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Savitz ST, Stevens MA, Nath B, D’Onofrio G, Melnick ER, Jeffery MM. Trends in the Prescribing of Buprenorphine for Opioid Use Disorder, 2019-2023. Mayo Clin Proc Innov Qual Outcomes 2024; 8:308-320. [PMID: 38841599 PMCID: PMC11152959 DOI: 10.1016/j.mayocpiqo.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Objective To evaluate whether access to buprenorphine to treat opioid use disorder (OUD) was associated with the coronavirus disease pandemic, the relaxation of training requirements to obtain an X-Waiver to prescribe buprenorphine (April 2021), and the removal of the X-Waiver (December 2022). Patients and Methods The OptumLabs Data Warehouse, which includes claims from Commercial and Medicare Advantage enrollees, was used to evaluate trends in prescription fills from January 1, 2019, to June 30, 2023. We compared fill patterns of buprenorphine for OUD with acamprosate to treat alcohol use disorder and naltrexone to treat alcohol use disorder or OUD. We evaluated trends in the rate ratio (RR) of overall fills; RR by days supply; distribution of fills by daily dose; and distribution of fills by prescriber type. Results Coronavirus disease (RR, 1.06; 95% CI, 1.01-1.11) was associated with a slightly increased rate of fills for Commercial enrollees but not overall or for Medicare Advantage enrollees. There were also no significant increases (P>0.05) associated with the change in training requirements or removal of the X-Waiver. Over the study period, there was an increasing share of fills for 16+ mg for Commercial enrollees, and buprenorphine prescribers were more likely to be advanced practice nurses or physician assistants. Conclusion We did not find meaningful improvement in access in response to coronavirus disease or the changes in the X-Waiver. These findings suggest that interventions beyond removing the X-Waiver may be needed to improve buprenorphine access.
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Affiliation(s)
- Samuel T. Savitz
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | - Maria A. Stevens
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Molly M. Jeffery
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
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Wong AH, Nath B, Shah D, Kumar A, Brinker M, Faustino IV, Boyce M, Dziura JD, Heckmann R, Yonkers KA, Bernstein SL, Adapa K, Taylor RA, Ovchinnikova P, McCall T, Melnick ER. Formative evaluation of an emergency department clinical decision support system for agitation symptoms: a study protocol. BMJ Open 2024; 14:e082834. [PMID: 38373857 PMCID: PMC10882402 DOI: 10.1136/bmjopen-2023-082834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
INTRODUCTION The burden of mental health-related visits to emergency departments (EDs) is growing, and agitation episodes are prevalent with such visits. Best practice guidance from experts recommends early assessment of at-risk populations and pre-emptive intervention using de-escalation techniques to prevent agitation. Time pressure, fluctuating work demands, and other systems-related factors pose challenges to efficient decision-making and adoption of best practice recommendations during an unfolding behavioural crisis. As such, we propose to design, develop and evaluate a computerised clinical decision support (CDS) system, Early Detection and Treatment to Reduce Events with Agitation Tool (ED-TREAT). We aim to identify patients at risk of agitation and guide ED clinicians through appropriate risk assessment and timely interventions to prevent agitation with a goal of minimising restraint use and improving patient experience and outcomes. METHODS AND ANALYSIS This study describes the formative evaluation of the health record embedded CDS tool. Under aim 1, the study will collect qualitative data to design and develop ED-TREAT using a contextual design approach and an iterative user-centred design process. Participants will include potential CDS users, that is, ED physicians, nurses, technicians, as well as patients with lived experience of restraint use for behavioural crisis management during an ED visit. We will use purposive sampling to ensure the full spectrum of perspectives until we reach thematic saturation. Next, under aim 2, the study will conduct a pilot, randomised controlled trial of ED-TREAT at two adult ED sites in a regional health system in the Northeast USA to evaluate the feasibility, fidelity and bedside acceptability of ED-TREAT. We aim to recruit a total of at least 26 eligible subjects under the pilot trial. ETHICS AND DISSEMINATION Ethical approval by the Yale University Human Investigation Committee was obtained in 2021 (HIC# 2000030893 and 2000030906). All participants will provide informed verbal consent prior to being enrolled in the study. Results will be disseminated through publications in open-access, peer-reviewed journals, via scientific presentations or through direct email notifications. TRIAL REGISTRATION NUMBER NCT04959279; Pre-results.
