University of California San Francisco, Department of Emergency Medicine, San Francisco, California.
West J Emerg Med. 2024 Jul;25(4):449-456. doi: 10.5811/westjem.18040.
The opioid epidemic is a major cause of morbidity and mortality in the United States. Prior work has shown that emergency department (ED) opioid prescribing can increase the incidence of opioid use disorder in a dose-dependent manner, and systemic changes that decrease default quantity of discharge opioid tablets in the electronic health record (EHR) can impact prescribing practices. However, ED leadership may be interested in the impact of communication around the intervention as well as whether the intervention may differentially impact different types of clinicians (physicians, physician assistants [PA], and nurse practitioners). We implemented and evaluated a quality improvement intervention of an announced decrease in EHR default quantities of commonly prescribed opioids at a large, academic, urban, tertiary-care ED.
We gathered EHR data on all ED discharges with opioid prescriptions from January 1, 2019-December 6, 2021, including chief complaint, clinician, and opioid prescription details. Data was captured and analyzed on a monthly basis throughout this time period. On March 29, 2021, we implemented an announced decrease in EHR default dispense quantities from 20 tablets to 12 tablets for commonly prescribed opioids. We measured pre- and post-intervention quantities of opioid tablets prescribed per discharge receiving opioids, distribution by patient demographics, and inter-clinician variability in prescribing behavior.
The EHR change was associated with a 14% decrease in quantity of opioid tablets per discharge receiving opioids, from 14 to 12 tablets ( = <.001). We found no statistically significant disparities in prescriptions based on self-reported patient race ( = 0.68) or gender ( = 0.65). Nurse practitioners and PAs prescribed more opioids per encounter than physicians on average and had a statistically significant decrease in opioid prescriptions associated with the EHR change. Physicians had a lesser but still significant drop in opioid prescribing in the post-intervention period.
Decreasing EHR defaults is a robust, simple tool for decreasing opioid prescriptions, with potential for implementation in the 42% of EDs nationwide that have defaults exceeding the recommended 12-tablet supply. Considering significant inter-clinician variability, future interventions to decrease opioid prescriptions should examine the effects of combining EHR default changes with targeted interventions for clinician groups or individual clinicians.
阿片类药物泛滥是美国发病率和死亡率的主要原因。先前的研究表明，急诊室（ED）阿片类药物的开具与阿片类药物使用障碍的发生率呈剂量依赖性相关，并且电子健康记录（EHR）中减少默认出院阿片类药物片数的系统变化可能会影响开具处方的行为。然而，ED 领导层可能会关注干预措施的沟通效果，以及该干预措施是否会对不同类型的临床医生（医生、医师助理（PA）和执业护士）产生不同的影响。我们在一家大型、学术性、城市性、三级保健 ED 实施并评估了一项关于宣布减少常用阿片类药物 EHR 默认剂量的质量改进干预措施。
我们收集了 2019 年 1 月 1 日至 2021 年 12 月 6 日期间所有开具阿片类药物处方的 ED 出院患者的 EHR 数据，包括主要投诉、临床医生和阿片类药物处方详情。在此期间，我们每月进行数据采集和分析。2021 年 3 月 29 日，我们宣布减少 EHR 中常用阿片类药物的默认配药量，从 20 片减至 12 片。我们测量了接受阿片类药物治疗的每位出院患者的阿片类药物片数，根据患者人口统计学分布，以及不同临床医生开具处方行为的差异。
EHR 变更与每位接受阿片类药物治疗的出院患者的阿片类药物片数减少 14%有关，从 14 片减至 12 片（ = <.001）。我们发现，根据自我报告的患者种族（ = 0.68）或性别（ = 0.65），处方没有统计学上的显著差异。护士和 PA 平均开具的阿片类药物处方比医生多，并且与 EHR 变更相关的阿片类药物处方数量有统计学显著下降。在干预后期间，医生的阿片类药物处方也明显减少，但仍有显著下降。
减少 EHR 默认值是减少阿片类药物处方的一种强大、简单的工具，在全国 42%的 ED 中都有实施的潜力，这些 ED 的默认值超过了推荐的 12 片供应量。考虑到临床医生之间存在显著的差异，未来减少阿片类药物处方的干预措施应该研究结合 EHR 默认值更改与针对临床医生群体或个别临床医生的针对性干预措施的效果。
