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Grailey K, Brazier A, Franklin BD, McCrudden C, Fernandez Crespo R, Brown H, Bird J, Acharya A, Gregory A, Darzi A, Huf S. Raising the barcode: improving medication safety behaviours through a behavioural science-informed feedback intervention. A quality improvement project and difference-in-difference analysis. BMJ Qual Saf 2024:bmjqs-2023-016868. [PMID: 38902018 DOI: 10.1136/bmjqs-2023-016868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 05/13/2024] [Indexed: 06/22/2024]
Abstract
Barcode medication administration (BCMA) technology can improve patient safety by using scanning technology to ensure the right drug and dose are given to the right patient. Implementation can be challenging, requiring adoption of different workflows by nursing staff. In one London National Health Service trust scanning rates were lower than desired at around 0-20% of doses per ward. Our objective was to encourage patient safety behaviours in the form of medication scanning through implementation of a feedback intervention. This was informed by behavioural science, codesigned with nurses and informed by known barriers to use. Five wards were selected to trial the intervention over an 18-week period beginning August 2021. The remaining 14 hospital wards acted as controls. Intervention wards had varying uptake of BCMA at baseline and represented a range of specialties. A bespoke feedback intervention comprising three behavioural science constructs (gamification, the messenger effect and framing) was delivered to each intervention ward each week. A linear difference-in-difference analysis was used to evaluate the impact of our intervention on scan rates, both for the overall 18-week period and at two weekly intervals within this timeframe. We identified a 23.1 percentage point increase in medication scan rates (from an average baseline of 15.0% to 38.1%) on the intervention wards compared with control (p<0.001) following implementation of the intervention. Feedback had most impact in the first 6 weeks, with an initial percentage point increase of 26.3 (p<0.001), which subsequently plateaued. Neither clinical specialty nor number of beds on each ward were significant factors in our models. Our study demonstrated that a feedback intervention, codesigned with end users and incorporating behavioural science constructs, can lead to a significant increase in the adoption of BCMA scanning.
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Affiliation(s)
- Kate Grailey
- Centre for Health Policy, Imperial College London Institute of Global Health Innovation, London, UK
| | | | - Bryony Dean Franklin
- Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK
- Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Clare McCrudden
- Helix Centre, Imperial College London Institute of Global Health Innovation, London, UK
| | - Roberto Fernandez Crespo
- Centre for Health Policy, Imperial College London Institute of Global Health Innovation, London, UK
| | | | - James Bird
- Imperial College Healthcare NHS Trust, London, UK
| | - Amish Acharya
- Centre for Health Policy, Imperial College London Institute of Global Health Innovation, London, UK
| | - Alice Gregory
- Helix Centre, Imperial College London Institute of Global Health Innovation, London, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial College London Institute of Global Health Innovation, London, UK
| | - Sarah Huf
- Imperial College London Institute of Global Health Innovation, London, UK
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Candon M, Shen S, Rothbard A, Reed A, Everett M, Demp N, Weingartner M, Fadeyibi O. Incorporating clinician insight and care plans into an audit and feedback initiative for antipsychotic prescribing to Medicaid-enrolled youth in Philadelphia. BMC Health Serv Res 2024; 24:574. [PMID: 38702737 PMCID: PMC11067128 DOI: 10.1186/s12913-024-11029-5] [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: 08/03/2023] [Accepted: 04/22/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Audit and feedback (A/F), which include initiatives like report cards, have an inconsistent impact on clinicians' prescribing behavior. This may be attributable to their focus on aggregate prescribing measures, a one-size-fits-all approach, and the fact that A/F initiatives rarely engage with the clinicians they target. METHODS In this study, we describe the development and delivery of a report card that summarized antipsychotic prescribing to publicly-insured youth in Philadelphia, which was introduced by a Medicaid managed care organization in 2020. In addition to measuring aggregate prescribing behavior, the report card included different elements of care plans, including whether youth were receiving polypharmacy, proper medication management, and the concurrent use of behavioral health outpatient services. The A/F initiative elicited feedback from clinicians, which we refer to as an "audit and feedback loop." We also evaluate the impact of the report card by comparing pre-post differences in prescribing measures for clinicians who received the report card with a group of clinicians who did not receive the report card. RESULTS Report cards indicated that many youth who were prescribed antipsychotics were not receiving proper medication management or using behavioral health outpatient services alongside the antipsychotic prescription, but that polypharmacy was rare. In their feedback, clinicians who received report cards cited several challenges related to antipsychotic prescribing, such as the logistical difficulties of entering lab orders and family members' hesitancy to change care plans. The impact of the report card was mixed: there was a modest reduction in the share of youth receiving polypharmacy following the receipt of the report card, while other measures did not change. However, we documented a large reduction in the number of youth with one or more antipsychotic prescription fill among clinicians who received a report card. CONCLUSIONS A/F initiatives are a common approach to improving the quality of care, and often target specific practices such as antipsychotic prescribing. Report cards are a low-cost and feasible intervention but there is room for quality improvement, such as adding measures that track medication management or eliciting feedback from clinicians who receive report cards. To ensure that the benefits of antipsychotic prescribing outweigh its risks, it is important to promote quality and safety of antipsychotic prescribing within a broader care plan.