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Affiliation(s)
- Ambrose H Wong
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Dhruvil Shah
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anusha Kumar
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Morgan Brinker
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Isaac V Faustino
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael Boyce
- Yale New Haven Health System, New Haven, Connecticut, USA
| | - James D Dziura
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Rebekah Heckmann
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kimberly A Yonkers
- Department of Psychiatry, University of Massachusetts System, Worchester, Massachusetts, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Karthik Adapa
- Carolina Health Informatics Program, University of North Carolina System, Chapel Hill, North Carolina, USA
| | - Richard Andrew Taylor
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Polina Ovchinnikova
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Terika McCall
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Edward R Melnick
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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3
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Gao E, Melnick ER, Paek H, Nath B, Taylor RA, Loza AJ. Adoption of Emergency Department-Initiated Buprenorphine for Patients With Opioid Use Disorder: Secondary Analysis of a Cluster Randomized Trial. JAMA Netw Open 2023; 6:e2342786. [PMID: 37948075 PMCID: PMC10638655 DOI: 10.1001/jamanetworkopen.2023.42786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/02/2023] [Indexed: 11/12/2023] Open
Abstract
Importance Emergency department (ED) initiation of buprenorphine is safe and effective but underutilized in practice. Understanding the factors affecting adoption of this practice could inform more effective interventions. Objective To quantify the factors, including social contagion, associated with the adoption of the practice of ED initiation of buprenorphine for patients with opioid use disorder. Design, Setting, and Participants This is a secondary analysis of the EMBED (Emergency Department-Initiated Buprenorphine For Opioid Use Disorder) trial, a multicentered, cluster randomized trial of a clinical decision support intervention targeting ED initiation of buprenorphine. The trial occurred from November 2019 to May 2021. The study was conducted at ED clusters across health care systems from the northeast, southeast, and western regions of the US and included attending physicians, resident physicians, and advanced practice practitioners. Data analysis was performed from August 2022 to June 2023. Exposures This analysis included both the intervention and nonintervention groups of the EMBED trial. Graph methods were used to construct the network of clinicians who shared in the care of patients for whom buprenorphine was initiated during the trial before initiating the practice themselves, termed exposure. Main Outcomes and Measures Cox proportional hazard modeling with time-dependent covariates was performed to assess the association of the number of these exposures with self-adoption of the practice of ED initiation of buprenorphine while adjusting for clinician role, health care system, and intervention site status. Results A total of 1026 unique clinicians in 18 ED clusters across 5 health care systems were included. Analysis showed associations of the cumulative number of exposures to others initiating buprenorphine with the self-practice of buprenorphine initiation. This increased in a dose-dependent manner (1 exposure: hazard ratio [HR], 1.31; 95% CI, 1.16-1.48; 5 exposures: HR, 2.85; 95% CI, 1.66-4.89; 10 exposures: HR, 3.55; 95% CI, 1.47-8.58). Intervention site status was associated with practice adoption (HR, 1.50; 95% CI, 1.04-2.18). Health care system and clinician role were also associated with practice adoption. Conclusions and Relevance In this secondary analysis of a multicenter, cluster randomized trial of a clinical decision support tool for buprenorphine initiation, the number of exposures to ED initiation of buprenorphine and the trial intervention were associated with uptake of ED initiation of buprenorphine. Although systems-level approaches are necessary to increase the rate of buprenorphine initiation, individual clinicians may change practice of those around them. Trial Registration ClinicalTrials.gov Identifier: NCT03658642.
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Affiliation(s)
- Evangeline Gao
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
| | - Hyung Paek
- Information Technology Services, Yale New Haven Health, Stratford, Connecticut
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - R. Andrew Taylor
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew J. Loza
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
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Sangal RB, Sharifi M, Rhodes D, Melnick ER. Clinical Decision Support: Moving Beyond Interruptive "Pop-up" Alerts. Mayo Clin Proc 2023; 98:1275-1279. [PMID: 37661138 PMCID: PMC10491420 DOI: 10.1016/j.mayocp.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/22/2023] [Accepted: 05/30/2023] [Indexed: 09/05/2023]
Affiliation(s)
- Rohit B Sangal
- Department of Emergency Medicine, School of Medicine, Yale University, New Haven, CT.
| | - Mona Sharifi
- Section of General Pediatrics, Department of Pediatrics, School of Medicine, Yale University, New Haven, CT
| | - Deborah Rhodes
- Department of Medicine, Yale New Haven Hospital, New Haven, CT
| | - Edward R Melnick
- Department of Emergency Medicine, School of Medicine, Yale University, New Haven, CT
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Simpson MJ, Ritger C, Hoppe JA, Holland WC, Morris MA, Nath B, Melnick ER, Tietbohl C. Implementation strategies to address the determinants of adoption, implementation, and maintenance of a clinical decision support tool for emergency department buprenorphine initiation: a qualitative study. Implement Sci Commun 2023; 4:41. [PMID: 37081581 PMCID: PMC10117277 DOI: 10.1186/s43058-023-00421-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/22/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Untreated opioid use disorder (OUD) is a significant public health problem. Buprenorphine is an evidence-based treatment for OUD that can be initiated in and prescribed from emergency departments (EDs) and office settings. Adoption of buprenorphine initiation among ED clinicians is low. The EMBED pragmatic clinical trial investigated the effectiveness of a clinical decision support (CDS) tool to promote ED clinicians' behavior related to buprenorphine initiation in the ED. While the CDS intervention was not associated with increased rates of buprenorphine treatment for patients with OUD at intervention ED sites, attending physicians at intervention EDs were more likely to initiate buprenorphine at least once over the duration of the study compared to those in the usual care arms (44.4% vs 34.0%, P = 0.01). This suggests the CDS intervention may be associated with increased adoption of buprenorphine initiation. As a secondary aim, we sought to identify the determinants of CDS adoption, implementation, and maintenance in a variety of ED settings and geographic locations. METHODS We purposively sampled and conducted semi-structured, in-depth interviews with clinicians across EMBED trial sites randomized to the intervention arm from five healthcare systems. Interviews elicited clinician experiences regarding buprenorphine initiation and CDS use. Interviews were analyzed using directed content analysis informed by the Practical, Robust Implementation and Sustainability Model (PRISM). We used a hybrid approach (a priori codes informed by PRISM and emergent codes) for codebook development. ATLAS.ti (version 9.0) was used for data management. Coded data were analyzed within individual interview transcripts and across all interviews to identify major themes. This process involved (1) combining, comparing, and making connections between codes; (2) writing analytic memos about observed patterns; and (3) frequent team meetings to discuss emerging patterns. RESULTS Twenty-eight interviews were conducted. Major themes that influenced the successful adoption, implementation, and maintenance of the EMBED intervention and ED-initiated BUP were organizational culture and commitment, clinician training and support, the ability to connect patients to ongoing treatment, and the ability to tailor implementation to each ED. These findings informed the identification of implementation strategies (framed using PRISM domains) to enhance the ED initiation of buprenorphine. CONCLUSION The findings from this qualitative analysis can provide guidance to build better systems to promote the adoption of ED-initiated buprenorphine.
