Department of Emergency Medicine, University of California, San Francisco.
Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, California.
JAMA Intern Med. 2020 Apr 1;180(4):487-493. doi: 10.1001/jamainternmed.2019.6544.
Prescription opioids play a significant role in the ongoing opioid crisis. Guidelines and physician education have had mixed success in curbing opioid prescriptions, highlighting the need for other tools that can change prescriber behavior, including nudges based in behavioral economics.
To determine whether and to what extent changes in the default settings in the electronic medical record (EMR) are associated with opioid prescriptions for patients discharged from emergency departments (EDs).
DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study randomly altered, during a series of five 4-week blocks, the prepopulated dispense quantities of discharge prescriptions for commonly prescribed opioids at 2 large, urban EDs. These changes were made without announcement, and prescribers were not informed of the study itself. Participants included all health care professionals (physicians, nurse practitioners, and physician assistants) working clinically in either of the 2 EDs. Data were collected from November 28, 2016, through July 9, 2017, and analyzed from July 16, 2017, through May 14, 2018.
Default quantities for opioids were changed from status quo quantities of 12 and 20 tablets to null, 5, 10, and 15 tablets according to a block randomization scheme. Regardless of the default quantity, each health care professional decided for whom to prescribe opioids and could modify the quantity prescribed without restriction.
The primary outcome was the number of tablets of opioid-containing medications prescribed under each default setting.
A total of 104 health care professionals wrote 4320 prescriptions for opioids during the study period. Using linear regression, an increase of 0.19 tablets prescribed (95% CI, 0.15-0.22) was found for each tablet increase in default quantity. When evaluating each of the 15 pairwise comparisons of default quantities (eg, 5 vs 15 tablets), a lower default was associated with a lower number of pills prescribed in more than half (8 of the 15) of the pairwise comparisons; there was a higher quantity in 1 and no difference in 6 comparisons.
These findings suggest that default settings in the EMR may influence the quantity of opioids prescribed by health care professionals. This low-cost, easily implementable, EMR-based intervention could have far-reaching implications for opioid prescribing and could be used as a tool to help combat the opioid epidemic.
ClinicalTrials.gov identifier: NCT04155229.
处方类阿片药物在持续的阿片类药物危机中发挥着重要作用。指南和医生教育在抑制阿片类药物处方方面取得了喜忧参半的效果，这凸显了需要其他能够改变处方医生行为的工具，包括基于行为经济学的“助推”。
确定电子病历（EMR）中的默认设置的更改是否以及在何种程度上与从急诊科（ED）出院的患者的阿片类药物处方有关。
设计、设置和参与者：这项质量改进研究在两个大型城市 ED 的常用阿片类药物的出院处方预填充分发数量方面，连续五个四周的阶段随机改变了默认设置。这些更改是在没有公告的情况下进行的，并且没有向开处方者告知研究本身。参与者包括在这 2 个 ED 中临床工作的所有医疗保健专业人员（医生、护士从业者和医师助理）。数据收集于 2016 年 11 月 28 日至 2017 年 7 月 9 日，并于 2017 年 7 月 16 日至 2018 年 5 月 14 日进行分析。
根据一个区块随机化方案，将阿片类药物的默认数量从 12 片和 20 片更改为 0、5、10 和 15 片。无论默认数量如何，每位医疗保健专业人员都可以决定为谁开阿片类药物处方，并可以不受限制地修改所开处方的数量。
主要结果是在每个默认设置下开出的含有阿片类药物的药物的片数。
在研究期间，共有 104 名医疗保健专业人员开出了 4320 份阿片类药物处方。使用线性回归，发现默认数量每增加 1 片，开出的处方数量就增加 0.19 片（95%CI，0.15-0.22）。当评估默认数量的 15 对比较中的每一对（例如，5 与 15 片）时，在超过一半（15 对中的 8 对）的比较中，较低的默认值与开出的药丸数量较少相关;在 1 对中较高，在 6 对中没有差异。
这些发现表明，EMR 中的默认设置可能会影响医疗保健专业人员开出的阿片类药物数量。这种低成本、易于实施的基于 EMR 的干预措施可能对阿片类药物处方产生深远影响，并可用作帮助对抗阿片类药物流行的工具。
ClinicalTrials.gov 标识符：NCT04155229。