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Affiliation(s)
- Molly Candon
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Siyuan Shen
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA
| | - Aileen Rothbard
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
| | - Abigail Reed
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mia Everett
- Community Behavioral Health, Philadelphia, PA, USA
| | - Neal Demp
- Community Behavioral Health, Philadelphia, PA, USA
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Kullgren JT, Kim HM, Slowey M, Colbert J, Soyster B, Winston SA, Ryan K, Forman JH, Riba M, Krupka E, Kerr EA. Using Behavioral Economics to Reduce Low-Value Care Among Older Adults: A Cluster Randomized Clinical Trial. JAMA Intern Med 2024; 184:281-290. [PMID: 38285565 PMCID: PMC10825788 DOI: 10.1001/jamainternmed.2023.7703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/22/2023] [Indexed: 01/31/2024]
Abstract
Importance Use of low-value care is common among older adults. It is unclear how to best engage clinicians and older patients to decrease use of low-value services. Objective To test whether the Committing to Choose Wisely behavioral economic intervention could engage primary care clinicians and older patients to reduce low-value care. Design, Setting, and Participants Stepped-wedge cluster randomized clinical trial conducted at 8 primary care clinics of an academic health system and a private group practice between December 12, 2017, and September 4, 2019. Participants were primary care clinicians and older adult patients who had diabetes, insomnia, or anxiety or were eligible for prostate cancer screening. Data analysis was performed from October 2019 to November 2023. Intervention Clinicians were invited to commit in writing to Choosing Wisely recommendations for older patients to avoid use of hypoglycemic medications to achieve tight glycemic control, sedative-hypnotic medications for insomnia or anxiety, and prostate-specific antigen tests to screen for prostate cancer. Committed clinicians had their photographs displayed on clinic posters and received weekly emails with alternatives to these low-value services. Educational handouts were mailed to applicable patients before scheduled visits and available at the point of care. Main Outcomes and Measures Patient-months with a low-value service across conditions (primary outcome) and separately for each condition (secondary outcomes). For patients with diabetes, or insomnia or anxiety, secondary outcomes were patient-months in which targeted medications were decreased or stopped (ie, deintensified). Results The study included 81 primary care clinicians and 8030 older adult patients (mean [SD] age, 75.1 [7.2] years; 4076 men [50.8%] and 3954 women [49.2%]). Across conditions, a low-value service was used in 7627 of the 37 116 control patient-months (20.5%) and 7416 of the 46 381 intervention patient-months (16.0%) (adjusted odds ratio, 0.79; 95% CI, 0.65-0.97). For each individual condition, there were no significant differences between the control and intervention periods in the odds of patient-months with a low-value service. The intervention increased the odds of deintensification of hypoglycemic medications for diabetes (adjusted odds ratio, 1.85; 95% CI, 1.06-3.24) but not sedative-hypnotic medications for insomnia or anxiety. Conclusions and Relevance In this stepped-wedge cluster randomized clinical trial, the Committing to Choose Wisely behavioral economic intervention reduced low-value care across 3 common clinical situations and increased deintensification of hypoglycemic medications for diabetes. Use of scalable interventions that nudge patients and clinicians to achieve greater value while preserving autonomy in decision-making should be explored more broadly. Trial Registration ClinicalTrials.gov Identifier: NCT03411525.
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Affiliation(s)
- Jeffrey T. Kullgren
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
- University of Michigan Center for Bioethics and Social Sciences in Medicine, Ann Arbor
| | - H. Myra Kim
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
| | - Megan Slowey
- Center for Health and Research Transformation, Ann Arbor, Michigan
| | - Joseph Colbert
- University of Michigan Center for Bioethics and Social Sciences in Medicine, Ann Arbor
| | - Barbara Soyster
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | | | - Kerry Ryan
- University of Michigan Center for Bioethics and Social Sciences in Medicine, Ann Arbor
| | - Jane H. Forman
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Melissa Riba
- Center for Health and Research Transformation, Ann Arbor, Michigan
| | - Erin Krupka
- University of Michigan School of Information, Ann Arbor
| | - Eve A. Kerr
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
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Wagner Z, Kirkegaard A, Mariano LT, Doctor JN, Yan X, Persell SD, Goldstein NJ, Fox CR, Brummett CM, Romanelli RJ, Bouskill K, Martinez M, Zanocco K, Meeker D, Mudiganti S, Waljee J, Watkins KE. Peer Comparison or Guideline-Based Feedback and Postsurgery Opioid Prescriptions: A Randomized Clinical Trial. JAMA HEALTH FORUM 2024; 5:e240077. [PMID: 38488780 PMCID: PMC10943416 DOI: 10.1001/jamahealthforum.2024.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/29/2023] [Indexed: 03/18/2024] Open
Abstract
Importance Excess opioid prescribing after surgery can result in prolonged use and diversion. Email feedback based on social norms may reduce the number of pills prescribed. Objective To assess the effectiveness of 2 social norm-based interventions on reducing guideline-discordant opioid prescribing after surgery. Design, Setting, and Participants This cluster randomized clinical trial conducted at a large health care delivery system in northern California between October 2021 and October 2022 included general, obstetric/gynecologic, and orthopedic surgeons with patients aged 18 years or older discharged to home with an oral opioid prescription. Interventions In 19 hospitals, 3 surgical specialties (general, orthopedic, and obstetric/gynecologic) were randomly assigned to a control group or 1 of 2 interventions. The guidelines intervention provided email feedback to surgeons on opioid prescribing relative to institutionally endorsed guidelines; the peer comparison intervention provided email feedback on opioid prescribing relative to that of peer surgeons. Emails were sent to surgeons with at least 2 