Assessing the use of a clinical decision support tool for pain management in primary care

Objective

Given time constraints, poorly organized information, and complex patients, primary care providers (PCPs) can benefit from clinical decision support (CDS) tools that aggregate and synthesize problem-specific patient information. First, this article describes the design and functionality of a CDS tool for chronic noncancer pain in primary care. Second, we report on the retrospective analysis of real-world usage of the tool in the context of a pragmatic trial.

Materials and methods

The tool known as OneSheet was developed using user-centered principles and built in the Epic electronic health record (EHR) of 2 health systems. For each relevant patient, OneSheet presents pertinent information in a single EHR view to assist PCPs in completing guideline-recommended opioid risk mitigation tasks, review previous and current patient treatments, view patient-reported pain, physical function, and pain-related goals.

Results

Overall, 69 PCPs accessed OneSheet 2411 times (since November 2020). PCP use of OneSheet varied significantly by provider and was highly skewed (site 1: median accesses per provider: 17 [interquartile range (IQR) 9-32]; site 2: median: 8 [IQR 5-16]). Seven "power users" accounted for 70% of the overall access instances across both sites. OneSheet has been accessed an average of 20 times weekly between the 2 sites.

Discussion

Modest OneSheet use was observed relative to the number of eligible patients seen with chronic pain.

Conclusions

Organizations implementing CDS tools are likely to see considerable provider-level variation in usage, suggesting that CDS tools may vary in their utility across PCPs, even for the same condition, because of differences in provider and care team workflows.

Multicomponent behavioral intervention to reduce exposure to anticholinergics in primary care older adults

OBJECTIVE

To test the impact of a multicomponent behavioral intervention to reduce the use of high-risk anticholinergic medications in primary care older adults.

DESIGN

Cluster-randomized controlled trial.

SETTING AND PARTICIPANTS

Ten primary care clinics within Eskenazi Health in Indianapolis.

INTERVENTION

The multicomponent intervention included provider- and patient-focused components. The provider-focused component was computerized decision support alerting of the presence of a high-risk anticholinergic and offering dose- and indication-specific alternatives. The patient-focused component was a story-based video providing education and modeling an interaction with a healthcare provider resulting in a medication change. Alerts within the medical record triggered staff to play the video for a patient. Our design intended for parallel, independent priming of both providers and patients immediately before an outpatient face-to-face interaction.

MEASUREMENT

Medication orders were extracted from the electronic medical record system to evaluate the prescribing behavior and population prevalence of anticholinergic users. The intervention was introduced April 1, 2019, through March 31, 2020, and a preintervention observational period of April 1, 2018, through March 31, 2019, facilitated difference in difference comparisons.

RESULTS

A total of 552 older adults had visits at primary care sites during the study period, with mean age of 72.1 (SD 6.4) years and 45.3% African American. Of the 259 provider-focused alerts, only three (1.2%) led to a medication change. Of the 276 staff alerts, 4.7% were confirmed to activate the patient-focused intervention. The intervention resulted in no significant differences in either the number of discontinue orders for anticholinergics (intervention: two additional orders; control: five fewer orders, p = 0.7334) or proportion of the population using anticholinergics following the intervention (preintervention: 6.2% and postintervention: 5.1%, p = 0.6326).

CONCLUSION

This multicomponent intervention did not reduce the use of high-risk anticholinergics in older adults receiving primary care. Improving nudges or a policy-focused component may be necessary to reduce use of high-risk medications.

Lack of benefit of ursodeoxycholic acid in drug-induced cholestasis in the rat

The administration of ursodeoxycholic acid (UDCA) has been reported to improve cholestasis in patients with primary biliary cirrhosis or sclerosing cholangitis. In the present study, we tested the hypothesis that UDCA similarly might reduce cholestasis induced by drugs. Rats were treated with three different drugs reported to induce cholestasis: 17 alpha-ethynylestradiol, alpha-napthylisothiocyanate, and cyclosporine A. UDCA administration (0.4.g/day-1.k-1 before and during administration of the cholestatic drug) did not improve survival, food intake, or serum indicators of cholestasis in any of these three animal models of cholestasis. To the extent that drug-induced cholestasis in rats mimics the human situation, we conclude that UDCA probably will not be beneficial in drug-induced cholestasis in humans.