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Affiliation(s)
- Matthew J Simpson
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, 12631 E. 17th Avenue, Box F496, Aurora, CO, 80045, USA.
| | - Carly Ritger
- Adult and Child Center for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 300, Aurora, CO, 80045, USA
| | - Jason A Hoppe
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, 12631 E. 17th Avenue, Box B215, Aurora, CO, 80045, USA
| | - Wesley C Holland
- Yale University School of Medicine, 333 Cedar St., New Haven, CT, 06510, USA
| | - Megan A Morris
- Adult and Child Center for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 300, Aurora, CO, 80045, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Ste 260, New Haven, CT, 06519, USA
| | - Edward R Melnick
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Ste 260, New Haven, CT, 06519, USA
| | - Caroline Tietbohl
- Adult and Child Center for Health Outcomes Research & Delivery Science, University of Colorado Anschutz Medical Campus, 13199 E. Montview Boulevard, Suite 300, Aurora, CO, 80045, USA
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Whiteside LK, D'Onofrio G, Fiellin DA, Edelman EJ, Richardson L, O'Connor P, Rothman RE, Cowan E, Lyons MS, Fockele CE, Saheed M, Freiermuth C, Punches BE, Guo C, Martel S, Owens PH, Coupet E, Hawk KF. Models for Implementing Emergency Department-Initiated Buprenorphine With Referral for Ongoing Medication Treatment at Emergency Department Discharge in Diverse Academic Centers. Ann Emerg Med 2022; 80:410-419. [PMID: 35752520 PMCID: PMC9588652 DOI: 10.1016/j.annemergmed.2022.05.010] [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: 12/17/2021] [Revised: 04/26/2022] [Accepted: 05/04/2022] [Indexed: 12/24/2022]
Abstract
There has been a substantial rise in the number of publications and training opportunities on the care and treatment of emergency department (ED) patients with opioid use disorder over the past several years. The American College of Emergency Physicians recently published recommendations for providing buprenorphine to patients with opioid use disorder, but barriers to implementing this clinical practice remain. We describe the models for implementing ED-initiated buprenorphine at 4 diverse urban, academic medical centers across the country as part of a federally funded effort termed "Project ED Health." These 4 sites successfully implemented unique ED-initiated buprenorphine programs as part of a comparison of implementation facilitation to traditional educational dissemination on the uptake of ED-initiated buprenorphine. Each site describes the elements central to the ED process, including screening, treatment initiation, referral, and follow-up, while harnessing organizational characteristics, including ED culture. Finally, we discuss common facilitators to program success, including information technology and electronic medical record integration, hospital-level support, strong connections with outpatient partners, and quality improvement processes.
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Affiliation(s)
- Lauren K Whiteside
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA.
| | - Gail D'Onofrio
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - David A Fiellin
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
| | - E Jennifer Edelman
- Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
| | - Lynne Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Patrick O'Connor
- Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ethan Cowan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael S Lyons
- Department of Emergency Medicine, Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Callan E Fockele
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caroline Freiermuth
- Department of Emergency Medicine, Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Brittany E Punches
- Department of Emergency Medicine, Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Clara Guo
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Shara Martel
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Patricia H Owens
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Edouard Coupet
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Kathryn F Hawk
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
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Zha H, Liu K, Tang T, Yin YH, Dou B, Jiang L, Yan H, Tian X, Wang R, Xie W. Acceptance of clinical decision support system to prevent venous thromboembolism among nurses: an extension of the UTAUT model. BMC Med Inform Decis Mak 2022; 22:221. [PMID: 35986284 PMCID: PMC9392358 DOI: 10.1186/s12911-022-01958-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Venous thromboembolism has been a major public health problem and caused a heavy disease burden. Venous thromboembolism clinical decision support system was proved to have a positive influence on the prevention and management of venous thromboembolism. As the direct users, nurses' acceptance of this system is of great importance to support the successful implementation of it. However, there are few relevant studies to investigate nurses' acceptance and the associated factors are still unclear.
Objective
To investigate the determinant factors of nurses' acceptance of venous thromboembolism clinical decision support system with the modified Unified Theory of Acceptance and Use of Technology.
Methods
We designed a questionnaire based on the modified Unified Theory of Acceptance and Use of Technology and then a cross-sectional survey was conducted among nurses in a tertiary hospital in Nanjing, China. Statistically, a Structural Equation Modeling -Partial Least Squares path modeling approach was applied to examine the research model.
Results
A total of 1100 valid questionnaires were recycled. The modified model explained 74.7%, 83.0% and 86% of the variance in user satisfaction, behavioral intention and user behavior, respectively. The results showed that performance expectancy (β = 0.254, p = 0.000), social influence (β = 0.136, p = 0.047), facilitating conditions (β = 0.245, p = 0.000), self-efficacy (β = 0.121, p = 0.048) and user satisfaction (β = 0.193, p = 0.001) all had significant effects on nurses' intention. Although effort expectancy (β = 0.010, p = 0.785) did not have a direct effect on nurses' intention, it could indirectly influence nurses' intention with user satisfaction as the mediator (β = 0.296, p = 0.000). User behavior was significantly predicted by facilitating conditions (β = 0.298, p = 0.000) and user intention (β = 0.654, p = 0.001).
Conclusion
The research enhances our understanding of the determinants of nurses' acceptance of venous thromboembolism clinical decision support system. Among these factors, performance expectancy was considered as the top priority. It highlights the importance of optimizing system performance to fit the users' needs. Generally, the findings in our research provide clinical technology designers and administrators with valuable information to better meet users' requirements and promote the implementation of venous thromboembolism clinical decision support system.