guideline-discordant prescriptions in the previous month. The control group had no intervention. Main Outcome and Measures The probability that a discharged patient was prescribed a quantity of opioids above the guideline for the respective procedure during the 12 intervention months. Results There were 38 235 patients discharged from 640 surgeons during the 12-month intervention period. Control-group surgeons prescribed above guidelines 36.8% of the time during the intervention period compared with 27.5% and 25.4% among surgeons in the peer comparison and guidelines arms, respectively. In adjusted models, the peer comparison intervention reduced guideline-discordant prescribing by 5.8 percentage points (95% CI, -10.5 to -1.1; P = .03) and the guidelines intervention reduced it by 4.7 percentage points (95% CI, -9.4 to -0.1; P = .05). Effects were driven by surgeons who performed more surgeries and had more guideline-discordant prescribing at baseline. There was no significant difference between interventions. Conclusions and Relevance In this cluster randomized clinical trial, email feedback based on either guidelines or peer comparison reduced opioid prescribing after surgery. Guideline-based feedback was as effective as peer comparison-based feedback. These interventions are simple, low-cost, and scalable, and may reduce downstream opioid misuse. Trial Registration ClinicalTrials.gov NCT05070338.
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Affiliation(s)
| | | | | | - Jason N. Doctor
- Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Xiaowei Yan
- Palo Alto Medical Foundation, Palo Alto, California
| | - Stephen D. Persell
- Division of General Internal Medicine, Department of Medicine, Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Noah J. Goldstein
- Anderson School of Management, Department of Psychology, and Geffen School of Medicine, University of California at Los Angeles, Los Angeles
| | - Craig R. Fox
- Anderson School of Management, Department of Psychology, and Geffen School of Medicine, University of California at Los Angeles, Los Angeles
| | | | - Robert J. Romanelli
- Palo Alto Medical Foundation, Palo Alto, California
- RAND Europe, Westbrook Centre, Cambridge, United Kingdom
| | | | | | - Kyle Zanocco
- Section of Endocrine Surgery, Division of General Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Daniella Meeker
- Keck School of Medicine, USC Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, California
- Yale School of Medicine, New Haven, Connecticut
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Joo JH, Liao JM. Using peer comparisons to address low-value care: Lessons for a persistent challenge. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2023; 11:100721. [PMID: 37972418 DOI: 10.1016/j.hjdsi.2023.100721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Joseph H Joo
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Program on Policy Evaluation and Learning in the Pacific Northwest, Seattle, WA, USA
| | - Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Program on Policy Evaluation and Learning in the Pacific Northwest, Seattle, WA, USA.
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Gangathimmaiah V, Drever N, Evans R, Moodley N, Sen Gupta T, Cardona M, Carlisle K. What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open 2023; 13:e072762. [PMID: 37945299 PMCID: PMC10649718 DOI: 10.1136/bmjopen-2023-072762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. DESIGN A mixed-methods scoping review was conducted using the Arksey and O'Malley framework. DATA SOURCES Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. ELIGIBILITY CRITERIA Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. DATA EXTRACTION AND SYNTHESIS Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. RESULTS The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. CONCLUSION High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Magnolia Cardona
- A/Prof Implementation Science, Faculty of Health and Behavioural Sciences, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Honorary A/Prof of Research Translation, Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Moffat AK, Apajee J, Le Blanc VT, Westaway K, Andrade AQ, Ramsay EN, Blacker N, Pratt NL, Roughead EE. Reducing opioid use for chronic non-cancer pain in primary care using an evidence-based, theory-informed, multistrategic, multistakeholder approach: a single-arm time series with segmented regression. BMJ Qual Saf 2023; 32:623-631. [PMID: 37105724 PMCID: PMC10646855 DOI: 10.1136/bmjqs-2022-015716] [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: 11/04/2022] [Accepted: 04/12/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Many countries have high opioid use among people with chronic non-cancer pain. Knowledge about effective interventions that could be implemented at scale is limited. We designed a national intervention that included audit and feedback, deprescribing guidance, information on catastrophising assessment, pain neuroscience education and a cognitive tool for use by patients with their healthcare providers. METHOD We used a single-arm time series with segmented regression to assess rates of people using opioids before (January 2015 to September 2017), at the time of (October 2017) and after the intervention (November 2017 to August 2019). We used a cohort with historical comparison group and log binomial regression to examine the rate of psychologist claims in opioid users not using psychologist services prior to the intervention. RESULTS 13 968 patients using opioids, 8568 general practitioners, 8370 pharmacies and accredited pharmacists and 689 psychologists were targeted. The estimated difference in opioid use was -0.51 persons per 1000 persons per month (95% CI -0.69, -0.34; p<0.001) as a result of the intervention, equating to 25 387 (95% CI 24 676, 26 131) patient-months of opioid use avoided during the 22-month follow-up. The targeted group had a significantly higher rate of incident patient psychologist claims compared with the historical comparison group (rate ratio: 1.37, 95% CI 1.16, 1.63; p<0.001), equating to an additional 690 (95% CI 289, 1167) patient-months of psychologist treatment during the 22-month follow-up. CONCLUSIONS Our intervention addressed the cognitive, affective and sensory factors that contribute to pain and consequent opioid use, demonstrating it could be implemented at scale and was associated with a reduction in opioid use and increasing utilisation of psychologist services.
