Burton John H, Hoppe Jason A, Echternach Jeff M, Rodgers Justin M, Donato Michael
Carilion Clinic, Department of Emergency Medicine, Roanoke, Virginia.
University of Colorado Denver School of Medicine, Department of Emergency Medicine, Aurora, Colorado; Rocky Mountain Poison and Drug Center, Denver, Colorado.
West J Emerg Med. 2016 May;17(3):258-63. doi: 10.5811/westjem.2016.3.29692. Epub 2016 May 2.
Addressing pain is a crucial aspect of emergency medicine. Prescription opioids are commonly prescribed for moderate to severe pain in the emergency department (ED); unfortunately, prescribing practices are variable. High variability of opioid prescribing decisions suggests a lack of consensus and an opportunity to improve care. This quality improvement (QI) initiative aimed to reduce variability in ED opioid analgesic prescribing.
We evaluated the impact of a three-part QI initiative on ED opioid prescribing by physicians at seven sites. Stage 1: Retrospective baseline period (nine months). Stage 2: Physicians were informed that opioid prescribing information would be prospectively collected and feedback on their prescribing and that of the group would be shared at the end of the stage (three months). Stage 3: After physicians received their individual opioid prescribing data with blinded comparison to the group means (from Stage 2) they were informed that individual prescribing data would be unblinded and shared with the group after three months. The primary outcome was variability of the standard error of the mean and standard deviation of the opioid prescribing rate (defined as number of patients discharged with an opioid divided by total number of discharges for each provider). Secondary observations included mean quantity of pills per opioid prescription, and overall frequency of opioid prescribing.
The study group included 47 physicians with 149,884 ED patient encounters. The variability in prescribing decreased through each stage of the initiative as represented by the distributions for the opioid prescribing rate: Stage 1 mean 20%; Stage 2 mean 13% (46% reduction, p<0.01), and Stage 3 mean 8% (60% reduction, p<0.01). The mean quantity of pills prescribed per prescription was 16 pills in Stage 1, 14 pills in Stage 2 (18% reduction, p<0.01), and 13 pills in Stage 3 (18% reduction, p<0.01). The group mean prescribing rate also decreased through each stage: 20% in Stage 1, 13% in Stage 2 (46% reduction, p<0.01), and 8% in Stage 3 (60% reduction, p<0.01).
ED physician opioid prescribing variability can be decreased through the systematic application of sharing of peer prescribing rates and prescriber specific normative feedback.
处理疼痛是急诊医学的一个关键方面。在急诊科（ED），处方阿片类药物通常用于治疗中度至重度疼痛；不幸的是，处方做法存在差异。阿片类药物处方决策的高度变异性表明缺乏共识，也存在改善护理的机会。这项质量改进（QI）举措旨在减少急诊科阿片类镇痛药物处方的变异性。
我们评估了一项分为三个部分的QI举措对七个地点的急诊科医生阿片类药物处方的影响。第1阶段：回顾性基线期（九个月）。第2阶段：告知医生将前瞻性收集阿片类药物处方信息，并在阶段结束时（三个月）分享他们以及该组的处方反馈。第3阶段：在医生收到他们的个人阿片类药物处方数据并与组均值（来自第2阶段）进行盲法比较后，告知他们个人处方数据将在三个月后解除盲法并与组内分享。主要结果是阿片类药物处方率的均值标准误差和标准差的变异性（定义为开具阿片类药物出院的患者数量除以每个提供者的总出院人数）。次要观察指标包括每张阿片类药物处方的平均药丸数量以及阿片类药物处方的总体频率。
研究组包括47名医生，涉及149,884次急诊科患者就诊。如阿片类药物处方率的分布所示，在举措的每个阶段，处方的变异性都有所降低：第1阶段均值为20%；第2阶段均值为13%（降低46%，p<0.01），第3阶段均值为8%（降低60%，p<0.01）。每张处方开具的药丸平均数量在第1阶段为16粒，第2阶段为14粒（降低18%，p<0.01），第3阶段为13粒（降低18%，p<0.01）。组平均处方率在每个阶段也有所下降：第1阶段为20%，第2阶段为13%（降低46%，p<0.01），第3阶段为8%（降低60%，p<0.01）。
通过系统地应用分享同行处方率和针对开处方者的特定规范反馈，可以降低急诊科医生阿片类药物处方的变异性。
