Prescription reporting with immediate medication utilization mapping (PRIMUM): development of an alert to improve narcotic prescribing

BACKGROUND

Prescription narcotic overdoses and abuse have reached alarming numbers. To address this epidemic, integrated clinical decision support within the electronic medical record (EMR) to impact prescribing behavior was developed and tested.

METHODS

A multidisciplinary Expert Panel identified risk factors for misuse, abuse, or diversion of opioids or benzodiazepines through literature reviews and consensus building for inclusion in a rule within the EMR. We ran the rule "silently" to test the rule and collect baseline data.

RESULTS

Five criteria were programmed to trigger the alert; based on data collected during a "silent" phase, thresholds for triggers were modified. The alert would have fired in 21.75 % of prescribing encounters (1.30 % of all encounters; n = 9998), suggesting the alert will have a low prescriber burden yet capture a significant number of at-risk patients.

CONCLUSIONS

While the use of the EMR to provide clinical decision support is not new, utilizing it to develop and test an intervention is novel. We successfully built an alert system to address narcotic prescribing by providing critical, objective information at the point of care. The silent phase data were useful to appropriately tune the alert and obtain support for widespread implementation. Future healthcare initiatives can utilize similar methodology to collect data prospectively via the electronic medical record to inform the development, delivery, and evaluation of interventions.

Prevalence of Opioid and Benzodiazepine Prescriptions for Osteoarthritis

OBJECTIVE

Opioids and benzodiazepines are commonly used for management of osteoarthritis, despite evidence-based recommendations to the contrary. This study aimed to quantify the prevalence of opioid and benzodiazepine prescribing for osteoarthritis. Additionally, we aimed to characterize risk factors for prescription drug misuse, abuse, and diversion among this population.

METHODS

We conducted a descriptive analysis of adult outpatient encounters with a primary diagnosis of osteoarthritis during a 1-year period at a large health care system, excluding cancer and outpatient procedures. Demographic data, prescription data, and patient-specific risk factors were collected. Descriptive analysis was conducted to characterize arthritis patients who received and did not receive prescription opioids.

RESULTS

During 1 year, our system had 31,123 outpatient encounters for osteoarthritis. Opioids and benzodiazepines were prescribed for nearly 27% of the encounters (n = 8,420). In all, 43% of the encounters involved patients age ≥65 years. Hydrocodone-acetaminophen was the most common medication prescribed (34.3%). Most prescriptions were written by pain specialists (53%). A total of 35.5% of patients had a risk factor for prescription misuse, the most prevalent being early refill and a history of receiving ≥3 prescriptions in the past month.

CONCLUSION

Prescriptions for opioids and benzodiazepines continue to be written for osteoarthritis. These prescriptions may pose a risk for adverse outcomes since >1 in 5 patients receiving prescriptions had a risk factor for misuse. Continued efforts to improve compliance with evidence-based guidelines as well as multimodal and alternative pain management pathways are critical to help curb the use of opioids for management of osteoarthritis-related pain.

LEVEL OF EVIDENCE

level IV.

Multimodal analgesia reduces opioid requirements in trauma patients with rib fractures

BACKGROUND

Rib fractures are common in trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is essential to avoid the complications associated with rib fractures. Opioids are frequently used for analgesia in these patients. This study compared the effect of a multimodal pain regimen (MMPR) on inpatient opioid use and outpatient opioid prescribing practices in adult trauma patients with rib fractures.

STUDY DESIGN

A pre-post cohort study of adult trauma patients with rib fractures was conducted at a Level I trauma center before (PRE) and after (POST) implementation of an MMPR. Patients on long-acting opioids before admission and those on continuous opioid infusions were excluded. Primary outcomes were oral opioid administration during the first 5 days of hospitalization and opioids prescribed at discharge. Opioid data were converted to morphine milligram equivalents (MMEs).

RESULTS

Six hundred fifty-three patients met inclusion criteria (323 PRE, 330 POST). There was a significant reduction in the daily MME during the second through fifth days of hospitalization; and the average inpatient MME over the first five inpatient days (23 MME PRE vs. 17 MME POST, p = 0.0087). There was a significant reduction in the total outpatient MME prescribed upon discharge (322 MME PRE vs. 225 MME POST, p = 0.006).

CONCLUSION

The implementation of an MMPR in patients with rib fractures resulted in significant reduction in inpatient opioid consumption and was associated with a reduction in the quantity of opiates prescribed at discharge.

