Clinical Decision Support to Reduce Opioid Prescriptions for Dental Extractions using SMART on FHIR: Implementation Report

BACKGROUND

Clinical decision support (CDS) has the potential to improve clinical decision-making consistent with evidence-based care. CDS can be designed to save health care providers time and help them provide safe and personalized analgesic prescribing.

OBJECTIVE

The aim of this report is to describe the development of a CDS system designed to provide dentists with personalized pain management recommendations to reduce opioid prescribing following extractions. The use of CDS is also examined.

METHODS

This study was conducted in HealthPartners, which uses an electronic health record (EHR) system that integrates both medical and dental information upon which the CDS application was developed based on SMART (Substitutable Medical Applications and Reusable Technologies) on FHIR (Fast Healthcare Interoperability Resources). The various tools used to bring relevant medical conditions, medications, patient history, and other relevant data into the CDS interface are described. The CDS application runs a drug interaction algorithm developed by our organization and provides patient-specific recommendations. The CDS included access to the state Prescription Monitoring Program database.

IMPLEMENTATION (RESULTS)

The pain management CDS was implemented as part of a study examining opioid prescribing among patients undergoing dental extraction procedures from February 17, 2020, to May 14, 2021. Provider-level use of CDS at extraction encounters ranged from 0% to 87.4% with 12.1% of providers opening the CDS for no encounters, 39.4% opening the CDS for 1%-20% of encounters, 36.4% opening it for 21%-50% of encounters, and 12.1% opening it for 51%-87% of encounters.

CONCLUSIONS

The pain management CDS is an EHR-embedded, provider-facing tool to help dentists make personalized pain management recommendations following dental extractions. The SMART on FHIR-based pain management CDS adapted well to the point-of-care dental setting and led to the design of a scalable CDS tool that is EHR vendor agnostic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03584789; https://clinicaltrials.gov/study/NCT03584789.

De-implementing opioid prescribing in a dental group practice: Lessons learned

BACKGROUND

Drug overdose has become a leading cause of accidental death in the United States. Between 2000 and 2015, the rate of deaths from drug overdoses increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (including opioid pain relievers and heroin). Unnecessary opioid prescribing is one of the factors driving this epidemic.

OBJECTIVES

The primary objective of this paper is to share lessons learned while conducting a randomized trial to de-implement opioids for post-extraction pain management utilizing clinical decision support (CDS) with and without patient education. The lessons learned from conducting this trial in a real-world setting can be applied to future dissemination and implementation oral health research.

METHODS

The sources informing lessons learned were generated from qualitative interviews conducted with 20 of the forty-nine dental providers involved in the study following the implementation phase of the trial. Ongoing policy, social and environmental factors were tracked throughout the study.

RESULTS

Dental providers in the trial identified the impact of training that involved health professionals sharing information about the personal impact of pain and opioid use. Additionally, they found utility in being presented with a dashboard detailing their prescribing patterns related to other dentists. For the 30 general dentists with access to the CDS, use of its portal varied widely, with most using it 10%-49% of the time related to extractions.

CONCLUSIONS

In the context of a downward trend in opioid prescribing and considering the influence of the COVID pandemic during the trial, dental providers indicated benefit in training about negative personal impacts of prescribing opioids, and personally relevant feedback about their prescribing patterns. Only modest use of the CDS was realized. Implementation of this trial was impacted by governmental and health system policies and the COVID pandemic, prompt the consideration of implications regarding continuing ways to limit opioid prescribing among dental providers.

De-Implementing Opioid Use and Implementing Optimal Pain Management Following Dental Extractions (DIODE): Protocol for a Cluster Randomized Trial

Background

Overdose deaths from prescription opioid analgesics are a continuing crisis in the United States. Opioid analgesics are among the most frequently prescribed drugs by dentists. An estimated 5 million people undergo third-molar extractions in the United States each year, resulting in postoperative pain. Studies show that, in most cases, the combination of ibuprofen and acetaminophen is an effective alternative to commonly prescribed opioid analgesics for the management of postextraction pain. Nevertheless, many dentists routinely prescribe opioids after dental extractions.

Objective

We describe the rationale, design, and methods for a randomized trial of interventions designed to de-implement opioid prescribing by dentists while implementing effective nonopioid analgesics following dental extractions.

