Background
Implementing clinical guidelines in healthcare organizations
Opioid prescribing
The implementation strategy
Study aim
Methods
Developing the content of the implementation strategy
Implementation study design
Setting and ethics approval
Study participants
Consultation team
Clinics and change teams
Clinics | Intervention (n = 4) | Controls (n = 4) | Refused (n = 3) |
---|---|---|---|
Average number of prescribers (MD, PA, NP) | 8.5 | 3.3 | 6.7 |
Average number annual patients | 7489 | 3324 | 3271 |
% Female | 47.1 | 49.7 | 45.6 |
% Hispanic | 2.2 | 2.5 | 2.5 |
% Asian | 2.4 | 1.6 | 0.7 |
% Black | 2.4 | 2.3 | 0.7 |
% Native | 0.5 | 0.5 | 0.5 |
% Other | 11.9 | 12.2 | 11.5 |
% White | 82.8 | 83.6 | 86.7 |
Study procedures
Clinic recruitment and randomization
Implementation timeline
Outcome measures
Sources of qualitative data
Results
Through 6 months (Effectiveness) | Baseline value—control clinics | Slope of control clinics (95% CI) | p value (pre-post within control clinics) | Baseline value—intervention clinics | Slope of intervention clinics (95% CI) | p value (pre-post within intervention clinics) | Slope of intervention minus control (95% CI) | p value (difference between intervention—control groups) |
---|---|---|---|---|---|---|---|---|
Proportion of patients with consistent opioid Rx a | 0.014 | − 0.0001 (0.0000, − 0.00002) | 0.152 | 0.013 | − 0.0002 (− 0.0001, − 0.0003) | 0.011 | − 0.0001 (0.0000, − 0.0002) | 0.237 |
Proportion with mental health screen b | 0.220 | 0.029 (0.052, 0.006) | 0.020 | 0.226 | 0.058 (0.079, 0.038) | 0.009 | 0.029 (0.053, 0.005) | 0.024 |
Proportion with urine drug testing b | 0.374 | 0.011 (0.035, − 0.013) | 0.025 | 0.399 | 0.041 (0.061, 0.020) | 0.009 | 0.029 (0.050, 0.008) | 0.011 |
Proportion with treatment agreement b | 0.368 | 0.029 (0.050, 0.009) | 0.009 | 0.428 | 0.059 (0.080, 0.038) | 0.010 | 0.03 (0.051, 0.008) | 0.012 |
Average morphine- equivalent daily dose (MEDD) b | 58.8 | 0.245 (−2.08, 2.57) | 0.646 | 86.3 | −0.337 (1.07, −1.75) | 0.449 | −0.581 (0.75, − 1.92) | 0.425 |
Proportion with MEDD > 120 b | 0.137 | − 0.002 (− 0.001, − 0.004) | 0.249 | 0.215 | −0.004 (− 0.002, − 0.005) | 0.045 | −0.001 (0.003, − 0.006) | 0.624 |
Proportion with co-prescribed benzodiazepines b | 0.055 | 0.001 (− 0.006, 0.008) | 0.654 | 0.080 | − 0.001 (0.006, − 0.007) | 0.637 | − 0.002 (0.000, − 0.003) | 0.019 |
Through 12 months (Maintenance) | Estimated value—control clinics (6-month mark) | Slope of control clinics (95% CI) | p value (pre-post within control clinics) | Estimated value—intervention clinics (6-month mark) | Slope of intervention clinics (95% CI) | p value (pre-post within intervention clinics) | Slope of intervention minus control (95% CI) | p value (difference between intervention—control groups) |
---|---|---|---|---|---|---|---|---|
Proportion of patients with consistent opioid Rx a | 0.013 | − 0.0001 (0.0000, − 0.0002) | 0.007 | 0.012 | − 0.0001 (− 0.0001, − 0.0002) | 0.001 | 0.0000 (0.0001, − 0.0001) | 0.975 |
Proportion with mental health screen b | 0.394 | 0.016 (0.026, 0.006) | 0.002 | 0.574 | 0.033 (0.053, 0.014) | 0.001 | 0.017 (0.028, 0.006) | 0.003 |
Proportion with urine drug testing b | 0.440 | 0.012 (0.020, 0.005) | 0.001 | 0.645 | 0.018 (0.029, 0.006) | 0.002 | 0.005 (0.013, − 0.002) | 0.153 |
Proportion with treatment agreement b | 0.542 | 0.031 (0.048, 0.014) | 0.000 | 0.782 | 0.036 (0.056, 0.015) | 0.001 | 0.005 (0.012, − 0.002) | 0.146 |
Average morphine-equivalent daily dose (MEDD) b, c | 60.239 | 0.431 (0.909, − 0.048) | 0.078 | 84.278 | − 0.830 (− 0.264, − 1.396) | 0.004 | − 1.261 (− 0.425, − 2.097) | 0.003 |