LEVEL OF EVIDENCE

Therapeutic/Care Management; level IV.

The Association Between Preconception Care Receipt and the Timeliness and Adequacy of Prenatal Care: An Examination of Multistate Data from Pregnancy Risk Assessment Monitoring System (PRAMS) 2009-2011

Objectives Prenatal care (PNC) is a critical preventive health service for pregnant women and infants. While timely PNC has been associated with improved birth outcomes, improvements have slowed since the late 1990s. Therefore, focus has shifted to interventions prior to pregnancy. Preconception care is recommended for all women of reproductive age. This study aimed to examine preconception care and its association with timeliness and adequacy of PNC. Methods This retrospective cohort study used data from a large sample of United States first-time mothers (n = 13,509) who participated in the 2009-2011 Pregnancy Risk Assessment Monitoring System in ten states. Timeliness and adequacy of PNC data came from birth certificates, while preconception care receipt was self-reported. Logistic regression provided odds ratios (ORs) and 95% confidence intervals (CIs) to model the association between preconception care receipt and the two PNC outcomes. Results After adjustment, women who received preconception care had statistically significant increased odds of timely (OR 1.30, 95% CI 1.08, 1.57), but not adequate PNC (OR 1.08, 95% CI 0.94, 1.24) as compared to women who did not receive preconception care. Pregnancy intention modified these associations. Associations were strongest among women with intended pregnancies (timely PNC: OR 1.63 and adequate PNC: OR 1.22). Conclusions for Practice Given that untimely PNC is associated with adverse birth outcomes, the observed association warrants increased focus on implementing preconception care. Future studies should investigate how specific components of preconception care are associated with PNC timeliness/adequacy, health behaviors during pregnancy, and birth outcomes.

Pre-Hip Fracture Falls: A Missed Opportunity for Intervention

Introduction

The purpose of this study is to examine utilization of acute care services in the year prior to hip fracture to inform development and implementation of an intervention to prevent subsequent falls and hip fracture that targets high-risk patients.

Methods

Elderly patients (age >55) with hip fractures managed at a level one trauma center during 1 year (n = 134) were included. All "preadmissions," defined as an emergency department (ED) visit or inpatient admission within our hospital system in the year before fall with fracture, were documented. Proportion of patients with a "preadmission," reason for "preadmission," demographic characteristics, medical comorbidities, history of falls with fracture, cause of fracture, and time between preadmission and fracture were documented and described.

Results

Of all, 45.5% of patients (n = 61) had a preadmission. Falls was the reason for presentation in 27.5% of the preadmission encounters, and the median interval between preadmission and fracture was 217 days. Only 8% of the patients presenting for falls in the ED received falls counseling. Patients who experienced preadmission were younger, had a higher Charlson Comorbidity Index, and were more likely to be male. Seventy-nine percent were community dwelling at the time of preadmission, and 68% were discharged home.

Discussion

Nearly half of hip fracture patients were seen in a high acuity care environment in the year prior to fracture. A quarter presented for falls, supporting previous findings that history of falls is an important risk factor for future falls and injury. However, very few received falls counseling, documenting a major missed opportunity to address falls prevention in the acute care setting.

Conclusions

Preventing subsequent falls and hip fractures in a targeted, high-risk population in the year prior to potential hip fracture has important implications for improving individual morbidity and mortality and population health. Community-based falls prevention programs are a viable option for this high-risk, community-dwelling population. Collaborative interventions are needed to actively link patients to evidence-based community resources.

Pilot randomized trial of pre-hospital advanced therapies for the control of hemorrhage (PATCH) using pelvic binders

BACKGROUND

Pelvic fractures represent a small percent of all skeletal injuries but are associated with significant morbidity and mortality secondary to hemodynamic instability from bleeding bone surfaces and disrupted pelvic vasculature. Stabilization of the pelvis prior to arrival at a treatment facility may mitigate the hemodynamic consequences of pelvic ring injuries and improve morbidity and mortality. Whether pelvic compression devices such as pelvic binders or sheets can be safely applied in the prehospital setting has not been well-studied. This study aims to evaluate the safety of applying a pelvic binder to at-risk patients in the field after scalable training and the feasibility of conducting a randomized trial evaluating this practice in the prehospital setting.