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Melnick ER, Nath B, Dziura JD, Casey MF, Jeffery MM, Paek H, Soares WE, Hoppe JA, Rajeevan H, Li F, Skains RM, Walter LA, Patel MD, Chari SV, Platts-Mills TF, Hess EP, D'Onofrio G. User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial. BMJ 2022; 377:e069271. [PMID: 35760423 PMCID: PMC9231533 DOI: 10.1136/bmj-2021-069271] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder. DESIGN Pragmatic cluster randomized controlled trial (EMBED). SETTING 18 emergency department clusters across five healthcare systems in five states representing the north east, south east, and western regions of the US, ranging from community hospitals to tertiary care centers, using either the Epic or Cerner electronic health record platform. PARTICIPANTS 599 attending emergency physicians caring for 5047 adult patients presenting with opioid use disorder. INTERVENTION A user centered, physician facing clinical decision support system seamlessly integrated into user workflows in the electronic health record to support initiating buprenorphine in the emergency department by helping clinicians to diagnose opioid use disorder, assess the severity of withdrawal, motivate patients to accept treatment, and complete electronic health record tasks by automating clinical and after visit documentation, order entry, prescribing, and referral. MAIN OUTCOME MEASURES Rate of initiation of buprenorphine (administration or prescription of buprenorphine) in the emergency department among patients with opioid use disorder. Secondary implementation outcomes were measured with the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. RESULTS 1 413 693 visits to the emergency department (775 873 in the intervention arm and 637 820 in the usual care arm) from November 2019 to May 2021 were assessed for eligibility, resulting in 5047 patients with opioid use disorder (2787 intervention arm, 2260 usual care arm) under the care of 599 attending physicians (340 intervention arm, 259 usual care arm) for analysis. Buprenorphine was initiated in 347 (12.5%) patients in the intervention arm and in 271 (12.0%) patients in the usual care arm (adjusted generalized estimating equations odds ratio 1.22, 95% confidence interval 0.61 to 2.43, P=0.58). Buprenorphine was initiated at least once by 151 (44.4%) physicians in the intervention arm and by 88 (34.0%) in the usual care arm (1.83, 1.16 to 2.89, P=0.01). CONCLUSIONS User centered clinical decision support did not increase patient level rates of initiating buprenorphine in the emergency department. Although streamlining and automating electronic health record workflows can potentially increase adoption of complex, unfamiliar evidence based practices, more interventions are needed to look at other barriers to the treatment of addiction and increase the rate of initiating buprenorphine in the emergency department in patients with opioid use disorder. TRIAL REGISTRATION ClinicalTrials.gov NCT03658642.
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Affiliation(s)
- Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - James D Dziura
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Martin F Casey
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Molly M Jeffery
- Department of Emergency Medicine and Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Hyung Paek
- Yale School of Public Health, New Haven, CT, USA
| | - William E Soares
- Department of Emergency Medicine, University of Massachusetts Medical School, Springfield, MA, USA
| | - Jason A Hoppe
- Department of Emergency Medicine, University of Colorado, Aurora, CO, USA
| | | | - Fangyong Li
- Yale School of Public Health, New Haven, CT, USA
| | - Rachel M Skains
- Department of Emergency Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Lauren A Walter
- Department of Emergency Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Srihari V Chari
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Erik P Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
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Carayon P, Hose BZ, Wooldridge A, Brazelton TB, Dean SM, Eithun BL, Kelly MM, Kohler JE, Ross J, Rusy DA, Hoonakker PLT. Human-centered design of team health IT for pediatric trauma care transitions. Int J Med Inform 2022; 162:104727. [PMID: 35305517 PMCID: PMC9437147 DOI: 10.1016/j.ijmedinf.2022.104727] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/20/2022] [Accepted: 02/21/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND As problems of acceptance, usability and workflow integration continue to emerge with health information technologies (IT), it is critical to incorporate human factors and ergonomics (HFE) methods and design principles. Human-centered design (HCD) provides an approach to integrate HFE and produce usable technologies. However, HCD has been rarely used for designing team health IT, even though team-based care is expanding. OBJECTIVE To describe the HCD process used to develop a usable team health IT (T3 or Teamwork Transition Technology) that provides cognitive support to pediatric trauma care teams during transitions from the emergency department to the operating room and the pediatric intensive care unit. METHODS The HCD process included seven steps in three phases of analysis, design activities and feedback. RESULTS The HCD process involved multiple perspectives and clinical roles that were engaged in inter-related activities, leading to design requirements, i.e., goals for the technology, a set of 47 information elements, and a list of HFE design principles applied to T3. Results of the evaluation showed a high usability score for T3. CONCLUSIONS HFE can be integrated in the HCD process through a range of methods and design principles. That design process can produce a usable technology that provides cognitive support to a large diverse team involved in pediatric trauma care transitions. Future research should continue to focus on HFE-based design of team health IT.
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Affiliation(s)
- Pascale Carayon
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, United States; Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, United States.
| | - Bat-Zion Hose
- Department of Anesthesiology and Critical Care at the Perelman School of Medicine, University of Pennsylvania, United States
| | - Abigail Wooldridge
- Department of Industrial and Enterprise Systems Engineering, University of Illinois at Urbana-Champaign, United States
| | - Thomas B Brazelton
- American Family Children's Hospital, UW Health, United States; Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, United States
| | - Shannon M Dean
- Department of Pediatric Medicine, St Jude's Hospital, United States
| | - Ben L Eithun
- American Family Children's Hospital, UW Health, United States
| | - Michelle M Kelly
- American Family Children's Hospital, UW Health, United States; Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, United States
| | | | - Joshua Ross
- American Family Children's Hospital, UW Health, United States; Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, United States; Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, United States
| | - Deborah A Rusy
- American Family Children's Hospital, UW Health, United States; Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, United States
| | - Peter L T Hoonakker
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, United States
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Situational Awareness of Opioid Consumption: The Missing Link to Reducing Dependence After Surgery? Anesth Analg 2022; 135:653-658. [PMID: 35110517 DOI: 10.1213/ane.0000000000005923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A tool for collecting and analyzing morphine milligram equivalents (MMEs) can be used to overcome barriers to situational awareness around opioid utilization in the setting of multimodal pain management. Our software application (App) has facilitated data collection, analysis, and benchmarking in a manner that is not logistically feasible using manual methods. Real-time postoperative tracking of MME over the course of an episode of care can be prohibitively labor-intensive, and teams must have practical strategies to overcome this obstacle. In view of the link between the magnitude of opioid prescriptions at discharge and persistent opioid use after cardiac surgery, we believe that improving situational awareness among the patient care team is a vital first step in reducing opioid dependence after cardiac surgery.
