other covariates were adjusted for, the relative risk of BUP initiation rate was 2.73 (95% confidence interval [CI] = 0.62 to 12.0, p = 0.18). Similarly, the number of unique attendings who initiated BUP increased modestly 7/53 (13.0%) to 13/57 (22.8%, p = 0.10) after offering just-in-time training during the implementation period. The rate of naloxone prescribed at discharge also increased (6.5% preimplementation and 11.5% implementation; p < 0.01). The intervention received a system usability scale score of 82.0 (95% CI = 76.7 to 87.2). CONCLUSION Implementation of user-centered CDS at a single ED was feasible, acceptable, and associated with increased rates of ED-initiated BUP and naloxone prescribing in patients with OUD and a doubling of the number of unique physicians adopting the practice. We have implemented this intervention across several health systems in an ongoing trial to assess its effectiveness, scalability, and generalizability.
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Affiliation(s)
| | | | - Fangyong Li
- Yale Center for Analytical SciencesNew HavenCT
| | | | - Hyung Paek
- Information Technology ServicesYale New Haven HealthNew HavenCT
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25
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Progress Report on EMBED: A Pragmatic Trial of User-Centered Clinical Decision Support to Implement EMergency Department-Initiated BuprenorphinE for Opioid Use Disorder. JOURNAL OF PSYCHIATRY AND BRAIN SCIENCE 2020; 5. [PMID: 32309637 PMCID: PMC7164817 DOI: 10.20900/jpbs.20200003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Buprenorphine (BUP) can safely and effectively reduce craving, overdose, and mortality rates in people with opioid use disorder (OUD). However, adoption of ED-initiation of BUP has been slow partly due to physician perception this practice is too complex and disruptive. We report progress of the ongoing EMBED (EMergency department-initiated BuprenorphinE for opioid use Disorder) project. This project is a five-year collaboration across five healthcare systems with the goal to develop, integrate, study, and disseminate user-centered Clinical Decision Support (CDS) to promote the adoption of Emergency Department (ED)-initiation of buprenorphine/naloxone (BUP) into routine emergency care. Soon to enter its third year, the project has already completed multiple milestones to achieve its goals including (1) user-centered design of the CDS prototype, (2) integration of the CDS into an automated electronic health record (EHR) workflow, (3) data coordination including derivation and validation of an EHR-based computable phenotype, (4) meeting all ethical and regulatory requirements to achieve a waiver of informed consent, (5) pilot testing of the intervention at a single site, and (6) launching a parallel group-randomized 18-month pragmatic trial in 20 EDs across 5 healthcare systems. Pilot testing of the intervention in a single ED was associated with increased rates of ED-initiated BUP and naloxone prescribing and a doubling of the number of unique physicians adopting the practice. The ongoing multi-center pragmatic trial will assess the intervention’s effectiveness, scalability, and generalizability with a goal to shift the emergency care paradigm for OUD towards early identification and treatment.
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26
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Melnick ER, Holland WC, Ahmed OM, Ma AK, Michael SS, Goldberg HS, Lagier C, D’Onofrio G, Stachowiak T, Brandt C, Solad Y. An integrated web application for decision support and automation of EHR workflow: a case study of current challenges to standards-based messaging and scalability from the EMBED trial. JAMIA Open 2019; 2:434-439. [PMID: 32025639 PMCID: PMC6994013 DOI: 10.1093/jamiaopen/ooz053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/01/2019] [Indexed: 12/02/2022] Open
Abstract
Computerized clinical decision support (CDS) faces challenges to interoperability and scalability. Centralized, web-based solutions offer a mechanism to share the cost of CDS development, maintenance, and implementation across practices. Data standards have emerged to facilitate interoperability and rapid integration of such third-party CDS. This case report describes the challenges to implementation and scalability of an integrated, web-based CDS intervention for EMergency department-initiated BuprenorphinE for opioid use Disorder which will soon be evaluated in a trial across 20 sites in five healthcare systems. Due to limitations of current standards, security concerns, and the need for resource-intensive local customization, barriers persist related to centralized CDS at this scale. These challenges demonstrate the need and importance for future standards to support two-way messaging (read and write) between electronic health records and web applications, thus allowing for more robust sharing across health systems and decreasing redundant, resource-intensive CDS development at individual sites.
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Affiliation(s)
- Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Osama M Ahmed
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anthony K Ma
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sean S Michael
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Howard S Goldberg
- Department of Medicine, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts, USA
| | | | - Gail D’Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Tomek Stachowiak
- Yale New-Haven Health, Information Technology Services, New Haven, Connecticut, USA
| | - Cynthia Brandt
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Yauheni Solad
- Yale University School of Medicine, New Haven, Connecticut, USA
- Yale New-Haven Health, Information Technology Services, New Haven, Connecticut, USA
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