A retrospective quantitative implementation evaluation of Safer Opioid Prescribing, a Canadian continuing education program

From Two Dimensions to Multidimensions: A Mechanistic Model to Support Deliberate CPD Development, Coordination, and Evaluation

INTRODUCTION

The effectiveness of continuing professional development as an intervention to improve health professional behavior and patient health is variable and contentious. To clarify the causal relationships underlying program outcomes and facilitate a necessary shift from outcomes-only-based approaches to outcome-based and theory-based approaches in program development and evaluation, we developed a model of mechanisms mapped to relevant outcomes.

METHODS

Mechanisms identified in a prior realist synthesis of opioid agonist therapy continuing professional development programs were iteratively tested and refined using purposive and opportunistic sampling and realist approaches against two systematic reviews of programs in analgesic prescribing and palliative care. Further testing involved practical application within programs in sustainable health care and pain management.

RESULTS

Ninety reports on 75 programs and practical application to multiple additional programs informed the final model consisting of five distinct mechanisms: motivation transformation, expert influence, confidence development, self-efficacy facilitation, and community of practice expansion. The mechanisms and related analysis emphasize that continuing professional development is heterogeneous, complex, and context dependent.

DISCUSSION

Shifting toward outcome-based and theory-based approaches facilitates further conceptual shifts at intraprogram and interprogram and interintervention levels toward more deliberate program development and evaluation, increased program complementarity and subsequent collaboration. It clarifies opportunities for intercalation of continuing professional development with other intervention sciences. The model presents a resource for practitioners, researchers, and policymakers to advance continuing professional development planning, coordination, and evaluation.

Principles-Focused Evaluation: A Promising Practice in the Evaluation of Continuing Professional Development

ABSTRACT

Outcome-based evaluations still dominate in continuing professional development (CPD) despite the availability of evaluation approaches that address program processes and contexts. Our continued reliance on outcomes-based evaluation fails to respect the importance of complexity and the human element of program planning and implementation. Therefore, it is time that the field of CPD embrace complementary approaches to program evaluation that consider the complexity and maturity of programs and their contexts, while providing credible and relevant information to inform strategic decisions regarding the future of a program. Principles-focused evaluation provides a complement to traditional evaluation approaches through the articulation of a program's values that can be actioned. These "actionable values," known as principles, become the focus of the evaluation for the purposes of program decision-making. This paper describes how one CPD program, designed as a response to growing opioid-related harms, adopted a principles-focused evaluation to inform ongoing iteration of the program. The process used to design the principles, how the principles are informing the transportability of the program, and implications for CPD evaluation are discussed.

A Scoping Review of Gaps Identified by Primary Care Providers in Caring for Patients with Chronic Noncancer Pain

Introduction/Aim

Primary care providers (PCPs), who provide the bulk of care for patients with chronic noncancer pain (CNCP), often report knowledge gaps, limited resources, and difficult patient encounters while managing chronic pain. This scoping review seeks to evaluate gaps identified by PCPs in providing care to patients with chronic pain.

Methods

The Arksey and O'Malley framework was used for this scoping review. A broad literature search was conducted for relevant articles on gaps in knowledge and skills of PCPs and in their health care environment for managing chronic pain, with multiple search term derivatives for concepts of interest. Articles from the initial search were screened for relevance, yielding 31 studies. Inductive and deductive thematic analysis was adopted.

Results

The studies included in this review reflected a variety of study designs, settings, and methods. However, consistent themes emerged with respect to gaps in knowledge and skills for assessment, diagnosis, treatment, and interprofessional roles in chronic pain, as well as broader systemic issues including attitudes toward CNCP. A general lack of confidence in tapering high dose or ineffective opioid regimes, professional isolation, challenges in managing patients with CNCP with complex needs, and limited access to pain specialists were reported by PCPs.

Discussion/Conclusions

This scoping review revealed common elements across the selected studies that will be useful in guiding creation of targeted supports for PCPs to manage CNCP. This review also yielded insights for pain clinicians at tertiary centers for supporting their PCP colleagues as well as systemic reforms required to support patients with CNCP.

A Conceptual Framework for Continuing Medical Education and Population Health

ISSUE

Health systems have been increasingly called upon to address population health concerns and continuing medical education (CME) is an important means through which clinical practices can be improved. This manuscript elaborates on existing conceptual frameworks in order to support CME practitioners, funders, and policy makers to develop, implement, and evaluate CME vis-a-vis population health concerns.

EVIDENCE

Existing CME conceptual models and conceptions of CME effectiveness require elaboration in order to meet goals of population health improvement. Frameworks for the design, implementation and evaluation of CME consistently reference population health, but do not adequately conceptualize it beyond the aggregation of individual patient health. As a pertinent example, opioid prescribing CME programs use the opioid epidemic to justify their programs, but evaluation approaches are inadequate for demonstrating population health impacts. CME programs that are built to have population health outcomes using frameworks intended primarily for physician performance and patient health outcomes are thus not able to recognize either non-linear associations or negative unintended consequences.

IMPLICATIONS

This proposed conceptual framework draws on the fields of clinical population medicine, the social determinants of health, health equity, and philosophies of population health to build conceptual bridges between the CME outcome levels of physician performance and patient health to population health. The authors use their experience developing, delivering, and evaluating opioid prescribing- and poverty-focused CME programs to argue that population health-focused CME must be re-oriented in at least five ways. These include: 1) scaling effective CME programs while evaluating at population health levels; 2) (re)interpreting evidence for program content from a population perspective; 3) incorporating social determinants of health into clinically-oriented CME activities; 4) explicitly building fluency in population health concepts and practices among health care providers and CME planners; and 5) attending to social inequity in every aspect of CME programs.