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Göttgens I, Oertelt-Prigione S. The Application of Human-Centered Design Approaches in Health Research and Innovation: A Narrative Review of Current Practices. JMIR Mhealth Uhealth 2021; 9:e28102. [PMID: 34874893 PMCID: PMC8691403 DOI: 10.2196/28102] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 07/16/2021] [Accepted: 10/21/2021] [Indexed: 12/14/2022] Open
Abstract
Background Human-centered design (HCD) approaches to health care strive to support the development of innovative, effective, and person-centered solutions for health care. Although their use is increasing, there is no integral overview describing the details of HCD methods in health innovations. Objective This review aims to explore the current practices of HCD approaches for the development of health innovations, with the aim of providing an overview of the applied methods for participatory and HCD processes and highlighting their shortcomings for further research. Methods A narrative review of health research was conducted based on systematic electronic searches in the PubMed, CINAHL, Embase, Cochrane Library, Web of Science, PsycINFO, and Sociological Abstracts (2000-2020) databases using keywords related to human-centered design, design thinking (DT), and user-centered design (UCD). Abstracts and full-text articles were screened by 2 reviewers independently based on predefined inclusion criteria. Data extraction focused on the methodology used throughout the research process, the choice of methods in different phases of the innovation cycle, and the level of engagement of end users. Results This review summarizes the application of HCD practices across various areas of health innovation. All approaches prioritized the user’s needs and the participatory and iterative nature of the design process. The design processes comprised several design cycles during which multiple qualitative and quantitative methods were used in combination with specific design methods. HCD- and DT-based research primarily targeted understanding the research context and defining the problem, whereas UCD-based work focused mainly on the direct generation of solutions. Although UCD approaches involved end users primarily as testers and informants, HCD and DT approaches involved end users most often as design partners. Conclusions We have provided an overview of the currently applied methodologies and HCD guidelines to assist health care professionals and design researchers in their methodological choices. HCD-based techniques are challenging to evaluate using traditional biomedical research methods. Previously proposed reporting guidelines are a step forward but would require a level of detail that is incompatible with the current publishing landscape. Hence, further development is needed in this area. Special focus should be placed on the congruence between the chosen methods, design strategy, and achievable outcomes. Furthermore, power dimensions, agency, and intersectionality need to be considered in co-design sessions with multiple stakeholders, especially when including vulnerable groups.
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Affiliation(s)
- Irene Göttgens
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - Sabine Oertelt-Prigione
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
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Shagerdi G, Ayatollahi H, Hemmat M. Emergency care for the elderly: A review of the application of health information technology. HEALTH POLICY AND TECHNOLOGY 2021. [DOI: 10.1016/j.hlpt.2021.100592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Guo CZ, D'Onofrio G, Fiellin DA, Edelman EJ, Hawk K, Herring A, McCormack R, Perrone J, Cowan E. Emergency department-initiated buprenorphine protocols: A national evaluation. J Am Coll Emerg Physicians Open 2021; 2:e12606. [PMID: 34877567 PMCID: PMC8630357 DOI: 10.1002/emp2.12606] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 10/28/2021] [Accepted: 11/02/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE Emergency department-initiated buprenorphine (BUP) for opioid use disorder is an evidence-based practice, but limited data exist on BUP initiation practices in real-world settings. We sought to characterize protocols for BUP initiation among a geographically diverse sample of emergency departments (EDs). METHODS In December 2020, we reviewed prestudy clinical BUP initiation protocols from all EDs participating in CTN0099 Emergency Department-INitiated bupreNOrphine VAlidaTION (ED-INNOVATION). We abstracted information on processes for identification of treatment-eligible patients, BUP administration, and discharge care. RESULTS All participating ED-INNOVATION sites across 22 states submitted protocols; 31 protocols were analyzed. Identification of treatment-eligible patients: Most EDs 22 (71%) relied on clinician judgment to determine appropriateness of BUP treatment with only 7 (23%) requiring decision support tools or diagnosis checklists. Before BUP initiation, 27 (87%) protocols required a documented Clinical Opiate Withdrawal Scale (COWS) score; 4 (13%) required a clinical diagnosis of withdrawal with optional COWS score. Twenty-seven (87%) recommended a minimum COWS score of 8 for ED-initiated BUP. BUP administration: Initial BUP dose ranged from 2-16 mg (mode = 4). For continued withdrawal symptoms, 27 (87%) protocols recommended an interval of 30-60 minutes between first and second BUP dose. Total BUP dose in the ED ranged from 8 to 32 mg. Discharge care: Twenty-eight (90%) protocols recommended a BUP prescription (mode 16 mg daily) at discharge. Naloxone prescription and/or provision was suggested in 23 (74%) protocols. CONCLUSIONS In this geographically diverse sample of EDs, protocols for ED-initiated BUP differed between sites. Future work should evaluate the association between this variation and patient outcomes.
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Affiliation(s)
- Clara Z. Guo
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Gail D'Onofrio
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - David A. Fiellin
- Department of Internal MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - E. Jennifer Edelman
- Department of Internal MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Kathryn Hawk
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Andrew Herring
- Department of Emergency MedicineHighland Hospital – Alameda Health SystemUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Ryan McCormack
- Department of Emergency MedicineNew York University School of MedicineNew YorkNew YorkUSA
| | - Jeanmarie Perrone
- Department of Emergency MedicinePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ethan Cowan
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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Mospan GA, Chaplin M. Initiation of buprenorphine for opioid use disorder in the hospital setting: Practice models, challenges, and legal considerations. Am J Health Syst Pharm 2021; 79:140-146. [PMID: 34554207 DOI: 10.1093/ajhp/zxab373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To provide health-system pharmacists with published examples of strategies utilized to offer buprenorphine to inpatients with opioid use disorder (OUD) along with information on challenges and legal considerations. SUMMARY Hospitals and emergency departments (EDs) are a constant source of healthcare for patients with OUD. As a result, hospital practitioners can screen, diagnose, begin treatment, and facilitate transfer of care to the outpatient setting. Offering sublingual buprenorphine in the hospital can bridge the gap before outpatient care is established. Multiple studies have shown that initiating treatment in the ED or during inpatient hospitalization results in 47% to 74% of patients utilizing medication-assisted treatment at day 30 of follow-up, statistically superior to the rates achieved with brief interventions or referral alone. Moreover, initiating buprenorphine treatment in the ED has been shown to decrease healthcare costs. Despite the benefits of offering buprenorphine in the inpatient setting, several challenges must be solved by hospital administration, such as achieving clinician readiness to prescribe buprenorphine, developing relationships with outpatient providers of buprenorphine, and creating an efficient workflow. Treatment of OUD with buprenorphine is heavily regulated on the federal level. Pharmacists can participate in the development of these programs and ensure compliance with applicable laws. CONCLUSION As health systems continue to care for patients with OUD, starting buprenorphine in the inpatient setting can improve the transition to outpatient treatment. Several institutions have developed programs with positive results. With an understanding of the typical barriers and relevant laws when initiating buprenorphine in the hospital setting, health-system pharmacists can assist in the development and operation of these initiatives.