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Affiliation(s)
- Anna K Moffat
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Jemisha Apajee
- Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vanessa T Le Blanc
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Kerrie Westaway
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Andre Q Andrade
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Emmae N Ramsay
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Natalie Blacker
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Nicole L Pratt
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
| | - Elizabeth Ellen Roughead
- Clinical and Health Sciences, University of South Australia, Adelaide, 5000, South Australia, Australia
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Laur C, Ladak Z, Hall A, Solbak NM, Nathan N, Buzuayne S, Curran JA, Shelton RC, Ivers N. Sustainability, spread, and scale in trials using audit and feedback: a theory-informed, secondary analysis of a systematic review. Implement Sci 2023; 18:54. [PMID: 37885018 PMCID: PMC10604689 DOI: 10.1186/s13012-023-01312-0] [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: 05/19/2023] [Accepted: 10/05/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Audit and feedback (A&F) is a widely used implementation strategy to influence health professionals' behavior that is often tested in implementation trials. This study examines how A&F trials describe sustainability, spread, and scale. METHODS This is a theory-informed, descriptive, secondary analysis of an update of the Cochrane systematic review of A&F trials, including all trials published since 2011. Keyword searches related to sustainability, spread, and scale were conducted. Trials with at least one keyword, and those identified from a forward citation search, were extracted to examine how they described sustainability, spread, and scale. Results were qualitatively analyzed using the Integrated Sustainability Framework (ISF) and the Framework for Going to Full Scale (FGFS). RESULTS From the larger review, n = 161 studies met eligibility criteria. Seventy-eight percent (n = 126) of trials included at least one keyword on sustainability, and 49% (n = 62) of those studies (39% overall) frequently mentioned sustainability based on inclusion of relevant text in multiple sections of the paper. For spread/scale, 62% (n = 100) of trials included at least one relevant keyword and 51% (n = 51) of those studies (31% overall) frequently mentioned spread/scale. A total of n = 38 studies from the forward citation search were included in the qualitative analysis. Although many studies mentioned the need to consider sustainability, there was limited detail on how this was planned, implemented, or assessed. The most frequent sustainability period duration was 12 months. Qualitative results mapped to the ISF, but not all determinants were represented. Strong alignment was found with the FGFS for phases of scale-up and support systems (infrastructure), but not for adoption mechanisms. New spread/scale themes included (1) aligning affordability and scalability; (2) balancing fidelity and scalability; and (3) balancing effect size and scalability. CONCLUSION A&F trials should plan for sustainability, spread, and scale so that if the trial is effective, the benefits can continue. A deeper empirical understanding of the factors impacting A&F sustainability is needed. Scalability planning should go beyond cost and infrastructure to consider other adoption mechanisms, such as leadership, policy, and communication, that may support further scalability. TRIAL REGISTRATION Registered with Prospero in May 2022. CRD42022332606.
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Affiliation(s)
- Celia Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.
- Institute of Health Policy, Management and Evaluation, Health Sciences Building, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.