Opioid Misuse: A Review of the Main Issues, Challenges, and Strategies

In the United States, from 1999 to 2019, opioid overdose, either regularly prescribed or illegally acquired, was the cause of death for nearly 500,000 people. In addition to this pronounced mortality burden that has increased gradually over time, opioid overdose has significant morbidity with severe risks and side effects. As a result, opioid misuse is a cause for concern and is considered an epidemic. This article examines the trends and consequences of the opioid epidemic presented in recent international literature, reflecting on the causes of this phenomenon and the possible strategies to address it. The detailed analysis of 33 international articles highlights numerous impacts in the social, public health, economic, and political spheres. The prescription opioid epidemic is an almost exclusively North American problem. This phenomenon should be carefully evaluated from a healthcare systems perspective, for consequential risks and harms of aggressive opioid prescription practices for pain management. Appropriate policies are required to manage opioid use and prevent abuse efficiently. Examples of proper policies vary, such as the use of validated questionnaires for the early identification of patients at risk of addiction, the effective use of regional and national prescription monitoring programs, and the proper dissemination and translation of knowledge to highlight the risks of prescription opioid abuse.

Education as drug policy: A realist synthesis of continuing professional development for opioid agonist therapy

BACKGROUND

Continuing professional development (CPD) for opioid agonist therapy (OAT) has been identified as a key health policy strategy to improve care for people living with opioid use disorder (OUD) and to address rising opioid-related harms. To design and deliver effective CPD programs, there is a need to clarify how they work within complex health system and policy contexts. This review synthesizes the literature on OAT CPD programs and educational theory to clarify which interventions work, for whom, and in what contexts.

METHODS

A systematic review and realist synthesis of evaluations of CPD programs focused on OAT was conducted. This included record identification and screening, theory familiarization, data collection, analysis, expert consultation, and iterative context-intervention-mechanism-outcome (CIMO) configuration development.

RESULTS

Twenty-four reports comprising 21 evaluation studies from 5 countries for 3373 providers were reviewed. Through iterative testing of included studies with relevant theory, five CIMO configurations were developed. The programs were categorized by who drove the learning outcomes (i.e., system/policy, instructor, learner) and their spheres of influence (i.e., micro, meso, macro). There was a predominance of instructor-driven programs driving change at the micro level, with few policy-driven macro-influential programs, inconsistent with the promotion of CPD as a clear opioid crisis policy-level intervention.

CONCLUSION

OAT CPD is challenged by mismatches in program justifications, objectives, activities, and outcomes. Depending on how these program factors interact, OAT CPD can operate as a barrier or facilitator to OUD care. With more deliberate planning and consideration of program theory, programs more directly addressing diverse learner and system needs may be developed and delivered. OAT CPD as drug policy does not operate in isolation; programs may feed into each other and intercalate with other policy initiatives to have micro, meso, and macro impacts on educational and population health outcomes.

Chronic Pain and Opioid Prescribing: Three Ways for Navigating Complexity at the Clinical‒Population Health Interface

Clinically focused interventions for people living with pain, such as health professional education, clinical decision support systems, prescription drug monitoring programs, and multidisciplinary care to support opioid tapering, have all been promoted as important solutions to the North American opioid crisis. Yet none have so far delivered substantive beneficial opioid-related population health outcomes. In fact, while total opioid prescribing has leveled off or reduced in many jurisdictions, population-level harms from opioids have continued to increase dramatically. We attribute this failure partly to a poor recognition of the epistemic and ethical complexities at the interface of clinical and population health. We draw on a framework of knowledge networks in wicked problems to identify 3 strategies to help navigate these complexities: (1) designing and evaluating clinically focused interventions as complex interventions, (2) reformulating evidence to make population health dynamics apparent, and (3) appealing to the inseparability of facts and values to support decision-making in uncertainty. We advocate that applying these strategies will better equip clinically focused interventions as complements to structural and public health interventions to achieve the desired beneficial population health effects. (Am J Public Health. 2022;112(S1):S56-S65. https://doi.org/10.2105/AJPH.2021.306500).

Evaluations of Continuing Health Provider Education Focused on Opioid Prescribing: A Scoping Review

PURPOSE

Continuing health provider education (HPE) is an important intervention supported by health policy to counter the opioid epidemic; knowledge regarding appropriate program design and evaluation is lacking. The authors aim to provide a comprehensive understanding of evaluations of opioid-related continuing HPE programs and their appropriateness as interventions to improve population health.

METHOD

In January 2020, the authors conducted a systematic search of 7 databases, seeking studies of HPE programs on opioid analgesic prescribing and overdose prevention. Reviewers independently screened the titles and abstracts of all studies and then assessed the full texts of all studies potentially eligible for inclusion. The authors extracted a range of data using categories for evaluating complex programs: the use of theory, program purpose, inputs, activities, outputs, outcomes, and industry involvement. Results were reported in a narrative synthesis.

RESULTS

Thirty-nine reports on 32 distinct HPE programs met inclusion criteria. Of these 32, 31 (97%) were U.S./Canadian programs and 28 (88%) were reported after 2010. Measurements of changes in knowledge and confidence were common. Performance outcomes were less common and typically self-reported. Most studies (n = 27 [84%]) used concerns of opioid-related harms at the population health level to justify the educational intervention, but only 5 (16%) measured patient- or population-level outcomes directly related to the educational programs. Six programs (19%) had direct or indirect opioid manufacturer involvement.

CONCLUSIONS

Continuing HPE has been promoted as an important means of addressing population-level opioid-related harms by policymakers and educators, yet published evaluations of HPE programs focusing on opioid analgesics inadequately evaluate patient- or population-level outcomes. Instead, they primarily focus on self-reported performance outcomes. Conceptual models are needed to guide the development and evaluation of continuing HPE programs intended to have population health benefits.