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Luo L, King AA, Carroll Y, Baumann AA, Brambilla D, Carpenter CR, Colla J, Gibson RW, Gollan S, Hall G, Klesges L, Kutlar A, Lyon M, Melvin CL, Norell S, Mueller M, Potter MB, Richesson R, Richardson LD, Ryan G, Siewny L, Treadwell M, Zun L, Armstrong-Brown J, Cox L, Tanabe P. Electronic Health Record-Embedded Individualized Pain Plans for Emergency Department Treatment of Vaso-occlusive Episodes in Adults With Sickle Cell Disease: Protocol for a Preimplementation and Postimplementation Study. JMIR Res Protoc 2021; 10:e24818. [PMID: 33861209 PMCID: PMC8087964 DOI: 10.2196/24818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 01/02/2023] Open
Abstract
Background Individuals living with sickle cell disease often require aggressive treatment of pain associated with vaso-occlusive episodes in the emergency department. Frequently, pain relief is poor. The 2014 National Heart, Lung, and Blood Institute evidence-based guidelines recommended an individualized treatment and monitoring protocol to improve pain management of vaso-occlusive episodes. Objective This study will implement an electronic health record–embedded individualized pain plan with provider and patient access in the emergency departments of 8 US academic centers to improve pain treatment for adult patients with sickle cell disease. This study will assess the overall effects of electronic health record–embedded individualized pain plans on improving patient and provider outcomes associated with pain treatment in the emergency department setting and explore barriers and facilitators to the implementation process. Methods A preimplementation and postimplementation study is being conducted by all 8 sites that are members of the National Heart, Lung, and Blood Institute–funded Sickle Cell Disease Implementation Consortium. Adults with sickle cell disease aged 18 to 45 years who had a visit to a participating emergency department for vaso-occlusive episodes within 90 days prior to enrollment will be eligible for inclusion. Patients will be enrolled in the clinic or remotely. The target analytical sample size of this study is 160 patient participants (20 per site) who have had an emergency department visit for vaso-occlusive episode treatment at participating emergency departments during the study period. Each site is expected to enroll approximately 40 participants to reach the analytical sample size. The electronic health record–embedded individualized pain plans will be written by the patient’s sickle cell disease provider, and sites will work with the local informatics team to identify the best method to build the electronic health record–embedded individualized pain plan with patient and provider access. Each site will adopt required patient and provider implementation strategies and can choose to adopt optional strategies to improve the uptake and sustainability of the intervention. The study is informed by the Technology Acceptance Model 2 and the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Provider and patient baseline survey, follow-up survey within 96 hours of an emergency department vaso-occlusive episode visit, and selected qualitative interviews within 2 weeks of an emergency department visit will be performed to assess the primary outcome, patient-perceived quality of emergency department pain treatment, and additional implementation and intervention outcomes. Electronic health record data will be used to analyze individualized pain plan adherence and additional secondary outcomes, such as hospital admission and readmission rates. Results The study is currently enrolling study participants. The active implementation period is 18 months. Conclusions This study proposes a structured, framework-informed approach to implement electronic health record–embedded individualized pain plans with both patient and provider access in routine emergency department practice. The results of the study will inform the implementation of electronic health record–embedded individualized pain plans at a larger scale outside of Sickle Cell Disease Implementation Consortium centers. Trial Registration ClinicalTrials.gov NCT04584528; https://clinicaltrials.gov/ct2/show/NCT04584528. International Registered Report Identifier (IRRID) DERR1-10.2196/24818
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Affiliation(s)
- Lingzi Luo
- Washington University School of Medicine, St Louis, MO, United States
| | - Allison A King
- Washington University School of Medicine, St Louis, MO, United States
| | - Yvonne Carroll
- St Jude Children's Research Hospital, Memphis, TN, United States
| | - Ana A Baumann
- Washington University in St. Louis, St Louis, MO, United States
| | | | | | - Joseph Colla
- University of Illinois Chicago, Chicago, IL, United States
| | | | | | - Greg Hall
- Medical University of South Carolina, Charleston, SC, United States
| | - Lisa Klesges
- Washington University School of Medicine, St Louis, MO, United States.,University of Memphis, Memphis, TN, United States
| | | | | | - Cathy L Melvin
- Medical University of South Carolina, Charleston, SC, United States
| | - Sarah Norell
- University of Illinois Chicago, Chicago, IL, United States
| | - Martina Mueller
- Medical University of South Carolina, Charleston, SC, United States
| | - Michael B Potter
- University of California San Francisco, San Francisco, CA, United States
| | | | | | - Gery Ryan
- The RAND Corporation, Santa Monica, CA, United States
| | | | - Marsha Treadwell
- University of California San Francisco, San Francisco, CA, United States
| | - Leslie Zun
- Chicago Medical School, North Chicago, IL, United States
| | | | - Lisa Cox
- RTI International, Durham, NC, United States