| | - Zeenat Ladak
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
- Ontario Institute for Studies in Education, University of Toronto, 252 Bloor Street West, Toronto, ON, M5S 1V6, Canada
| | - Alix Hall
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
- National Centre of Implementation Science, The University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Nathan M Solbak
- Physician Learning Program, Continuing Medical Education and Professional Development, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
- Health Quality Programs, Queen's University, 92 Barrie Street, Kingston, ON, K7L 3N6, Canada
| | - Nicole Nathan
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
- National Centre of Implementation Science, The University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Shewit Buzuayne
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Janet A Curran
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, B3H 4R2, Canada
| | - Rachel C Shelton
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Noah Ivers
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
- Institute of Health Policy, Management and Evaluation, Health Sciences Building, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, M5G 1V7, Canada
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Crowley AP, Sun C, Yan XS, Navathe A, Liao JM, Patel MS, Pagnotti D, Shen Z, Delgado MK. Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions. Acad Emerg Med 2023; 30:809-818. [PMID: 36876410 DOI: 10.1111/acem.14717] [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: 10/08/2022] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVES Racial and ethnic minorities receive opioid prescriptions at lower rates and dosages than White patients. Though opioid stewardship interventions can improve or exacerbate these disparities, there is little evidence about these effects. We conducted a secondary analysis of a cluster-randomized controlled trial conducted among 438 clinicians from 21 emergency departments and 27 urgent care clinics. Our objective was to determine whether randomly allocated opioid stewardship clinician feedback interventions that were designed to reduce opioid prescriptions had unintended effects on disparities in prescribing by patient race and ethnicity. METHODS The primary outcome was likelihood of receiving a low-pill prescription (low ≤10 pills, medium 11-19 pills, high ≥20 pills). Generalized mixed-effects models were used to determine patient characteristics associated with low-pill prescriptions during the baseline period. These models were then used to determine whether receipt of a low-pill prescription varied by patient race or ethnicity during the intervention period between usual care and three opioid stewardship interventions: (1) individual audit feedback, (2) peer comparison feedback, and (3) combined (individual audit + peer comparison) feedback. RESULTS Compared with White patients, Black patients were more likely to receive a low-pill prescription during the baseline (adjusted odds ratio [OR] 1.18, 95% confidence interval [CI] 1.06-1.31, p = 0.002) and intervention (adjusted OR 1.43, 95% CI 1.07-1.91, p = 0.015). While combined feedback was associated with an overall increase in low-pill prescriptions as intended (adjusted OR 1.89, 95% CI 1.28-2.78, p = 0.001), there were no significant differences in treatment effects of any of the interventions by patient race and ethnicity. CONCLUSIONS Combined individual audit and peer comparison feedback was associated with fewer opioid pills per prescription equally by patient race and ethnicity. However, the intervention did not significantly close the baseline disparity in prescribing by race.
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Affiliation(s)
- Aidan P Crowley
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chuxuan Sun
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Xiaowei Sherry Yan
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - Amol Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Joshua M Liao
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - David Pagnotti
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zijun Shen
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - M Kit Delgado
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Emergency Medicine and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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10
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Brummett CM, Wagner Z, Waljee JF. Best Practice Alerts: A Poke in the Eye or an Efficient Method for Safer Prescribing? Anesthesiology 2023:138340. [PMID: 37327362 DOI: 10.1097/aln.0000000000004623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Affiliation(s)
- Chad M Brummett
- Department of Anesthesiology Opioid Prescribing Engagement Network, University of Michigan, Ann Arbor, Michigan
| | | | - Jennifer F Waljee
- Opioid Prescribing Engagement NetworkDepartment of Surgery, University of Michigan, Ann Arbor, Michigan
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11
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Real-World Observational Evaluation of Common Interventions to Reduce Emergency Department Prescribing of Opioid Medications. Jt Comm J Qual Patient Saf 2023; 49:239-246. [PMID: 36914528 DOI: 10.1016/j.jcjq.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Prior work on opioid prescribing has examined dosing defaults, interruptive alerts, or "harder" stops such as electronic prescribing of controlled substances (EPCS), which has become increasingly required by state policy. Given that real-world opioid stewardship policies are concurrent and overlapping, the authors examined the effect of such policies on emergency department (ED) opioid prescriptions. METHODS The researchers performed observational analysis of all ED visits discharged between December 17, 2016, and December 31, 2019, across seven EDs of a hospital system. Four interventions were examined in chronological order, with each successive intervention added on top of all previous interventions: 12-pill prescription default, EPCS, electronic health record (EHR) pop-up alert, and 8-pill prescription default. The primary outcome was opioid prescribing, which was described as number of opioid prescriptions per 100 discharged ED visits and modeled as a binary outcome for each visit. Secondary outcomes included prescription morphine milligram equivalents (MME) and non-opioid analgesia prescriptions. RESULTS A total of 775,692 ED visits were included in the study. Compared to the preintervention period, cumulative reductions in opioid prescribing were seen with incremental interventions, including after adding a 12-pill default (odds ratio [OR] 0.88, 95% confidence interval [CI] 0.82-0.94), after adding EPCS (OR 0.7, 95% CI 0.63-0.77), after adding pop-up alerts (OR 0.67, 95% CI 0.63-0.71), and after adding an 8-pill default (OR 0.61, 95% CI 0.58-0.65). CONCLUSION EHR-implemented solutions such as EPCS, pop-up alerts, and pill defaults had varying but significant effects on reducing ED opioid prescribing. Policy makers and quality improvement leaders might achieve sustainable improvements in opioid stewardship while balancing clinician alert fatigue through policy efforts promoting implementation of EPCS and default dispense quantities.
