Departments of Family and Community Medicine, Public Health Sciences, and Anesthesiology and Perioperative Medicine, Penn State College of Medicine, 500 University Drive, PA, 17033, Hershey, USA.
Center for Health Systems Research and Analysis, University of Wisconsin-Madison, 1109C WARF Building, 610 Walnut Street, Madison, WI, 53726, USA.
BMC Fam Pract. 2020 Nov 28;21(1):245. doi: 10.1186/s12875-020-01320-9.
Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of "opioid guidelines" is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of "routine" system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations.
Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4-6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The QI participants were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse risk screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90 mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p < 0.05, 95% confidence intervals and/or Cohen's d.
Two-hundred-fifteen QI participants, a subset of clinical staff, received at least one QI component; 1255 patients in the QI and 1632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more QI than comparison clinic patients were screened for depression (8.1% vs 1.1%, p = 0.019) and prescribed ≥90 mg/day MED (23.0% vs 15.5%, p = 0.038). The stepped-wedge analysis did not show statistically significant changes in outcomes in the QI clinics, when accounting for the comparison clinics' trends. The Cohen's d values favored the QI clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90 mg/day MED in the QI compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p = 0.02), but not other outcomes (p ≥ 0.05).
Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, if broadly implemented.
Not applicable.
临床医生使用实践指南可以减少慢性非癌症疼痛中不当的阿片类药物处方和伤害；然而，“阿片类药物指南”的实施情况并不理想。我们假设，多组分质量改进（QI）增强“常规”系统层面实施工作将提高临床医生对阿片类药物指南驱动的政策建议的依从性。
在 26 家初级保健诊所系统实施阿片类药物政策。在这项非随机阶梯式 QI 项目中，选择了 9 家诊所（一个小时的学术详细信息；2 个在线教育模块；4-6 个月每月一个小时的实践促进会议）接受 QI 增强。QI 参与者是志愿诊所工作人员。目标患者人群为长期服用阿片类药物治疗慢性非癌症疼痛的成年人。结果包括诊所层面符合当前治疗协议的目标患者比例（主要结果）、阿片类药物-苯二氮䓬类药物联合处方、尿液药物检测、抑郁和阿片类药物滥用风险筛查以及处方药物监测数据库检查的发生率；其他措施包括每日吗啡等效剂量（MED），以及所有目标患者和每天处方≥90mg/MED 的患者的百分比。T 检验、混合回归和阶梯式分析评估了 QI 的影响，用双侧 p<0.05、95%置信区间和/或 Cohen's d 评估显著性和效应大小。
215 名 QI 参与者，临床工作人员的一个子集，至少接受了一个 QI 组成部分；1255 名 QI 患者和 1632 名比较诊所的患者被开处长期阿片类药物。在基线时，与比较诊所患者相比，更多的 QI 患者接受了抑郁筛查（8.1%对 1.1%，p=0.019）和处方≥90mg/MED（23.0%对 15.5%，p=0.038）。在考虑比较诊所的趋势后，阶梯式分析并未显示 QI 诊所的结果有统计学意义的变化。除了阿片类药物-苯二氮䓬类药物联合处方外，Cohen's d 值均有利于 QI 诊所的所有结果。亚组分析显示，与比较诊所相比，在 QI 诊所中，处方≥90mg/MED 的患者尿液药物检测率提高（38.8%对 19.1%，p=0.02），但其他结果无变化（p≥0.05）。
为志愿诊所工作人员提供的有针对性的 QI 干预措施，增强了常规政策的实施，但并未进一步提高符合阿片类药物指南的诊所层面护理指标。然而，观察到的效应大小表明，如果广泛实施，这种方法可能是有效的，特别是对高风险患者。
不适用。
