Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project

• Published in: BMC family practice Vol. 21; no. 1; p. 245
• Main Authors: Zgierska, Aleksandra E, Robinson, James M, Lennon, Robert P, Smith, Paul D, Nisbet, Kate, Ales, Mary W, Boss, Deanne, Tuan, Wen-Jan, Vidaver, Regina M, Hahn, David L
• Format: Journal Article
• Language: English
• Published: England BioMed Central Ltd 28-11-2020; BioMed Central; BMC
• Subjects: Analgesia; Chronic pain; Clinical practice guidelines; Clinics; Dosage and administration; Drug dosages; Drug therapy; Health care delivery; Health systems agencies; Intervention; Narcotics; Opioids; Pain; Patients; Physician behavior; Primary care; Primary health care; Quality control; Quality improvement; Questionnaires; Skin cancer; Therapeutic drug monitoring; United States; Quality improvement; Primary care; Physician behavior; Chronic pain; Health care delivery; Opioids
• ISSN: 1471-2296; 1471-2296
• 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.