Division of General Medicine and Geriatrics, Stony Brook University Hospital, Stony Brook, New York, USA.
Pain Med. 2019 Oct 1;20(10):1919-1924. doi: 10.1093/pm/pny239.
Objective Chronic pain and opioid management are challenging in primary care, especially for trainees with discontinuous ambulatory schedules and less practice experience. The study objective was to improve adherence to quality metrics and office visit utilization in a resident clinic. Design Before-after quality improvement intervention over two Plan-Do-Study-Act cycles. Setting Suburban, university-affiliated Internal Medicine resident clinic. Methods During the 2015-2017 academic years, two sequential interventions were implemented: 1) use of electronic pain and opioid management templates and workflow redesign routing opioid renewals through a registered nurse (RN); 2) RN previsit planning and daily nurse-physician huddles before patient visits. Outcomes included adherence to annual toxicology screening, risk assessment and opioid agreements, opioid dose prescribed, and office visit utilization. Results The template and workflow redesign intervention increased annual toxicology from 53% to 81% (P < 0.0015), annual opioid agreement from 13.8% to 53.5% (P < 0.0001), and risk assessment from 0% to 75.9% (P < 0.0001). Average daily morphine milligram equivalents (MME) decreased from 96.6 MME to 67.7 MME (P < 0.0001), and annual office visits decreased from 11.1 to 8.9 (P = 0.0004). Previsit planning and huddles did not show incremental increases in adherence to quality measures but did improve clinic utilization and maintained high levels of adherence to quality measures. Conclusions Quality improvement interventions can improve adherence to quality measures and clinic utilization. A critical role is served by midlevel nursing providers to provide continuity to patients and trainees. Teaching clinics need to develop sustainable systems of care to moderate quality assurance in opioid prescribing.
在初级保健中，慢性疼痛和阿片类药物管理具有挑战性，尤其是对于轮班时间不连续且实践经验较少的住院医师而言。本研究旨在提高居民诊所中遵循质量指标和就诊利用率。
在两个计划-执行-研究-行动循环中进行前后质量改进干预。
郊区，大学附属医院的内科住院医师诊所。
在 2015-2017 学年，实施了两项连续干预措施：1）使用电子疼痛和阿片类药物管理模板以及工作流程重新设计，将阿片类药物续药通过注册护士（RN）进行路由；2）RN 预诊前计划和每日护士-医师小组讨论，然后再进行患者就诊。结果包括年度毒理学筛查、风险评估和阿片类药物协议、阿片类药物处方剂量和就诊利用率的遵循情况。
模板和工作流程重新设计干预措施使年度毒理学筛查从 53％增加到 81％（P<0.0015），年度阿片类药物协议从 13.8％增加到 53.5％（P<0.0001），风险评估从 0％增加到 75.9％（P<0.0001）。平均每日吗啡毫克当量（MME）从 96.6 MME 减少到 67.7 MME（P<0.0001），年度就诊次数从 11.1 次减少到 8.9 次（P=0.0004）。预诊前计划和小组讨论并未显示出对质量指标遵循情况的额外增加，但确实改善了诊所利用率，并保持了对质量指标的高度遵循。
质量改进干预措施可以提高对质量指标的遵循率和就诊利用率。中级护理提供者在为患者和住院医师提供连续性方面发挥着重要作用。教学诊所需要制定可持续的护理系统，以适度控制阿片类药物处方的质量保证。
