1
|
Brown K, Farley J, Golberstein E, Satin D, Harper P, Pereira C, Slattengren AH, Riper KV, Schafer KM. Overcoming challenges of prescribing long-term opioid therapy in residency clinics. J Opioid Manag 2024; 20:297-309. [PMID: 39321050 DOI: 10.5055/jom.0869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
OBJECTIVES To describe the impact of a standardized opioid prescribing intervention when implemented in three family medicine (FM) residency training - clinics-environments that face operational challenges including regular resident turnover. DESIGN We performed a retrospective cohort study to compare patterns of long-term opioid prescribing between residency and nonresidency clinics. SETTING This study took place within a large, academic, health system. PATIENTS AND PARTICIPANTS Three FM residency clinics were compared with three nonresidency FM clinics. INTERVENTIONS A standardized opioid prescribing process was developed and implemented within the FM residency clinics. Nonresidency clinics used an independent process and were not exposed to the intervention. MAIN OUTCOME MEASURES Descriptive comparisons were performed for treatment and control clinics' opioid prescribing from 2015 to 2018. The primary outcome was a patient's annual opioid exposure supplied from these select clinics. We also examine coprescribing with high-risk medications that potentiate the overdose risk of opioid prescriptions. Difference-in-difference modeling was used to control for clinic-level variation in practice. RESULTS Statistically significant decreases were observed in both residency and nonresidency clinics for the mean number of opioid prescriptions and the mean daily morphine milligram equivalent. These decreases were comparable between the residency and nonresidency clinics. CONCLUSIONS Residency clinics face unique challenges and require innovative solutions to keep up with best practices in opioid prescribing. Our residency clinics' implementation of a standardized intervention, including electronic health record integration, standardized processes, and metric management, suggests steps that may be valuable in achieving outcomes comparable to nonresidency clinics in large health systems.
Collapse
Affiliation(s)
- Kathryn Brown
- St. John's Family Medicine Residency Program, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Joel Farley
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneap-olis, Minnesota
| | - Ezra Golberstein
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - David Satin
- University of Minnesota Medical Center Residency Program, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Peter Harper
- University of Minnesota Medical Center Residency Program, Department of Family Medicine and Com-munity Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Chrystian Pereira
- Department of Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | - Andrew H Slattengren
- North Memorial Family Medicine Residency Program, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Kristi Van Riper
- Operations Strategy Manager, University of Minnesota Physicians, Minneapolis, Minnesota
| | - Katherine Montag Schafer
- John's Family Medicine Residency Program, Department of Family Medicine and Commu-nity Health, University of Minnesota Medical School, Minneapolis, Minnesota. ORCID: https://orcid.org/0000-0003-1051-6281
| |
Collapse
|
2
|
Morley CP, Schad LA, Tumiel-Berhalter LM, Brady LA, Bentham A, Vitale K, Norton A, Noronha G, Swanger C. Improving Cancer Screening Rates in Primary Care via Practice Facilitation and Academic Detailing: A Multi-PBRN Quality Improvement Project. J Patient Cent Res Rev 2021; 8:315-322. [PMID: 34722799 PMCID: PMC8530242 DOI: 10.17294/2330-0698.1855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE In the United States, cancer screening rates are often below national targets. This project implemented practice facilitation and academic detailing aimed at increasing breast, cervical, and colorectal cancer screening rates in safety-net primary care practices. METHODS Three practice-based research networks across western and central New York State partnered to provide quality improvement strategies on breast, cervical, and colorectal cancer screening. Pre/postintervention screening rates for all participating practices were collected annually, as were means across all practices over 7 years. Simple ordinary least squares linear regression was used to calculate the trend for each cancer type and test for statistical significance (ie, P≤0.05), using the ordinal time point as a fixed effect. RESULTS An overall increase in mean screening rates was seen over the duration of this project for colorectal (24.6% preintervention to 48.0% in year 7 of intervention; P<0.001) and breast cancer (37.0% preintervention to 48.6% in year 7; P=0.460). Mean cervical cancer screening rates decreased (35.5% preintervention to 31.4% in year 7; P=0.209). Success in increasing screening rates varied across regions of New York State. CONCLUSIONS Practice facilitation and academic detailing were successful in significantly increasing, on average, colorectal cancer screening rate. Cervical cancer screening showed an overall decrease, likely due to difficulties for primary care practices in tracking and implementation, as many patients seek this service at outside gynecology facilities. Regional differences, guideline changes, and practice reorganization each may have played a part in observed trends. A standardization of queries being used to pull screening rates is an important step in increasing the reliability of these data.