METHODS

A pilot study (prospective randomized trial design) was conducted in the pre-hospital environment in an urban area surrounding a level-one trauma center. Pre-hospital emergency medical (EMS) personnel were trained to identify patients at high-risk for pelvic fracture and properly apply a commercial pelvic binder. Adult patients with a high-energy mechanism, suspected pelvic fracture, and "Priority 1" criteria were prospectively identified by paramedics and randomized to pelvic binder placement or usual care. Medical records were reviewed for safety outcomes. Secondary outcomes were parameters of efficacy including interventions needed to control hemorrhage (such as angioembolization and surgical control of bleeding) and mortality.

RESULTS

Forty-three patients were randomized to treatment (binder: N=20; nonbinder: N=23). No complications of binder placement were identified. Eight patients (40%) had binders placed correctly at the level of the greater trochanter. Two binders (10%) were placed too proximally and 10 (50%) binders were not visualized on x-ray. Two binder group patients and three nonbinder group patients required angioembolization. None required surgical control of pelvic bleeding. Two nonbinder group patients and one binder group patient were readmitted within 30 days and one nonbinder group patient died within 30 days.

CONCLUSION

Identification of pelvic fractures in the field remains a challenge. However, a scalable training model for appropriate binder placement was successful without secondary injury to patients. The model for conducting prospective, randomized trials in the prehospital setting was successful.

Use of a Prescription Drug-Monitoring Program by Emergency and Surgical Prescribers: Results of a Hospital Survey

BACKGROUND

Drug overdoses are the leading cause of death due to injury in the USA. Currently, 49 states have prescription drug-monitoring programs (PDMPs) available to prescribers.

QUESTIONS/PURPOSES

We aimed to assess knowledge and practice of two groups of acute-care prescribers regarding controlled substances.

METHODS

A 16-question survey was distributed to a list of surgical and emergency medicine prescribers at our institution. The survey asked about prescriber demographics, previous experiences with a PDMP, and opinions about patient risk factors available within an electronic medical record (EMR).

RESULTS

We received 60 responses (27.1% response rate). All prescribers recognized a growing problem with opioids, both in general and in their own practices, with an average rating of 8.3/10 and 7.9/10, respectively. Although 95% were aware a PDMP was available, only 60% were registered users. Emergency medicine prescribers were significantly more likely to have registered and used the database; 52% said the PDMP was too time-consuming and 23% said the information was not easy to use. All respondents who reported PDMP use indicated it carried some clinical utility, with 87% reporting it to be "somewhat" or "very" useful. Emergency medicine prescribers were more likely to use the PDMP regularly, with 73% selecting "somewhat frequently" or higher, while only 9% of surgery prescribers indicated the same. Of all respondents, 97% agreed that an integrated alert in the existing EMR would be helpful.

CONCLUSION

Acute-care prescribers at our institution are universally aware of the opioid epidemic, but efficient and useful tools for identifying at-risk patients are lacking. Our prescribers desired an alert system integrated into the EMR to highlight targeted risk factors.

Study protocol: randomized controlled trial of opioid-free vs. traditional perioperative analgesia in elective orthopedic surgery

BACKGROUND

The medical community is beginning to recognize the contribution of prescription opioids in the growing national opioid crisis. Many studies have compared the safety and efficacy of alternative analgesics to opioids, but none utilizing a completely opioid-free perioperative protocol in orthopedics.

METHODS

We developed and tested an opioid-free perioperative analgesic pathway (from preoperative to postoperative period) among patients undergoing common elective orthopedic procedures. Patients will be randomized to receive either traditional opioid-including or completely opioid-free perioperative medications. This study is being conducted across multiple orthopedic subspecialties in patients undergoing the following common elective orthopedic procedures: single-level or two-level ACDF/ACDA, 1st CMC arthroplasty, Hallux Valgus/Rigidus corrections, diagnostic knee arthroscopies, total hip arthroplasty (THA), and total shoulder arthroplasty/reverse total shoulder arthroplasty (TSA/RTSA). The primary outcome measure is pain score at 24 h postoperatively. Secondary outcome measures include pain scores at additional time points, medication side effects, and several patient-reported variables such as patient satisfaction, quality of life, and functional status.

DISCUSSION

We describe the methods for a feasibility randomized controlled trial comparing opioid-free perioperative analgesics to traditional opioid-including protocols. We present this study so that it may be replicated and incorporated into future studies at other institutions, as well as disseminated to additional orthopedic and/or non-orthopedic surgical procedures. The ultimate goal of presenting this protocol is to aid recent efforts in reducing the impact of prescription opioids on the national opioid crisis.

