Leeds Institute of Health Science, University of Leeds, Leeds, United Kingdom.
Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, United Kingdom.
PLoS Med. 2021 Oct 4;18(10):e1003796. doi: 10.1371/journal.pmed.1003796. eCollection 2021 Oct.
The rise in opioid prescribing in primary care represents a significant international public health challenge, associated with increased psychosocial problems, hospitalisations, and mortality. We evaluated the effects of a comparative feedback intervention with persuasive messaging and action planning on opioid prescribing in primary care.
A quasi-experimental controlled interrupted time series analysis used anonymised, aggregated practice data from electronic health records and prescribing data from publicly available sources. The study included 316 intervention and 130 control primary care practices in the Yorkshire and Humber region, UK, serving 2.2 million and 1 million residents, respectively. We observed the number of adult patients prescribed opioid medication by practice between July 2013 and December 2017. We excluded adults with coded cancer or drug dependency. The intervention, the Campaign to Reduce Opioid Prescribing (CROP), entailed bimonthly, comparative, and practice-individualised feedback reports to practices, with persuasive messaging and suggested actions over 1 year. Outcomes comprised the number of adults per 1,000 adults per month prescribed any opioid (main outcome), prescribed strong opioids, prescribed opioids in high-risk groups, prescribed other analgesics, and referred to musculoskeletal services. The number of adults prescribed any opioid rose pre-intervention in both intervention and control practices, by 0.18 (95% CI 0.11, 0.25) and 0.36 (95% CI 0.27, 0.46) per 1,000 adults per month, respectively. During the intervention period, prescribing per 1,000 adults fell in intervention practices (change -0.11; 95% CI -0.30, -0.08) and continued rising in control practices (change 0.54; 95% CI 0.29, 0.78), with a difference of -0.65 per 1,000 patients (95% CI -0.96, -0.34), corresponding to 15,000 fewer patients prescribed opioids. These trends continued post-intervention, although at slower rates. Prescribing of strong opioids, total opioid prescriptions, and prescribing in high-risk patient groups also generally fell. Prescribing of other analgesics fell whilst musculoskeletal referrals did not rise. Effects were attenuated after feedback ceased. Study limitations include being limited to 1 region in the UK, possible coding errors in routine data, being unable to fully account for concurrent interventions, and uncertainties over how general practices actually used the feedback reports and whether reductions in prescribing were always clinically appropriate.
Repeated comparative feedback offers a promising and relatively efficient population-level approach to reduce opioid prescribing in primary care, including prescribing of strong opioids and prescribing in high-risk patient groups. Such feedback may also prompt clinicians to reconsider prescribing other medicines associated with chronic pain, without causing a rise in referrals to musculoskeletal clinics. Feedback may need to be sustained for maximum effect.
初级保健中阿片类药物处方的增加是一个重大的国际公共卫生挑战，这与心理社会问题、住院和死亡率的增加有关。我们评估了具有说服力的信息和行动计划的比较反馈干预对初级保健中阿片类药物处方的影响。
使用匿名的、汇总的电子健康记录实践数据和公开来源的处方数据，进行了一项准实验对照中断时间序列分析。该研究包括英国约克郡和亨伯地区的 316 个干预和 130 个对照初级保健实践，分别为 220 万和 100 万居民提供服务。我们观察了每个实践中成年患者每月处方阿片类药物的数量。我们排除了有编码癌症或药物依赖的成年人。该干预措施是减少阿片类药物处方运动（CROP），包括每两个月向实践提供一次比较和个性化的反馈报告，为期 1 年，提供有说服力的信息和建议的行动。结果包括每个月每 1000 名成年人中开任何阿片类药物的成年人数量（主要结果）、开强阿片类药物、在高风险人群中开阿片类药物、开其他镇痛药和转诊到肌肉骨骼服务。在干预前，干预和对照实践中每个月每 1000 名成年人中开任何阿片类药物的人数都有所增加，分别增加了 0.18（95%CI 0.11，0.25）和 0.36（95%CI 0.27，0.46）。在干预期间，干预实践中每 1000 名成年人的处方量下降（变化-0.11；95%CI-0.30，-0.08），而对照实践中继续上升（变化 0.54；95%CI 0.29，0.78），差异为-0.65 每 1000 名患者（95%CI-0.96，-0.34），相当于减少了 15000 名患者开阿片类药物。这些趋势在干预后仍在继续，但速度较慢。强阿片类药物、总阿片类药物处方和高风险患者群体中的处方也普遍下降。其他镇痛药的处方减少，而肌肉骨骼转介并未增加。反馈停止后，效果减弱。研究的局限性包括仅限于英国的 1 个地区、常规数据中可能存在的编码错误、无法充分考虑同期干预措施以及如何实际使用反馈报告以及减少处方是否始终符合临床需要。
反复比较反馈提供了一种有前途且相对有效的人群水平方法，可以减少初级保健中的阿片类药物处方，包括开具强阿片类药物和开具高风险患者群体的处方。这种反馈还可能促使临床医生重新考虑开其他与慢性疼痛相关的药物，而不会导致肌肉骨骼诊所的转介增加。为了达到最大效果，反馈可能需要持续。