Collapse
Affiliation(s)
- Christopher P Morley
- Department of Public Health and Preventive Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, NY
| | - Laura A Schad
- Department of Public Health and Preventive Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, NY
| | - Laurene M Tumiel-Berhalter
- Department of Family Medicine, SUNY University at Buffalo, Buffalo, NY
- University at Buffalo Clinical and Translational Science Institute, Buffalo, NY
| | - Laura A Brady
- Department of Family Medicine, SUNY University at Buffalo, Buffalo, NY
| | | | - Karen Vitale
- University of Rochester Clinical and Translational Science Institute, Rochester, NY
| | - Amanda Norton
- A. Mandatory, Inc. (consulting for SUNY Upstate Medical University), Groton, NY
| | - Gary Noronha
- Center for Primary Care, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Carlos Swanger
- Center for Primary Care, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Health Reach for the Homeless, Rochester Regional Health, Rochester, NY
| |
Collapse
|
3
|
Successful Trial of Practice Facilitation for Plan, Do, Study, Act Quality Improvement. J Am Board Fam Med 2021; 34:991-1002. [PMID: 34535524 PMCID: PMC8571730 DOI: 10.3122/jabfm.2021.05.210140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Practice facilitation (PF) is a promising but relatively new intervention supporting data-driven practice change. There is a need to better detail research-based facilitation methods, which must balance intervention fidelity and time restrictions with the flexibility required for the intervention. As part of a multi-level 4-armed cluster randomized clinical trial (RCT), 32 rural primary care practices received PF for 1 year. We evaluated the feasibility of having facilitators guide practices to perform 4 key driver domain activities, implemented as Plan-Do-Study-Act (PDSA) cycles, to better understand facilitation "exposure." We describe the intervention and activity length such that our experiences may be useful to other PF research efforts. METHODS Thirty-two practices serving rural patients involved in the Southeastern Collaboration to Improvement Blood Pressure Control engaged with a facilitator to develop and implement PDSAs nested within key drivers of change domains. Numbers of months practices worked on activities deemed most likely to be sustained were captured along with practice satisfaction data. RESULTS All practices engaged in at least 4 domain-level activities, and 59% of the PDSAs were active for at least 3 months. There was variation by domain in the average length of the PDSA activities. Ninety-seven percent (31 of 32) of practices recommended similarly structured facilitation services to other primary care practices, and 84% (27 of 32) noted substantive changes in their care processes. CONCLUSION In this trial, it was feasible for PFs to engage practices in at least 4 Key Driver quality improvement activities within 1 year, which will inform PF methods and protocol development in future trials.
Collapse
|
4
|
Sokol RG, Pines R, Chew A. Multidisciplinary Approach for Managing Complex Pain and Addiction in Primary Care: A Qualitative Study. Ann Fam Med 2021; 19:224-231. [PMID: 34180842 PMCID: PMC8118484 DOI: 10.1370/afm.2648] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/19/2020] [Accepted: 09/28/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Primary care providers (PCPs) may feel ill-equipped to effectively and safely manage patients with chronic pain, an addiction, or both. This study evaluated a multidisciplinary approach of supporting PCPs in their management of this psychosocially complex patient population, to inform subsequent strategies clinics can use to support PCPs. METHODS Four years ago, at our academic community health safety-net system, we created a multidisciplinary consultation service to support PCPs in caring for complex patients with pain and addiction. We collected and thematically analyzed 66 referral questions to understand PCPs' initially expressed needs, interviewed 14 referring PCPs to understand their actual needs that became apparent during the consultation, and identified discrepancies between these sets of needs. RESULTS Many of the PCPs' expressed needs aligned with their actual needs, including needing expertise in the areas of addiction, safe prescribing of opioids, nonopioid treatment options, and communication strategies for difficult conversations, a comprehensive review of the case, and a biopsychosocial approach to management. But several PCP needs emerged after the initial consultation that they did not initially anticipate, including confirming their medical decision-making process, emotional validation, feeling more control, having an outside entity take the burden off the PCP for management decisions, boundary setting, and reframing the visit to focus on the patient's function, values, and goals. CONCLUSIONS A multidisciplinary consultation service can act as a mechanism to meet the needs of PCPs caring for psychosocially complex patients with pain and addiction, including unanticipated needs. Future research should explore the most effective ways to meet PCP needs across populations and health systems.