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Holland WC, Nath B, Li F, Maciejewski K, Paek H, Dziura J, Rajeevan H, Lu CC, Katsovich L, D'Onofrio G, Melnick ER. Interrupted Time Series of User-centered Clinical Decision Support Implementation for Emergency Department-initiated Buprenorphine for Opioid Use Disorder. Acad Emerg Med 2020; 27:753-763. [PMID: 32352206 PMCID: PMC7496559 DOI: 10.1111/acem.14002] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/08/2020] [Accepted: 04/23/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Adoption of emergency department (ED) initiation of buprenorphine (BUP) for opioid use disorder (OUD) into routine emergency care has been slow, partly due to clinicians' unfamiliarity with this practice and perceptions that it is complicated and time-consuming. To address these barriers and guide emergency clinicians through the process of BUP initiation, we implemented a user-centered computerized clinical decision support system (CDS). This study was conducted to assess the feasibility of implementation and to evaluate the preliminary efficacy of the intervention to increase the rate of ED-initiated BUP. METHODS An interrupted time series study was conducted in an urban, academic ED from April 2018 to February 2019 (preimplementation phase), March 2019 to August 2019 (implementation phase), and September 2019 to December 2019 (maintenance phase) to study the effect of the intervention on adult ED patients identified by a validated electronic health record (EHR)-based computable phenotype consisting of structured data consistent with potential cases of OUD who would benefit from BUP treatment. The intervention offers flexible CDS for identification of OUD, assessment of opioid withdrawal, and motivation of readiness to start treatment and automates EHR activities related to ED initiation of BUP (including documentation, orders, prescribing, and referral). The primary outcome was the rate of ED-initiated BUP. Secondary outcomes were launch of the intervention, prescription for naloxone at ED discharge, and referral for ongoing addiction treatment. RESULTS Of the 141,041 unique patients presenting to the ED over the preimplementation and implementation phases (i.e., the phases used in primary analysis), 906 (574 preimplementation and 332 implementation) met OUD phenotype and inclusion criteria. The rate of BUP initiation increased from 3.5% (20/574) in the preimplementation phase to 6.6% (22/332) in the implementation phase (p = 0.03). After the temporal trend of the number of physician's with X-waiver training and other covariates were adjusted for, the relative risk of BUP initiation rate was 2.73 (95% confidence interval [CI] = 0.62 to 12.0, p = 0.18). Similarly, the number of unique attendings who initiated BUP increased modestly 7/53 (13.0%) to 13/57 (22.8%, p = 0.10) after offering just-in-time training during the implementation period. The rate of naloxone prescribed at discharge also increased (6.5% preimplementation and 11.5% implementation; p < 0.01). The intervention received a system usability scale score of 82.0 (95% CI = 76.7 to 87.2). CONCLUSION Implementation of user-centered CDS at a single ED was feasible, acceptable, and associated with increased rates of ED-initiated BUP and naloxone prescribing in patients with OUD and a doubling of the number of unique physicians adopting the practice. We have implemented this intervention across several health systems in an ongoing trial to assess its effectiveness, scalability, and generalizability.
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Affiliation(s)
| | | | - Fangyong Li
- Yale Center for Analytical SciencesNew HavenCT
| | | | - Hyung Paek
- Information Technology ServicesYale New Haven HealthNew HavenCT
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Wong AH, Ray JM, Auerbach MA, Venkatesh AK, McVaney C, Burness D, Chmura C, Saxa T, Sevilla M, Flood CT, Patel A, Whitfill T, Dziura JD, Yonkers KA, Ulrich A, Bernstein SL. Study protocol for the ACT response pilot intervention: development, implementation and evaluation of a systems-based Agitation Code Team (ACT) in the emergency department. BMJ Open 2020; 10:e036982. [PMID: 32606062 PMCID: PMC7328814 DOI: 10.1136/bmjopen-2020-036982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Emergency department (ED) visits for behavioural conditions are rising, with 1.7 million associated episodes of patient agitation occurring annually in acute care settings. When de-escalation techniques fail during agitation management, patients are subject to use of physical restraints and sedatives, which are associated with up to 37% risk of hypotension, apnoea and physical injuries. At the same time, ED staff report workplace violence due to physical assaults during agitation events. We recently developed a theoretical framework to characterise ED agitation, which identified teamwork as a critical component to reduce harm. Currently, no structured team response protocol for ED agitation addressing both patient and staff safety exists. METHODS AND ANALYSIS Our proposed study aims to develop and implement the agitation code team (ACT) response intervention, which will consist of a standardised, structured process with defined health worker roles/responsibilities, work processes and clinical protocols. First, we will develop the ACT response intervention in a two-step design loop; conceptual design will engage users in the creation of the prototype, and iterative refinement will occur through in situ simulated agitated patient encounters in the ED to assess and improve the design. Next, we will pilot the intervention in the clinical environment and use a controlled interrupted time series design to evaluate its effect on our primary outcome of patient restraint use. The intervention will be considered efficacious if we effectively lower the rate of restraint use over a 6-month period. ETHICS AND DISSEMINATION Ethical approval by the Yale University Human Investigation Committee was obtained in 2019 (HIC #2000025113). Results will be disseminated through peer-reviewed publications and presentations at scientific meetings for each phase of the study. If this pilot is successful, we plan to formally integrate the ACT response intervention into clinical workflows at all EDs within our entire health system.