TRIAL REGISTRATION

The protocol was approved by the local institutional review board and registered with clinicaltrials.gov (Identifier: NCT04176783 ) on November 25, 2019, retrospectively registered.

Development of a Content Valid and Reliable Prehospital Environmental Falls Risk Assessment Tool for Older Adults

Introduction: The aging population reintroduces the need to establish early identification of falls risk as a means of primary and secondary prevention of falls. While there are several existing tools to assess environmental risk factors developed for consumers or home health providers, assessment of environmental falls risk by emergency medical services (EMS) providers represents a novel approach to primary and secondary prevention. The purpose of this study was to evaluate a content valid and reliable assessment of environmental fall risk to be performed in the prehospital setting. Methods: This was a mixed methods study, conducted from August, 2015 to September, 2017 in Mecklenburg County, NC, utilizing qualitative methodology to develop content valid items for an environmental falls risk assessment and quantitative methodology to assess those items for interrater reliability. Content validity was assessed using 2 expert panels. Expert Panel One was tasked with assessing validity of a construct to indicate an increased risk of an in-home fall for elderly individuals and expert Panel Two was responsible for assessing the likelihood of an EMS professional to identify a construct during their course of patient care. To assess reliability of the identified content valid items, 5 paramedics were recruited for interrater reliability (IRR) testing of the validated falls risk assessment tool. Each paramedic and their partner received education on documentation and deployment of the tool. Crews independently documented presence or absence of each item with pair agreement assessed using Cohen's kappa (κ). Results: A total of 87 items were identified for assessment through review of validated scales and relevant literature, with the content validation process reducing to 9 the number of items tested in the field for reliability. A total of 57 paired assessments were completed and included in analysis. One item returned almost perfect agreement (κ = 0.87), 5 items returned moderate agreement (κ = 0.41-0.54), with the remaining 3 items illustrating fair agreement (κ = 0.33-0.39). Conclusion: We developed a construct valid and reliable assessment of environmental falls risk to be performed in the prehospital setting. Further trials should be conducted using this tool to determine appropriate cut scores and deployment in the prehospital setting to help with primary and secondary fall prevention.

Teaching Cortical-Screw Tightening: A Simple, Affordable, Torque-Directed Training Protocol Improves Resident Performance

BACKGROUND

Cortical-screw insertion is a fundamental skill in orthopaedic surgery, yet, to our knowledge, no standardized method of teaching this skill exists. The purpose of this study was to evaluate a training protocol that was designed to teach residents how to tighten a cortical screw without causing any stripping.

METHODS

Twenty-five residents and 8 attending surgeons from an orthopaedic residency program tightened cortical screws in a synthetic bone model with a digital torque screwdriver using 3 different techniques: percutaneous; open, dominant hand; and open, nondominant hand. The residents then participated in a training protocol during which each tightened additional screws while receiving real-time torque feedback. During training, the residents targeted 50% to 70% of the stripping torque for each screw. They were assessed at baseline, immediately after training, and at 12 to 15 weeks after training. During each assessment, the percentage of screws that were tightened in the target range and the percentage of stripped screws were recorded. The costs of the training protocol were assessed.

RESULTS

After training, all of the residents tightened screws with lower insertional torque compared with their baseline, but only the senior residents tightened more screws in the target range and stripped fewer screws. The attending surgeons, when compared with the residents at baseline, tightened more screws in the target range and tended to strip fewer screws, but these differences were absent at final testing. Costs included $1,927 for durable equipment and an estimated $74 per resident per training session for consumable goods.

CONCLUSIONS

The senior residents inserted more screws in the target range and stripped fewer screws after participating in this training protocol, but the junior residents did not show significant improvement. Implementation of this training protocol for all residents may improve clinical performance but, because our sample size was limited, additional study is required to assess skill transfer to clinical practice.

CLINICAL RELEVANCE

Cortical-screw tightening is a fundamental skill in orthopaedics, and completion of this torque-directed training protocol may accelerate residents' skill acquisition.

Depression Screening and Behavioral Health Integration in Musculoskeletal Trauma Care

OBJECTIVES

To report our experiences in implementing a behavioral health integration pathway, including a validated depression screening and referral to care.

DESIGN

Retrospective case series.