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12
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Sacarny A, Avilova T, Powell D, Williamson I, Merrick W, Jacobson M. A Randomized Trial Of Letters To Encourage Prescription Monitoring Program Use And Safe Opioid Prescribing. Health Aff (Millwood) 2023; 42:140-149. [PMID: 36623221 DOI: 10.1377/hlthaff.2022.00859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
To facilitate safer prescribing of opioids and other drugs, nearly all states operate prescription monitoring programs (PMPs), which collect and share data on controlled substance dispensing. Policy makers have sought to raise clinicians' engagement with these programs but lack evidence on effective interventions. Working with the Minnesota Prescription Monitoring Program, we conducted a randomized trial to assess whether letters to clinicians increased program use and decreased risky coprescribing of opioids with benzodiazepines or gabapentinoids. In March 2021 we randomly assigned 12,000 coprescribers to either a control arm or one of three study arms sent differing letters. The respective letters highlighted a new mandate to check the PMP before prescribing, provided information about coprescribing risks with a list of coprescribed patients, or contained both messages combined. Letters highlighting the mandate alone or along with coprescribing information increased PMP search rates by 4.5 and 4.0 percentage points, respectively, with no significant effect on coprescribing. These letters also increased PMP account-holding rates among clinicians. Effects persisted for at least eight months. The letter with only coprescribing information had no detected effects on key outcomes. Our results support the use of simple letter interventions as evidence-based tools to increase PMP engagement and potentially facilitate better-informed prescribing.
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Affiliation(s)
- Adam Sacarny
- Adam Sacarny , Columbia University, New York, New York
| | | | - David Powell
- David Powell, RAND Corporation, Arlington, Virginia
| | - Ian Williamson
- Ian Williamson, Minnesota Management and Budget Agency, Saint Paul, Minnesota
| | | | - Mireille Jacobson
- Mireille Jacobson, University of Southern California, Los Angeles, California
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13
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Vock DM, Neprash HT, Hanson AV, Elert BA, Satin DJ, Rothman AJ, Short S, Karaca-Mandic P, Markowitz R, Melton GB, Golberstein E. PRescribing Interventions for Chronic pain using the Electronic health record (PRINCE): Study protocol. Contemp Clin Trials 2022; 121:106905. [PMID: 36057376 DOI: 10.1016/j.cct.2022.106905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/23/2022] [Accepted: 08/28/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Primary care is a frequent source of pain treatment and opioid prescribing. The objective of the Prescribing Interventions for Chronic Pain using the Electronic health record (PRINCE) study is to assess the effects of two behavioral economics-informed interventions embedded within the electronic health record (EHR) on guideline-concordant pain treatment and opioid prescribing decisions in primary care settings. METHODS Setting: The setting for this study is 43 primary care clinics in Minnesota. DESIGN The PRINCE study uses a cluster-randomized 2 × 2 factorial design to test the effects of two interventions. An adaptive design allows for the possibility of secondary randomization to test if interventions can be titrated while maintaining efficacy. INTERVENTIONS One intervention alters the "choice architecture" within the EHR to nudge clinicians toward non-opioid treatments for opioid-naïve patients and toward tapering for patients currently receiving a "high risk" opioid. The other intervention integrates the prescription drug monitoring program (PDMP) directly within the EHR. OUTCOME The primary outcome for opioid-naïve patients is whether an opioid is prescribed in a primary care visit without a non-opioid alternative pain treatment. The primary outcome for current opioid-using patients is whether opioid prescriptions were tapered with a documented rationale. DISCUSSION The PRINCE study will provide real-world evidence on two approaches to improving pain treatment in primary care using the EHR. The adaptive study design strikes a balance between establishing intervention efficacy and testing whether efficacy varies with intervention intensity.
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Affiliation(s)
- David M Vock
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Hannah T Neprash
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | | | | | - David J Satin
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Sonja Short
- Fairview Health Services, Minneapolis, MN, USA
| | | | - Rebecca Markowitz
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Genevieve B Melton
- Fairview Health Services, Minneapolis, MN, USA; Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Ezra Golberstein
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA.
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14
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Sacarny A, Safran E, Steffel M, Dunham JR, Abili OD, Mohajeri L, Oh PT, Sim A, Brutcher RE, Spevak C. Effect of Pharmacist Email Alerts on Concurrent Prescribing of Opioids and Benzodiazepines by Prescribers and Primary Care Managers. JAMA HEALTH FORUM 2022; 3:e223378. [PMID: 36218952 PMCID: PMC9526090 DOI: 10.1001/jamahealthforum.2022.3378] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Question Can pharmacist email alerts to practitioners reduce concurrent prescribing of opioids and benzodiazepines? Findings In this randomized clinical trial of 2237 patients coprescribed opioids and benzodiazepines and 789 practitioners who treated them, email alerts failed to detectably reduce concurrent prescribing of opioids and benzodiazepines, which can put patients at risk of overdose. The email alerts had no statistically significant effect on patient receipt of these medications or on practitioner prescribing. Meaning These findings suggest that alternative strategies may be more fruitful targets for efforts to make opioid prescribing safer and demonstrate that pairing randomization with quality improvement activities can generate evidence for stakeholders. Importance Policy makers have sought to discourage concurrent prescribing of opioids and benzodiazepines (coprescribing) because it is associated with overdose. Email alerts sent by pharmacists may reduce coprescribing, but this intervention lacks randomized evidence. Objective To investigate whether pharmacist emails to practitioners caring for