Methods

Using a prospective, 3-arm, cluster randomized trial design with dentists as the unit randomized and patient-level prescribing data as the primary outcome, we will compare different strategies to reduce the reliance on opioids and increase the use of alternative pain management approaches utilizing information support tools aimed at both providers and their patients. The study will test the efficacy of 2 interventions to decrease opioid prescribing following dental extractions: clinical decision support with (CDS-E) and without patient education (CDS). Providers will be randomized to CDS, CDS-E, or standard practice. Patient-level outcomes will be determined via review of comprehensive electronic health records. We will compare study arms on differential change in prescribing patterns from pre- to postimplementation of the intervention. The primary outcome of interest is a binary indicator of whether or not the patient received an opioid prescription on the day of the extraction encounter. We will also examine recommendations or prescriptions for nonopioid analgesics, patients’ perceptions of shared decision making, and patients’ pain experiences following the extraction.

Results

The HealthPartners Institutional Review Board approved the study. All study materials including the CDS and patient education materials have been developed and pilot tested, and the protocol has been approved by the National Institute of Dental and Craniofacial Research. The intervention was implemented in February 2020, with 51 dentists who were randomized to 1 of the 3 arms.

Conclusions

If the intervention strategies are shown to be effective, they could be implemented more broadly in dental settings with high levels of opioid prescribing.

Trial Registration

ClinicalTrials.gov NCT03584789, https://clinicaltrials.gov/ct2/show/NCT03584789

International Registered Report Identifier (IRRID)

DERR1-10.2196/24342

Dental Decision Simulation (DDSim): Development of a virtual training environment

PURPOSE

Case-based simulations are powerful training tools that can enhance learning and drive behavior change. This is an overview of the design/development of Dental Decision Simulation (DDSim), a web-based simulation of an electronic dental record (EDR). The purpose was to use DDSim to train dentists to make evidence-based treatment planning decisions consistent with current evidence. This simulated EDR provides case-based information in support of a set of defined evidence-based learning objectives.

METHODS

The development of this complex simulation model required coordinated efforts to create several components: identify behavior changes, case authoring mechanism, create virtual patient visits, require users to make treatment plan decisions related to learning objectives, and a feedback mechanism to help users recognize departures from those learning objectives. This simulation was evaluated in a 2-arm, clinic-randomized, controlled pilot study examining the extent to which DDSim changed dentists' planned treatment to conform to evidence-based treatment guidelines relative to change in dentists not exposed to DDSim. Outcomes were measured by comparing preintervention and postintervention patient EDR treatment data.

RESULTS

Changes in behavior over time did not favor intervention or control clinics.

CONCLUSION

DDSim provides a standardized learning platform that cannot be achieved through the use of live patients. Both live patients and case-based simulations can be used to transfer knowledge and skill development. DDSim offers the advantage of providing a platform for developing treatment planning skills in a low-risk environment. However, further research examining behavior change is needed.

[Quality of butter sold in Dakar (Sénégal)]

Among foods that are introduced in Senegal, butter takes a significant place particularly at home where it is frequently eaten. Nevertheless, Senegalese authorities don't carry out any quality control under those different types (mark) of butter. In consequence, to find butter without quality or characteristics of authentic butter may be high. The aim of this work is to analyse quality of main varieties of butter in Dakar market. Chemical methods were used to determine the characteristic of butter samples and gas chromatography was made to authentify their fatty acid profile. Our results have shown that most of analysed sample respected the standards of quality. In fact the composition of fatty acid and characteristic factors of authentic butter were certified by this study.