Proportion with MEDD > 120 b, c | 0.125 | − 0.000 (0.002, − 0.002) | 0.942 | 0.191 | − 0.003 (− 0.001, − 0.005) | 0.004 | −0.003 (− 0.001, − 0.006) | 0.018 |
Proportion with co-prescribed benzodiazepines b | 0.061 | 0.001 (0.002, − 0.001) | 0.291 | 0.074 | 0.002 (0.004, − 0.001) | 0.136 | 0.001 (0.003, − 0.001) | 0.353 |
Reach
Effectiveness
Adoption
Intervention clinic | Members | Composition | Attendance at intervention meetings |
---|---|---|---|
Team 1 | 6 | MD, NP, RN, LPN, Lab, COM | 81% |
Team 2 | 7 | MD (2), RN, MA (3), Reception | 88% |
Team 3 | 8 | MD (2), RN, MA (2), Reception, Lab, COA | 69% |
Team 4 | 6 | MD, RN, LPN (2), Reception, COM | 92% |
Question | Strongly agree (%) | Agree (%) | Neutral (%) | Disagree (%) | Strongly disagree (%) |
---|---|---|---|---|---|
I have a better understanding of the benefits and risks of long-term opioid prescribing for chronic pain | 50 | 27 | 18 | 5 | 0 |
I am more familiar with current literature regarding evidence-based guidelines for long-term opioid prescribing for chronic pain | 50 | 32 | 18 | 0 | 0 |
My clinic’s workflows related to opioid prescribing are easier | 48 | 35 | 17 | 0 | 0 |
I utilize screening processes for mental health and substance abuse issues with patients who are prescribed long-term opioids for chronic pain more often | 39 | 26 | 35 | 0 | 0 |
I utilize treatment agreements with patients who are prescribed long-term opioids for chronic pain more often | 36 | 27 | 36 | 0 | 0 |
I utilize urine drug testing as a precautionary measure with more patients who are prescribed long-term opioids for chronic pain | 32 | 36 | 32 | 0 | 0 |
I have more discussions with my colleagues regarding opioid prescribing for chronic pain | 48 | 39 | 9 | 4 | 0 |
I feel more able to meet the recommendations of the ongoing UWHealth initiative related to opioid prescribing | 58 | 38 | 4 | 0 | 0 |
Implementation
Maintenance
Qualitative results
Intervention element | Key adaptations |
---|---|
Clinic recruitment | Reach out to clinic directors personally (not by email) and hold recruitment meetings in person (not by conference call). Request presence of prescribers and clinic leadership at recruitment meeting. Bring food to recruitment meeting. |
Change team composition and responsibilities | Seek representation from all occupational groups and work teams affected by the intervention. Encourage participation of influential prescriber(s). Encourage change team to institute regular communication with clinic staff who are not part of the change team. Facilitate understanding of roles and responsibilities for change team members individually and collectively. |
Consulting roles and responsibilities | Split consulting roles and responsibilities between a clinical expert (physician consultant) and a facilitator. Be sure that physician consultants and study facilitators are consistent in their communications to the clinic change team. Train consultants to assess clinic needs and provide tailored assistance. Clarify upfront the nature and extent of consultants’ services (e.g., not available for direct patient care). Provide explicit instruction in the purpose and use of consulting tools. Be flexible about tool use. Facilitate access to an electronic health records expert. Schedule meetings at lunchtime and provide meals. Plan and communicate agendas for meetings Support intra- and inter-clinic knowledge sharing. Leverage opportunities created by organizational policy. Recognize and make use of similarities between new opioid prescribing practices and chronic disease management protocols already in place. |