patients who recently received opioids and benzodiazepines reduce coprescribing of these medications. Design, Setting, and Participants Randomized clinical trial (intention to treat) conducted in 2019-2021 of patients and their practitioners (prescribers and primary care managers) in the National Capital Region of the Military Health System. Participants were 2237 patients who were recently coprescribed opioids and benzodiazepines. These patients had 789 practitioners eligible for emails. Interventions Patients were randomized to email alerts to their practitioners or as-usual care. Clinical pharmacists sent the email alert. Messages were standardized and designed to facilitate coordination between practitioners, increase awareness of guidelines, and provide action steps and resources. Main Outcomes and Measures The primary outcomes were patients’ days received of opioids, benzodiazepines, and concurrent opioids and benzodiazepines during the 90 days following enrollment evaluated using 1-sided hypothesis tests. Secondary outcomes included total prescribing of opioids and benzodiazepines by patients’ practitioners, including to patients outside the study, to test for broader outcomes on their prescribing. Results Of 2237 patients, 1187 were assigned to treatment and 1050 to control; 1275 (57%) were women. Patients received a mean (SD) of 31 (44) days of opioids and 33 (34) days of benzodiazepines in the 90 days before enrollment. There were no detected differences in the primary end points, including patients’ receipt of opioids (adjusted difference, 1.1 days; 95% CI, -∞ to 3.0; P = .81), benzodiazepines (adjusted difference, −0.6 days; 95% CI, -∞ to 1.4; P = .30), and opioids and benzodiazepines together (adjusted difference, −0.1 days; 95% CI, -∞ to 0.7; P = .41). Of 789 practitioners, 429 were considered the treatment group, 325 were considered controls, and 35 were excluded. There were no detected differences in practitioners’ total prescribing of opioids, benzodiazepines, or both drug classes together. Conclusions and Relevance In this randomized clinical trial of pharmacist emails to practitioners, email alerts failed to detectably reduce coprescribing, highlighting the value of alternative approaches. Combining randomization with quality improvement activities may help stakeholders seeking evidence-based interventions to encourage guideline-concordant care. Trial Registration ClinicalTrials.gov Identifier: NCT03887247
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Affiliation(s)
- Adam Sacarny
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York
| | - Elana Safran
- Office of Evaluation Sciences, US General Services Administration, Washington, DC
| | - Mary Steffel
- D’Amore-McKim School of Business, Northeastern University, Boston, Massachusetts
| | | | - Orolo D. Abili
- Department of Anesthesia, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Lobat Mohajeri
- Department of Pharmacy, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Patricia T. Oh
- Department of Pharmacy, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Alan Sim
- Enterprise Intelligence and Data Solutions Program Management Office, Defense Health Agency, Falls Church, Virginia
| | - Robert E. Brutcher
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Christopher Spevak
- National Capital Regional Pain Initiative, Department of Anesthesia and Pain Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
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15
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Candon M, Xue L, Shen S, Cole ES, Donohue J, Rothbard A. The impact of opioid prescribing report cards in Medicaid. J Manag Care Spec Pharm 2022; 28:862-870. [PMID: 35876292 PMCID: PMC10373013 DOI: 10.18553/jmcp.2022.28.8.862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND: Performance feedback has been used for decades to improve health care quality and safety, with varying degrees of success. One example is the use of customized report cards that target inappropriate prescribing of high-risk medications, including opioids. Randomized controlled trials suggest that report cards are an effective tool to change opioid prescribing behavior, but their effectiveness in community settings is unclear. OBJECTIVE: To evaluate the impact of opioid prescribing report cards, which were mailed to Medicaid providers in Philadelphia, Pennsylvania. METHODS: Using a quasi-experimental approach, we compared trends in opioid prescribing by Medicaid providers in Philadelphia, who received a report card in late 2017, with Medicaid providers in surrounding counties, who did not receive report cards. First, we used propensity score matching to balance observed differences in the treatment and comparison groups; matching variables included provider specialty, sex, and selected characteristics of providers' Medicaid patient panels. We then estimated a difference-in-differences model to isolate the impact of report cards on opioid prescribing. RESULTS: The analytical sample included 1,598 providers in Philadelphia and 2,117 providers in surrounding counties, who prescribed opioids to 99,548 Medicaid patients during the study period. Although the number of Medicaid patients receiving opioids and the days supplied of opioids declined in both Philadelphia and surrounding counties during the study period, there was a larger reduction in Philadelphia Medicaid than in surrounding counties after the report cards were mailed. In the 6 months after the report cards were mailed (January 2018 to June 2018) compared with the 6 months before they were mailed (July 2017 to December 2017), we estimate that the reduction in opioid prescribing in Philadelphia Medicaid amounted to nearly 3 fewer Medicaid patients with an opioid prescription per month. CONCLUSIONS: After customized opioid prescribing report cards were mailed to Medicaid providers in Philadelphia, Pennsylvania, there was a statistically significant reduction in opioid prescribing to Medicaid patients relative to surrounding counties. Our findings suggest that opioid prescribing report cards with peer comparison are an effective way to influence opioid prescribing behavior among Medicaid providers. Report cards can complement other initiatives that target inappropriate opioid prescribing, such as prescription drug monitoring programs and prior authorization. DISCLOSURES: Drs Candon and Rothbard and Ms Shen received funding from Community Behavioral Health in Philadelphia, Pennsylvania. Drs Xue, Cole, and Donohue received funding from Pennsylvania Department of Human Services. Neither Community Behavioral Health nor the Pennsylvania Department of Human Services was involved in the study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication.
