Hoppe Jason A, McStay Christopher, Sun Benjamin C, Capp Roberta
University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado.
Oregon Health and Science University, Department of Emergency Medicine, Portland, Oregon.
West J Emerg Med. 2017 Oct;18(6):1135-1142. doi: 10.5811/westjem.2017.7.33306. Epub 2017 Sep 18.
Despite treatment guidelines suggesting alternatives, as well as evidence of a lack of benefit and evidence of poor long-term outcomes, opioid analgesics are commonly prescribed for back pain from the emergency department (ED). Variability in opioid prescribing suggests a lack of consensus and an opportunity to standardize and improve care. We evaluated the variation in attending emergency physician (EP) opioid prescribing for patients with uncomplicated, low acuity back pain (LABP).
This retrospective study evaluated the provider-specific proportion of LABP patients discharged from an urban academic ED over a seven-month period with a prescription for opioids. LABP was strictly defined as (1) back pain chief complaint, (2) discharged from ED with no interventions, and (3) predefined discharge diagnosis of back pain. We excluded providers if they had less than 25 LABP patients in the study period. The primary outcome was the physician-specific proportion of LABP patients discharged with an opioid analgesic prescription. We performed a descriptive analysis and then risk standardized prescribing proportion by adjusting for patient and clinical characteristics using hierarchical logistic regression.
During the seven-month study period, 23 EPs treated and discharged at least 25 LABP patients and were included. Eight (34.8%) were female, and six (26.1%) were junior attendings (≤ 5 years after residency graduation). There were 943 LABP patients included in the analysis. Provider-specific proportions ranged from 3.7% to 88.1% (mean 58.4% [SD +/- 22.2]), and we found a 22-fold variation in prescribing proportions. There was a six-fold variation in the adjusted, risk-standardized prescribing proportion with a range from 12.0% to 78.2% [mean 50.4% (SD +/-16.4)].
We found large variability in opioid prescribing practices for LABP that persisted after adjustment for patient and clinical characteristics. Our findings support the need to further standardize and improve adherence to treatment guidelines and evidence suggesting alternatives to opioids.
尽管治疗指南推荐了其他替代方法，且有证据表明使用阿片类镇痛药并无益处，长期效果不佳，但急诊科（ED）仍普遍为背痛患者开具此类药物。阿片类药物处方的差异表明缺乏共识，也意味着有机会规范和改善治疗。我们评估了急诊医生为单纯性、低 acuity 背痛（LABP）患者开具阿片类药物的差异。
这项回顾性研究评估了在七个月期间从城市学术急诊科出院的 LABP 患者中，由特定医生开具阿片类药物处方的比例。LABP 被严格定义为：（1）以背痛为主诉；（2）未经干预从急诊科出院；（3）预定义的背痛出院诊断。如果在研究期间某医生的 LABP 患者少于 25 例，则将其排除。主要结局是 LABP 患者出院时开具阿片类镇痛药处方的医生特定比例。我们进行了描述性分析，然后通过分层逻辑回归调整患者和临床特征，对处方比例进行风险标准化。
在七个月的研究期间，23 名急诊医生治疗并出院了至少 25 例 LABP 患者并被纳入研究。其中八名（34.8%）为女性，六名（26.1%）为初级主治医师（住院医师毕业后≤5 年）。分析共纳入 943 例 LABP 患者。医生特定比例范围为 3.7%至 88.1%（平均 58.4% [标准差±22.2]），我们发现处方比例存在 22 倍的差异。调整后的风险标准化处方比例差异为六倍，范围为 12.0%至 78.2% [平均 50.4%（标准差±16.4）]。
我们发现 LABP 的阿片类药物处方实践存在很大差异，在调整患者和临床特征后这种差异仍然存在。我们的研究结果支持进一步规范和提高对治疗指南的依从性以及采用阿片类药物替代方法的必要性。