Collapse
Affiliation(s)
| | - Rachyl Pines
- Terasaki Institute for Biomedical Innovation, Los Angeles, California
| | | |
Collapse
|
5
|
Halladay JR, Weiner BJ, In Kim J, DeWalt DA, Pierson S, Fine J, Lefebvre A, Mackey M, Bergmire D, Cené C, Henderson K, Cykert S. Practice level factors associated with enhanced engagement with practice facilitators; findings from the heart health now study. BMC Health Serv Res 2020; 20:695. [PMID: 32723386 PMCID: PMC7388469 DOI: 10.1186/s12913-020-05552-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 07/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Practice facilitation is a promising strategy to enhance care processes and outcomes in primary care settings. It requires that practices and their facilitators engage as teams to drive improvement. In this analysis, we explored the practice and facilitator factors associated with greater team engagement at the mid-point of a 12-month practice facilitation intervention focused on implementing cardiovascular prevention activities in practice. Understanding factors associated with greater engagement with facilitators in practice-based quality improvement can assist practice facilitation programs with planning and resource allocation. METHODS One hundred thirty-six ambulatory care small to medium sized primary care practices that participated in the EvidenceNow initiative's NC Cooperative, named Heart Health Now (HHN), fit the eligibility criteria for this analysis. We explored the practice and facilitator factors associated with greater team engagement at the mid-point of a 12-month intervention using a retrospective cohort design that included baseline survey data, monthly practice activity implementation data and information about facilitator's experience. Generalized linear mixed-effects models (GLMMs) identified variables associated with greater odds of team engagement using an ordinal scale for level of team engagement. RESULTS Among our practice cohort, over half were clinician-owned and 27% were Federally Qualified Health Centers. The mean number of clinicians was 4.9 (SD 4.2) and approximately 40% of practices were in Medically Underserved Areas (MUA). GLMMs identified a best fit model. The Model presented as odd ratios and 95% confidence intervals suggests greater odds ratios of higher team engagement with greater practice QI leadership 17.31 (5.24-57.19), [0.00], and practice location in a MUA 7.25 (1.8-29.20), [0.005]. No facilitator characteristics were independently associated with greater engagement. CONCLUSIONS Our analysis provides information for practice facilitation stakeholders to consider when considering which practices may be more amendable to embracing facilitation services.
Collapse
Affiliation(s)
- Jacqueline R Halladay
- Department of Family Medicine, School of Medicine, The University of North Carolina at Chapel Hill, 590 Manning Drive, CB #7595, Chapel Hill, NC, 27599-7595, USA. .,Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., CB #7590, Chapel Hill, NC, 27599-7590, USA.
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Box 357965, Seattle, WA, 98195-7965, USA
| | - Jung In Kim
- Department of Statistics, Eberly College of Science, The Pennsylvania State University, University Park, State College, PA, USA.,Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, State College, PA, USA
| | - Darren A DeWalt
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, The University of North Carolina at Chapel Hill, 5034 Old Clinic Bldg, CB #7110, Chapel Hill, NC, 27599-7110, USA
| | - Stephanie Pierson
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., CB #7590, Chapel Hill, NC, 27599-7590, USA
| | - Jason Fine
- Department of Biostatistics, Gilling's School of Global Public Health, The University of North Carolina at Chapel Hill, 135 Dauer Drive, 3101 McGavran-Greenberg Hall, CB #7420, Chapel Hill, NC, 27599-7420, USA
| | - Ann Lefebvre
- Department of Family Medicine, South Carolina Area Health Education Center, Medical University of South Carolina, 5 Charleston Center, Suite 263, Charleston, SC, 29425, USA
| | - Monique Mackey
- Area L AHEC, 1631 S Wesleyan Blvd, Rocky Mount, NC, 27804, USA
| | - Dawn Bergmire
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., CB #7590, Chapel Hill, NC, 27599-7590, USA
| | - Crystal Cené
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, The University of North Carolina at Chapel Hill, 5034 Old Clinic Bldg, CB #7110, Chapel Hill, NC, 27599-7110, USA
| | - Kamal Henderson
- Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill, 6th Floor, Burnett-Womack Bldg, 160 Dental Circle, CB #7075, Chapel Hill, NC, 27599-7075, USA
| | - Samuel Cykert
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., CB #7590, Chapel Hill, NC, 27599-7590, USA.,Division of General Medicine and Clinical Epidemiology, Department of Medicine, The University of North Carolina at Chapel Hill, 5034 Old Clinic Bldg, CB #7110, Chapel Hill, NC, 27599-7110, USA
| |
Collapse
|