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Affiliation(s)
- Molly Candon
- Departments of Psychiatry and Health Care Management, Perelman School of Medicine and the Wharton School, University of Pennsylvania, Philadelphia
| | - Lingshu Xue
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pennsylvania
| | - Siyuan Shen
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Evan S Cole
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pennsylvania
| | - Julie Donohue
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pennsylvania
| | - Aileen Rothbard
- Department of Psychiatry, Perelman School of Medicine and School of Social Policy & Practice, University of Pennsylvania, Philadelphia
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16
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Kraemer KL, Althouse AD, Salay M, Gordon AJ, Wright E, Anisman D, Cochran G, Fischer G, Gellad WF, Hamm M, Kern M, Wasan AD. Effect of Different Interventions to Help Primary Care Clinicians Avoid Unsafe Opioid Prescribing in Opioid-Naive Patients With Acute Noncancer Pain: A Cluster Randomized Clinical Trial. JAMA HEALTH FORUM 2022; 3:e222263. [PMID: 35983579 PMCID: PMC9338412 DOI: 10.1001/jamahealthforum.2022.2263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/01/2022] [Indexed: 12/31/2022] Open
Abstract
Importance Prescription opioids can treat acute pain in primary care but have potential for unsafe use and progression to prolonged opioid prescribing. Objective To compare clinician-facing interventions to prevent unsafe opioid prescribing in opioid-naive primary care patients with acute noncancer pain. Design Setting and Participants We conducted a multisite, cluster-randomized, 2 × 2 factorial, clinical trial in 3 health care systems that comprised 48 primary care practices and 525 participating clinicians from September 2018 through January 2021. Patient participants were opioid-naive outpatients, 18 years or older, who presented for a qualifying clinic visit with acute noncancer musculoskeletal pain or nonmigraine headache. Interventions Practices randomized to: (1) control; (2) opioid justification; (3) monthly clinician comparison emails; or (4) opioid justification and clinician comparison. All groups received opioid prescribing guidelines via the electronic health record at the time of a new opioid prescription. Main Outcomes and Measures Primary outcome measures were receipt of an initial opioid prescription at the qualifying clinic visit. Other outcomes were opioid prescribing for more than 3 months and a concurrent opioid/benzodiazepine prescription over 12-month follow-up. Results Among 22 616 enrolled patient participants (9740 women [43.1%]; 64 American Indian/Alaska Native [0.3%]; 590 Asian [2.6%], 1120 Black/African American [5.0%], 1777 Hispanic [7.9%], 225 Native Hawaiian/Pacific Islander [1.0%], and 18 981 White [83.9%] individuals), the initial opioid prescribing rates at the qualifying clinic visit were 3.1% in the total sample, 4.2% in control, 3.6% in opioid justification, 2.6% in clinician comparison, and 1.9% in opioid justification and clinician comparison. Compared with control, the adjusted odds ratio (aOR) for a new opioid prescription was 0.74 (95% CI, 0.46-1.18; P = .20) for opioid justification and 0.60 (95% CI, 0.38-0.96; P = .03) for clinician comparison. Compared with control, clinician comparison was associated with decreased odds of opioid therapy of more than 3 months (aOR, 0.79; 95% CI, 0.69-0.91; P = .001) and concurrent opioid/benzodiazepine prescription (aOR, 0.85; 95% CI, 0.72-1.00; P = .04), whereas opioid justification did not have a significant effect. Conclusions and Relevance In this cluster randomized clinical trial, comparison emails decreased the proportion of opioid-naive patients with acute noncancer pain who received an opioid prescription, progressed to treatment with long-term opioid therapy, or were exposed to concurrent opioid and benzodiazepine therapy. Health care systems can consider adding clinician-targeted nudges to other initiatives as an efficient, scalable approach to further decrease potentially unsafe opioid prescribing. Trial Registration ClinicalTrials.gov Identifier: NCT03537573.
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Affiliation(s)
- Kevin L Kraemer
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Andrew D Althouse
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Melessa Salay
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Adam J Gordon
- University of Utah School of Medicine, Salt Lake City.,VA Salt Lake City Healthcare System, Salt Lake City, Utah
| | | | - David Anisman
- University of Utah School of Medicine, Salt Lake City
| | - Gerald Cochran
- University of Utah School of Medicine, Salt Lake City.,VA Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Gary Fischer
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Megan Hamm
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Ajay D Wasan
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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17
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Effects of opioid addiction risk information on Americans’ agreement with postoperative opioid minimization and perceptions of quality. Healthcare (Basel) 2022; 10:100629. [DOI: 10.1016/j.hjdsi.2022.100629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 05/10/2022] [Accepted: 05/23/2022] [Indexed: 11/19/2022] Open
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