SETTING

Single surgeon's musculoskeletal trauma outpatient practice during calendar year 2019.

PATIENTS

All patients presenting to the practice during 2019 were included (n = 573).

INTERVENTION

We piloted the usage of Patient Health Questionnaire (PHQ)-2 and PHQ-9 screening. An evidence-based, real-time treatment protocol embedded in the electronic health record was triggered when a patient screened positive for depression including an automated behavioral health integration pathway.

MAIN OUTCOME MEASUREMENTS

The percentage of patients screened, the results of the PHQ screening, and the number of patients referred and enrolled in behavioral health programs were collected.

RESULTS

Of the 573 patients, 476 (83%) received the PHQ-2 screening, 80 (14%) had a current screening on file (within 1 year), and 17 (3.0%) were not screened. One hundred seventy-two patients (36%) had a PHQ-2 score of 2 or greater and completed the PHQ-9; of them, 60 (35% of patients screened with full PHQ-9, 13% of patients screened) screened positive for symptoms of moderate depression (PHQ-9 score ≥10), and 19 (4.0%) reported passive suicidal ideation (PHQ-9 item 9). Fifty of these patients were referred to behavioral health through the pathway, and 8 patients enrolled in the program. Ten patients were not referred because of a technical error that was quickly resolved. Patients reporting suicidal ideation were managed with psychiatric crisis resources including immediate virtual consult in the examination room.

CONCLUSIONS

This case series demonstrates the feasibility of screening patients for depressive symptoms and making necessary referrals to behavioral health in outpatient musculoskeletal trauma care. We identified 50 patients with depression and appropriately triaged them for further care in our community.

Traumatic Arthrotomies: Do They All Need the Operating Room?

OBJECTIVES

To compare complications and cost of care in patients with traumatic arthrotomies (TAs) treated with surgical debridement, irrigation, and closure to those treated with nonoperative treatment and local wound care.

DESIGN

This is a prospective observational multicenter study.

SETTING

This study was conducted at multiple Level I trauma centers.

PATIENTS

Patients with TAs.

INTERVENTION

Patients were treated with operative versus nonoperative management decided by the attending surgeon. Nonoperative treatment of TAs included bedside irrigation, primary closure, antibiotics, and discharge from the emergency department with close follow-up unless admission was otherwise indicated.

MAIN OUTCOME MEASUREMENTS

Primary outcomes included adverse outcomes and cost. VR-12 was captured at the time of injury and 3 months postinjury.

RESULTS

Of 189 major joint TAs, 64 arthrotomies were treated nonoperatively and 125 operatively. Seventy percent of the arthrotomies in the nonoperative group were small (less than 50 mm in size) and 95% had minimal/no gross contamination, whereas the operative group (OG) had significantly more arthrotomies greater than 50 mm in size and with moderate/severe gross contamination. There was one septic joint in the nonoperative group (1.5%) and 7 in the OG (5.6%). Nonoperative treatment was associated with significantly lower total charges when compared with the OG.

CONCLUSIONS

Although further study may still be needed, this study suggests that small, minimally contaminated TAs with no associated fracture have a low risk of adverse complications, can safely be treated nonoperatively, and are associated with a significantly decreased cost of care.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association

Objectives

Fracture is a common injury after a traumatic event. The efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) to treat acute pain related to fractures is not well established.

Methods

Clinically relevant questions were determined regarding NSAID use in the setting of trauma-induced fractures with clearly defined patient populations, interventions, comparisons and appropriately selected outcomes (PICO). These questions centered around efficacy (pain control, reduction in opioid use) and safety (non-union, kidney injury). A systematic review including literature search and meta-analysis was performed, and the quality of evidence was graded per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The working group reached consensus on the final evidence-based recommendations.

Results

A total of 19 studies were identified for analysis. Not all outcomes identified as critically important were reported in all studies, and the outcome of pain control was too heterogenous to perform a meta-analysis. Nine studies reported on non-union (three randomized control trials), six of which reported no association with NSAIDs. The overall incidence of non-union in patients receiving NSAIDs compared with patients not receiving NSAIDs was 2.99% and 2.19% (p=0.04), respectively. Of studies reporting on pain control and reduction of opioids, the use of NSAIDs reduced pain and the need for opioids after traumatic fracture. One study reported on the outcome of acute kidney injury and found no association with NSAID use.