Meniscal substitutes--human experience

A number of clinical series have described the effect of meniscus allograft replacement in humans. The general indication has been disabling pain following loss of a meniscus in a skeletally mature individual. Overall, healing of the graft to the capsule occurs in up to 80% of all transplants. Revascularization and cell repopulation is found in all grafts but is highly variable. The risk for graft failure seems to be greater with irradiated grafts and in patients with grade III or IV osteoarthritic changes. In most series, patients experienced a decrease in pain and an increase in activity level postoperatively. In many series, concominant surgery (cruciate ligament reconstruction or osteotomy) had been performed. Meniscus replacement with frozen or cryopreserved allografts seems to give the most promising short-term results in patients with post-meniscectomy pain. Controlled, randomized prospective studies are needed to confirm a long-term benefit and better define transplantation indications. Viable meniscus allografts seem to survive transplantation, as donor cells were found in the graft after 2 years. Clinically, pain was reduced and activity increased following transplantation, but after 4 years some of these gains were lost. There was no correlation between postoperative findings on MRI and clinical outcome. Meniscal replacement with a quadriceps tendon autograft in humans resulted in pain reduction, but at second-look arthroscopy, only 2 of 9 tendon autografts looked like a meniscus. Six were in position but still looked like tendons. Total medial meniscus replacement by quadriceps tendon autrograft is still an experimental procedure. There is no proof at present that meniscal substitutes (meniscus allografts or tendon autografts) in humans can protect the hyaline cartilage of the knee from the degeneration, following loss of a meniscus. There is some evidence in animal experiments that under circumstances not yet exactly known, a meniscus substitute can have a protective effect on articular cartilage. Three factors have been identified that prevent proper meniscal function: poor fixation of the meniscal horns, no contact of the graft with the articulating surfaces under load and incorrect positioning of the horns. Meniscal allograft transplantation sensitizes humoral and cell mediated immune systems. Bone plugs attached to meniscal allograft tissue may increase cell surface antigenicity. Deep freezing and especially freeze drying of meniscal tissue decreases host immunogenicity. Cryopreservation maintains the content of donor HLA encoded antigens and is likely more sensitizing to the host. The clinical importance of immune responses to meniscal allografts is not known, but it has not been shown to result in graft failure or rejection. Prospective studies are needed.

Vascularized fibular grafting compared with core decompression in the treatment of femoral head osteonecrosis

A prospective study was undertaken to compare vascularized fibular grafting (VFG) with core decompression for Ficat Grade II and III femoral head osteonecrosis. The study group included 39 hips in 34 patients-20 VFGs and 19 core decompressions. Independent evaluation of results was performed by an orthopedic surgeon and a radiologist at a minimum of 2 years postoperatively (range: 2 to 5 years). Disease extent was assessed by Ficat radiographic gradings. VFGs failed (conversion to total hip arthroplasty for functionally incapacitating pain) at a rate of 20%, significantly lower than the 58% failure rate of core decompressions (P = .025). Complications included 2 proximal femur fractures in each group, ankle pain in 6 VFGs, and graft vessel thrombosis in 1 VFG. Vascularized fibular grafting appears superior to core decompression in prolonging hip joint survivorship for Ficat Grades II and III femoral head osteonecrosis.

Purification and some properties of the histidyl-tRNA synthetase from the cytosol of rabbit reticulocytes

The histidyl-tRNA synthetase of rabbit reticulocyte cytosol has been purified 84 000-fold to apparent homogeneity with a specific activity of 687 nmol of histidyl-tRNA formed per min per mg of protein. Ten to 15% of the enzyme activity is sedimented with the ribosomes while the remainder is in the cytosol. The purified enzyme has a molecular weight of 122 000 as determined by sucrose density gradient centrifugation. Gel electrophoresis in the presence of 0.1% sodium dodecyl sulfate suggests that it is composed of two similar subunits with a molecular weight of approximately 64 000. The enzyme has a magnesium optimum of 45 mM; however, this is reduced to 5 mM in the presence of an intracellular potassium concentration (160 nM). The enzyme acylates the two histidine tRNA isoacceptors of rabbit reticulocytes with similar Km values and at similar rates.

Carbohydrate metabolism during ascospore development in yeast

Carbohydrate metabolism, under sporulation conditions, was compared in sporulating and non-sporulating diploids of Saccharomyces cerevisiae. Total carbohydrate was fractionated into trehalose, glycogen, mannan, and an alkali-insoluble fraction composed of glucan and insoluble glycogen. The behavior of three fractions was essentially the same in both sporulating and non-sporulating strains; trehalose, mannan, and the insoluble fraction were all synthesized to about the same extent regardless of a strain's ability to undergo meiosis or sporulation. In contrast, aspects of soluble glycogen metabolism depended on sporulation. Although glycogen synthesis took place in both sporulating and non-sporulating strains, only sporulating strains exhibited a period of glycogen degradation, which coincided with the final maturation of ascospores. We also determined the carbohydrate composition of spores isolated from mature asci. Spores contained all components present in vegetative cells, but in different proportions. In cells, the most abundant carbohydrate was mannan, followed by glycogen, then trehalose, and finally the alkali-insoluble fraction; in spores, trehalose was most abundant, followed by the alkali-insoluble fraction, glycogen, and mannan in that order.