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Affiliation(s)
- Ambrose H Wong
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Jessica M Ray
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Marc A Auerbach
- Department of Pediatrics and Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Caitlin McVaney
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Danielle Burness
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Christopher Chmura
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Thomas Saxa
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Mark Sevilla
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Colin T Flood
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Amitkumar Patel
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Travis Whitfill
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - James D Dziura
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States
| | - Kimberly A Yonkers
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, United States
- Departments of Psychiatry and Obstetrics & Gynecology, Yale University, New Haven, Connecticut, USA
| | - Andrew Ulrich
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, United States
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Progress Report on EMBED: A Pragmatic Trial of User-Centered Clinical Decision Support to Implement EMergency Department-Initiated BuprenorphinE for Opioid Use Disorder. JOURNAL OF PSYCHIATRY AND BRAIN SCIENCE 2020; 5. [PMID: 32309637 PMCID: PMC7164817 DOI: 10.20900/jpbs.20200003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Buprenorphine (BUP) can safely and effectively reduce craving, overdose, and mortality rates in people with opioid use disorder (OUD). However, adoption of ED-initiation of BUP has been slow partly due to physician perception this practice is too complex and disruptive. We report progress of the ongoing EMBED (EMergency department-initiated BuprenorphinE for opioid use Disorder) project. This project is a five-year collaboration across five healthcare systems with the goal to develop, integrate, study, and disseminate user-centered Clinical Decision Support (CDS) to promote the adoption of Emergency Department (ED)-initiation of buprenorphine/naloxone (BUP) into routine emergency care. Soon to enter its third year, the project has already completed multiple milestones to achieve its goals including (1) user-centered design of the CDS prototype, (2) integration of the CDS into an automated electronic health record (EHR) workflow, (3) data coordination including derivation and validation of an EHR-based computable phenotype, (4) meeting all ethical and regulatory requirements to achieve a waiver of informed consent, (5) pilot testing of the intervention at a single site, and (6) launching a parallel group-randomized 18-month pragmatic trial in 20 EDs across 5 healthcare systems. Pilot testing of the intervention in a single ED was associated with increased rates of ED-initiated BUP and naloxone prescribing and a doubling of the number of unique physicians adopting the practice. The ongoing multi-center pragmatic trial will assess the intervention’s effectiveness, scalability, and generalizability with a goal to shift the emergency care paradigm for OUD towards early identification and treatment.
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Melnick ER, Holland WC, Ahmed OM, Ma AK, Michael SS, Goldberg HS, Lagier C, D’Onofrio G, Stachowiak T, Brandt C, Solad Y. An integrated web application for decision support and automation of EHR workflow: a case study of current challenges to standards-based messaging and scalability from the EMBED trial. JAMIA Open 2019; 2:434-439. [PMID: 32025639 PMCID: PMC6994013 DOI: 10.1093/jamiaopen/ooz053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/01/2019] [Indexed: 12/02/2022] Open
Abstract
Computerized clinical decision support (CDS) faces challenges to interoperability and scalability. Centralized, web-based solutions offer a mechanism to share the cost of CDS development, maintenance, and implementation across practices. Data standards have emerged to facilitate interoperability and rapid integration of such third-party CDS. This case report describes the challenges to implementation and scalability of an integrated, web-based CDS intervention for EMergency department-initiated BuprenorphinE for opioid use Disorder which will soon be evaluated in a trial across 20 sites in five healthcare systems. Due to limitations of current standards, security concerns, and the need for resource-intensive local customization, barriers persist related to centralized CDS at this scale. These challenges demonstrate the need and importance for future standards to support two-way messaging (read and write) between electronic health records and web applications, thus allowing for more robust sharing across health systems and decreasing redundant, resource-intensive CDS development at individual sites.
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Affiliation(s)
- Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Osama M Ahmed
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anthony K Ma
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sean S Michael
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Howard S Goldberg
- Department of Medicine, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts, USA
| | | | - Gail D’Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Tomek Stachowiak
- Yale New-Haven Health, Information Technology Services, New Haven, Connecticut, USA
| | - Cynthia Brandt
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Yauheni Solad
- Yale University School of Medicine, New Haven, Connecticut, USA
- Yale New-Haven Health, Information Technology Services, New Haven, Connecticut, USA
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Ahmed OM, Mao JA, Holt SR, Hawk K, D'Onofrio G, Martel S, Melnick ER. A scalable, automated warm handoff from the emergency department to community sites offering continued medication for opioid use disorder: Lessons learned from the EMBED trial stakeholders. J Subst Abuse Treat 2019; 102:47-52. [PMID: 31202288 PMCID: PMC6578846 DOI: 10.1016/j.jsat.2019.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 05/03/2019] [Accepted: 05/06/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND In order to streamline the emergency department (ED) referral process in a multi-network automated opioid treatment referral program, we performed a needs assessment of community providers for Medication for Opioid Use Disorder (MOUD) in the EMergency department-initiated BuprenorphinE for opioid use Disorder (EMBED) trial network. METHODS A needs assessment was conducted in two phases: (1) key stakeholder meetings and (2) a survey of community sites offering MOUD. Stakeholder meetings were conducted with five key stakeholder groups: 1) ED clinicians and staff, 2) community sites offering MOUD, 3) the investigative team, 4) health system IT staff, and 5) medical ethics experts. Meetings continued until each stakeholder group stated that their priorities and needs were understood. Major categories of needs were extracted pragmatically based on recurrence across stakeholder groups. Informed by needs expressed by IT and MOUD site stakeholders, nineteen MOUD sites were surveyed to better characterize information needs of community sites offering MOUD when receiving an ED referral. RESULTS Three major categories of needs for referral system were identified: 1) The system to be automated, flexible and allow multiple channels of referral, 2) Referral metrics are retrievable in a HIPAA compliant manner, 3) Patients are scheduled into community sites offering MOUD as urgently as possible. Of the MOUD sites surveyed, 68.4% (13/19) responded. Based on the responses, specific patient identifiers were required for most MOUD site referrals, and encrypted emails and EHR were the preferred methods of communication for the handoff. 53.8% (7/13) of the sites were able to accept patients within 3 days with only 1 site requiring >7 days. CONCLUSION These findings can inform IT solutions to address the discordant priorities of the ED (rapid and flexible referral process) and the community sites offering (referrals minimize variability and overbooking). To prevent drop-out in the referral cascade, our findings emphasize the need for increased availability and accessibility to MOUD on demand and protected communication channels between EDs and community providers of MOUD.
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Affiliation(s)
- Osama M Ahmed
- Yale University School of Medicine, New Haven, CT, USA
| | - Jodi A Mao
- Eastern Virginia Medical School, Norfolk, VA, USA
| | - Stephen R Holt
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kathryn Hawk
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Shara Martel
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA.
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