Conclusions

In patients with traumatic fractures, NSAIDs appear to reduce post-trauma pain, reduce the need for opioids and have a small effect on non-union. We conditionally recommend the use of NSAIDs in patients suffering from traumatic fractures as the benefit appears to outweigh the small potential risks.

Impact of Anesthesia selection on Post-Op Pain Management in Operatively treated Hip Fractures

OBJECTIVES

To determine if the use of Peripheral Nerve Block (PNB) versus Local Infiltration Analgesia (LIA) for hip fracture patients, affected opioid consumption in the early post-operative period.

DESIGN

Retrospective cohort study SETTING: Two level 1 trauma centers PATIENTS/INTERVENTION: 588 patients with surgically treated AO/OTA 31A and 31B fractures between February 2016-October 2017 were included. 415 (70.6%) received general anesthesia (GA) alone, 152 received GA plus perioperative PNB (25.9%), and 21 had GA plus LIA intra-operatively (3.6%). Median age was 82 years; predominantly female (67%) and AO/OTA 31A fractures (55.37%).

MAIN OUTCOME MEASURES

Morphine Milligram Equivalents (MME) at 24 and 48 hours postoperatively, length of stay (LOS) and the occurrence of any complication after surgery RESULTS: The PNB cohort was less likely to use any opioid than the GA group at 24 and 48 hours postoperatively (OR: 0.36, 95% CI: 0.22-0.61 and OR: 0.56, 95% CI: 0.35-0.89 respectively). LOS ≥ 10 days had 3.24 times the odds of 24- and 48-hour opioid administration compared to LOS ≤ 10 days (OR: 3.24, 95% CI 1.11-9.42; OR: 2.98, 95% CI 1.38-6.41, respectively). The most common complication was post-operative delirium, with PNB more likely to present with any complication compared to GA (OR= 1.88, 95% CI 1.09-3.26). There was no difference when comparing LIA to general anesthesia.

CONCLUSIONS

Our findings suggest PNB for hip fracture can help limit the use of post-operative opioids with adequate pain relief. Regional analgesia does not seem to avoid complications such as delirium.

Opioid Prescribing Risk Factors in Nonoperative Ankle Fractures: The Impact of a Prospective Clinical Decision Support Intervention

Opioids are frequently used for acute pain management of musculoskeletal injuries, which can lead to misuse and abuse. This study aimed to identify the opioid prescribing rate for ankle fractures treated nonoperatively in the ambulatory and emergency department setting across a single healthcare system and to identify patients considered at high risk for abuse, misuse, or diversion of prescription opioids that received an opioid. A retrospective cohort study was performed at a large healthcare system. The case list included nonoperatively treated emergency department, urgent care and outpatient clinic visits for ankle fracture and was merged with the Prescription Reporting With Immediate Medication Mapping (PRIMUM) database to identify encounters with prescription for opioids. Descriptive statistics characterize patient demographics, treatment location and prescriber type. Rates of prescribing among subgroups were calculated. There were 1,324 patient encounters identified, of which, 630 (47.6%) received a prescription opioid. The majority of patients were 18-64 years old (60.3%). Patients within this age range were more likely to receive an opioid prescription compared to other age groups (p < .0001). Patients treated in the emergency department were significantly more likely to receive an opioid medication (68.3%) compared to patients treated at urgent care (33.7%) or in the ambulatory setting (16.4%) (p < .0001). Utilizing the PRIMUM tool, 14.2% of prescriptions were provided to patients with at least one risk factor. Despite the recent emphasis on opioid stewardship, 14.2% of patients with risk factors for misuse, abuse, or diversion received opioid analgesics in this study, identifying an area of improvement for prescribers.

Obstacles Affecting the Implementation of the O-SCORE for Assessment of Orthopedic Surgical Skills Competency

OBJECTIVES

There is a need for meaningful and reliable measures of surgical competency in residency education. The goal of the current study is to incorporate the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) into the process of resident evaluation at our institution and to assess the feasibility and effectiveness of its use through a web-based platform.

DESIGN

This is a feasibility study that prospectively assesses the implementation of a web-based O-SCORE at our institution. Over a 16-week period, 19 orthopedic surgery residents (PGY2-PGY5) participated in a quality improvement study, which involved collecting 2 feedback forms per week. Each form consisted of a resident form and a linked attending form. At the conclusion of the 16-week trial period, residents and faculty members were asked to complete a survey about their perceptions of the O-SCORE program.

SETTING

An academic medical center.

