Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project
Abstract Background Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-lev...
| Main Authors: | , , , , , , , , , |
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| Format: | Article |
| Language: | English |
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BMC
2020-11-01
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| Series: | BMC Family Practice |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s12875-020-01320-9 |
| _version_ | 1828310194882347008 |
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| author | Aleksandra E. Zgierska James M. Robinson Robert P. Lennon Paul D. Smith Kate Nisbet Mary W. Ales Deanne Boss Wen-Jan Tuan Regina M. Vidaver David L. Hahn |
| author_facet | Aleksandra E. Zgierska James M. Robinson Robert P. Lennon Paul D. Smith Kate Nisbet Mary W. Ales Deanne Boss Wen-Jan Tuan Regina M. Vidaver David L. Hahn |
| author_sort | Aleksandra E. Zgierska |
| collection | DOAJ |
| description | Abstract Background Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations. Methods Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4–6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The QI participants were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse risk screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90 mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p < 0.05, 95% confidence intervals and/or Cohen’s d. Results Two-hundred-fifteen QI participants, a subset of clinical staff, received at least one QI component; 1255 patients in the QI and 1632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more QI than comparison clinic patients were screened for depression (8.1% vs 1.1%, p = 0.019) and prescribed ≥90 mg/day MED (23.0% vs 15.5%, p = 0.038). The stepped-wedge analysis did not show statistically significant changes in outcomes in the QI clinics, when accounting for the comparison clinics’ trends. The Cohen’s d values favored the QI clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90 mg/day MED in the QI compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p = 0.02), but not other outcomes (p ≥ 0.05). Conclusions Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, if broadly implemented. Trial registration Not applicable. |
| first_indexed | 2024-04-13T15:40:44Z |
| format | Article |
| id | doaj.art-6460080dc2ed41db860b6a7a3a28f4f2 |
| institution | Directory Open Access Journal |
| issn | 1471-2296 |
| language | English |
| last_indexed | 2024-04-13T15:40:44Z |
| publishDate | 2020-11-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Family Practice |
| spelling | doaj.art-6460080dc2ed41db860b6a7a3a28f4f22022-12-22T02:41:09ZengBMCBMC Family Practice1471-22962020-11-0121111110.1186/s12875-020-01320-9Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement projectAleksandra E. Zgierska0James M. Robinson1Robert P. Lennon2Paul D. Smith3Kate Nisbet4Mary W. Ales5Deanne Boss6Wen-Jan Tuan7Regina M. Vidaver8David L. Hahn9Departments of Family and Community Medicine, Public Health Sciences, and Anesthesiology and Perioperative Medicine, Penn State College of MedicineCenter for Health Systems Research and Analysis, University of Wisconsin-MadisonDepartment of Family and Community Medicine, Penn State College of Medicine, 500 University DriveDepartment of Family Medicine and Community Health, Wisconsin Research and Education Network (WREN), University of Wisconsin-Madison, School of Medicine and Public HealthInterstate Postgraduate Medical AssociationInterstate Postgraduate Medical AssociationDepartment of Family Medicine and Community Health, Wisconsin Research and Education Network (WREN), University of Wisconsin-Madison, School of Medicine and Public HealthDepartment of Family Medicine and Community Health, University of Wisconsin-Madison, School of Medicine and Public HealthDepartment of Family Medicine and Community Health, Wisconsin Research and Education Network (WREN), University of Wisconsin-Madison, School of Medicine and Public HealthDepartment of Family Medicine and Community Health, Wisconsin Research and Education Network (WREN), University of Wisconsin-Madison, School of Medicine and Public HealthAbstract Background Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations. Methods Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4–6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The QI participants were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse risk screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90 mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p < 0.05, 95% confidence intervals and/or Cohen’s d. Results Two-hundred-fifteen QI participants, a subset of clinical staff, received at least one QI component; 1255 patients in the QI and 1632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more QI than comparison clinic patients were screened for depression (8.1% vs 1.1%, p = 0.019) and prescribed ≥90 mg/day MED (23.0% vs 15.5%, p = 0.038). The stepped-wedge analysis did not show statistically significant changes in outcomes in the QI clinics, when accounting for the comparison clinics’ trends. The Cohen’s d values favored the QI clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90 mg/day MED in the QI compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p = 0.02), but not other outcomes (p ≥ 0.05). Conclusions Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, if broadly implemented. Trial registration Not applicable.https://doi.org/10.1186/s12875-020-01320-9Quality improvementPrimary careChronic painHealth care deliveryPhysician behaviorOpioids |
| spellingShingle | Aleksandra E. Zgierska James M. Robinson Robert P. Lennon Paul D. Smith Kate Nisbet Mary W. Ales Deanne Boss Wen-Jan Tuan Regina M. Vidaver David L. Hahn Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project BMC Family Practice Quality improvement Primary care Chronic pain Health care delivery Physician behavior Opioids |
| title | Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project |
| title_full | Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project |
| title_fullStr | Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project |
| title_full_unstemmed | Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project |
| title_short | Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project |
| title_sort | increasing system wide implementation of opioid prescribing guidelines in primary care findings from a non randomized stepped wedge quality improvement project |
| topic | Quality improvement Primary care Chronic pain Health care delivery Physician behavior Opioids |
| url | https://doi.org/10.1186/s12875-020-01320-9 |
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