PARTICIPANTS

The study included only residents in postgraduate training years (PGY) 2 through 5 (n = 20) and attendings (n = 37).

RESULTS

During the 16-week study period, 608 resident surveys were requested for the 19 participating residents, of which 404 surveys (66.5%) were completed. Faculty completed 207 of 326 surveys for an overall compliance rate of 63.5%. The O-SCORE was able to significantly differentiate between all training years (p < 0.0001) with the exception of PGY3 residents when compared to PGY4 residents. Overall, residents and faculty found the program valuable and feasible. Resident and faculty perception of the value of the O-SCORE correlated with compliance rate of the O-SCORE surveys.

CONCLUSIONS

This study demonstrates that implementation of an immediate feedback program utilizing an electronic platform is achievable and offers reproducible construct validity. However, issues affecting compliance among both residents and faculty physicians must temper optimism for the program and should be systematically addressed to allow for successful implementation.

Prevalence of Prescription Opioids for Nonoperative Treatment of Rotator Cuff Disease Is High

Purpose

To quantify the prevalence of opioid and benzodiazepine prescriptions for patients with rotator cuff disease across a large health care system and to describe evidence-based risk factors for opioid use within this population.

Methods

We conducted a retrospective cohort study at a major health care system of all patients with qualifying diagnostic codes. Emergency department, urgent care, and outpatient encounters between January and December 2016 for an acute rotator cuff tear, listed as the primary diagnosis, were included. Encounters with prescriptions for opioids or benzodiazepines were identified using the Prescription Reporting With Immediate Medication Utilization Mapping (PRIMUM) system. Descriptive statistics and the rate of controlled-substance prescribing were calculated for the population as a whole and among subgroups.

Results

We identified 9,376 encounters meeting the inclusion criteria. Of these encounters, 1,559 (16.6%) resulted in 1 or more prescriptions for an opioid or benzodiazepine that were issued during the visit. A total of 2,007 opioid and/or benzodiazepine prescriptions were issued for the 1,559 encounters (rate of 1.29 prescriptions per prescribing encounter). This represented 5,310 patients, of whom 1,096 (20.6%) received a prescription for an opioid or benzodiazepine during at least 1 of their encounters. Of patients who received a prescription, 20.9% had at least 1 risk factor for prescription misuse; 3.6% of patients had more than 1 risk factor. There were no demographic differences between patients with risk factors and patients without them.

Conclusions

The prescribing of opioids for the treatment of pain in patients with rotator cuff disease remains high across multiple locations and specialties within a large health care system. Using alternative pain management pathways as primary prevention for opioid misuse and abuse in high opioid-prescribing locations-and especially for patients identified as having a high risk of opioid misuse-is an important practice to continue in our shift away from opioid use as a health care system.

Level of Evidence

Level IV, case series.

Dental pain management with prescription opioids by nondental healthcare professionals in a healthcare system network

OBJECTIVES

Patients with dental pain seek treatment in Urgent and Emergency Care settings by physicians and advanced practice practitioners (APPs) unable to provide definitive care, often relying on prescriptions for pain management including opioids. In the face of an opioid epidemic, this study assessed the impact of an electronic health record (EHR) clinical decision support tool to identify patients at high risk for opioid misuse using objective, evidence-based criteria, and guide safer prescribing.

METHODS

Dental pain encounters occurring between January 2016 and June 2018 within our healthcare system were identified and linked to the database supporting a real-time clinical decision support intervention, Prescription Reporting with Immediate Medication Utilization Mapping (PRIMUM), to characterize opioid prescribing patterns and prescribers' response to alert. Descriptive analysis of the data was performed.

RESULTS

There were 30,649 dental pain encounters of which opioids were written in 45.5 percent (N = 13,957) encounters. A total of 16.6 percent of patients prescribed an opioid had a risk factor for misuse and triggered the PRIMUM alert at the point of care. In response to the PRIMUM alert (N = 2,501 encounters), clinician decision-making was influenced in 9.5 percent (N = 237) of encounters, which was defined by cancelation of the original opioid prescription. Of those 9.5 percent encounters, 48.1 percent (N = 114) resulted in no opioid prescription written.

CONCLUSIONS

There is potential for a clinical decision support tool embedded in the EHR to guide safer prescribing practice by alerting providers to objective, evidence-based risk characteristics at the point of care.

Preventing Fragility Fractures: A 3-Month Critical Window of Opportunity

Introduction:

Low-energy falls are the leading cause of injury-related morbidity and mortality in the elderly. In the past, physicians focused on treating fractures resulting from falls rather than preventing them. The purpose of this study is to identify patients with a hospital encounter for fall prior to a fracture as an opportunity for pre-injury intervention when patients might be motivated to engage in falls prevention.

Materials & Methods:

A retrospective analysis of all emergency room and inpatient encounters in 2016 with an ICD10 diagnosis code including “fall” across a tri-state health system was performed. Subsequent encounters with diagnosis of fracture within 2 years were then identified. Data was collected for time to subsequent fracture, fracture type and location, and length of stay of initial encounter.

Results:

There were 12,382 encounters for falls among 10,589 patients. Of those patients, 1,040 (9.8%) sustained a subsequent fracture. Fractures were most commonly lower extremity fractures (661 fractures; 63.5%), including hip fractures (447 fractures; 45.87%). Median time from fall to fracture was 105 days (IQR 16-359 days).

Discussion:

Falls are an important, modifiable risk factor for fragility fracture. This study demonstrates that patients are presenting to the hospital with one of the main modifiable risk factors for fracture within a time window that allows for intervention.

Conclusions:

Presentation to the hospital for a fall is a vital opportunity to intervene and prevent subsequent fracture in a high-risk population.

Osseointegration programmatic development: interdisciplinary team with a patient-centered approach

Successful implementation of an osseointegration program requires a skilled and committed interdisciplinary team engaged in supporting patients and their families throughout the OI process. The roles and responsibilities of clinical and ancillary team members are described in detail, along with a discussion of the needed patient and family support resources. Time spent developing the interdisciplinary team, with strong regulatory support and engagement of hospital administration and the health system, will promote higher patient satisfaction and outcomes and innovative future directions.

Opioid Prescribing for Chronic Musculoskeletal Conditions: Trends over Time and Implementation of Safe Opioid-Prescribing Practices

OBJECTIVES

This study aimed (1) to determine the impact of a clinical decision support (CDS) tool on rate of opioid prescribing and opioid dose for patients with chronic musculoskeletal conditions and (2) to identify prescriber and facility characteristics associated with adherence to the Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain in this population.We conducted an interrupted time series analysis to assess trends in percentage of patients from 2016 to 2020, receiving an opioid and the average opioid dose, as well as the change associated with implementation of the CDS toolkit. We conducted a retrospective cohort study to assess the association between prescriber and facility characteristics and safe opioid-prescribing practices.

METHODS

We assessed the impact of the CDS intervention on percent of patients receiving an opioid and average opioid dose (morphine milligram equivalents). We operationalized safe opioid prescribing as a composite score of several behaviors (i.e., prescribing naloxone, initiating a pain agreement, prescribing <90 MME, avoiding extended-release prescriptions for opioid-naïve patients, and avoiding coprescribing opioids and benzodiazepines) and used a hierarchical linear regression model to assess associations between prescriber and facility characteristics and safe opioid prescribing.

RESULTS

This CDS intervention had a modest but statistically significant 1.6% reduction on the percent of patients (n = 1,290,746) receiving an opioid (mean: 15% preintervention; 10% postintervention). The average dose of opioid prescriptions did not significantly change. Advanced practice providers and prescribers with higher percentages of patients aged 18 to 64 exhibited safer opioid prescribing, while prescribers with higher percentages of white patients and larger numbers of patients on opioids exhibited less safe opioid prescribing.

CONCLUSION

A CDS intervention was associated with a small improvement in percent of patients receiving an opioid, but not on average dose. Clinicians are not prescribing opioids for chronic musculoskeletal conditions frequently, when they do, they are generally adhering to guidelines.

[Periodontal treatment requirements, motivation and information levels in a groups of 35-year-old Zurich residents]

A representative sample of 35-year old residents of Zurich was examined with the PTN-system to determine their periodontal treatment needs. 8.8% required no periodontal treatment. An additional 7.0% required only oral hygiene instruction and motivation to restore their gingival health. 37.1% of the sample needed removal of marginal irritants. 47.1% of the sample population had periodontal pockets in two or more quadrants, in need of surgical treatment (curettage, flap surgery). Responses to a questionnaire completed by all participants in the study revealed a strong desire on their part to retain their teeth. However, knowledge of periodontal prophylactic measures and individual oral hygiene was inadequate.