Article Figures & Data
Figures
- Figure 1.
Evolution of a Quality Improvement (QI) toolkit for opioid prescribing practices.
- Figure 2.
Top 12 strategies selected by 27 ambulatory care clinics by trial period. Abbreviations: PDMP, prescription drug monitoring programs; Pt, Patient.
Tables
- Table 1.
Final Strategy Description List of 28 Strategies Organized by Category, Trial 3 (2018 to 2019)
Maintain Regulatory Compliance 1. Consider nonopioid alternatives, where possible 2. Provide patient education on benefits and risks, initiate treatment agreement, and obtain informed consent* 3. Conduct ongoing risk assessment, such as the Current Opioid Misuse Measure (COMM), and update plan regularly* 4. Assess patient function 5. Assess patient pain 6. Check Prescription Drug Monitoring Program* 7. Screen urine at least annually for presence/absence of substances (may screen randomly, depending on risk)* 8. Use best practices in prescribing: prescribe immediate release opioids, monitor closely any doses of greater than 50 or 90 MME/day, or concurrent dosing of benzodiazepines, and provide naloxone 9. Track dosage in MMEs, not only quantity prescribed 10. Short interval follow up after initiating new opioid treatment to review effect 11. Ongoing visits at least every 3 months* Improve Workflow/Streamline Care 12. Prescribe in multiples of 7 days in duration of dosage (eg, for 28 day, 56 days, … up to 84 days) to support consistent provider/patient relationships* 13. Prewrite prescriptions for up to 84 days when management is stable* 14. Use a flowsheet to document repeating strategies for opioid management* 15. Roster: Include patient in registry for population management reports* Provide Peer-to-Peer Support 16. Use a team-based care approach to opioid treatment* 17. Use strategies from the toolkit consistently, so that all patients receive care consistently across the clinic* 18. Convene clinic members in a “Pain Management Council” regularly to review and discuss complex patient needs* 19. Share skills that are widely useful; eg, how to have “trigger” conversations 20. Build community support with other partners/agencies Monitor and Respond to Patients who may be at Risk 21. Conduct an initial Risk Assessment* 22. Assess side effects (bowel habit, nausea, vomiting…) 23. Recognize special issues presented by patients for therapeutic conversations 24. Prescribe bubble packs if risk level increasing, depending on availability† 25. Conduct pill counts or random pill counts* 26. Create a tapering schedule with visits based on individual need 27. Identify resources that may be helpful and update periodically 28. Build a patient resource list or offer a library with books, CDs, etc. Intervention and Clinic Characteristics Trial 1, 2012 to 2013 (n = 10 clinics) Trial 2, 2014 to 2017 (n = 7) Trial 3, 2018 to 2019 (n = 10) Intervention Approach No Toolkit Expert Facilitation 1st and 2nd Editions For Facilitators 3rd Edition For PC Clinics Specialty PC, family medicine 6 3 1 PC, internal medicine 1 1 0 PC, combined specialties 2 0 9 Surgical specialist 1 1 0 Medical specialist 0 1 0 Dental care/oral surgery 0 1 0 Number of providers in clinics (range) 48 (2–11) 61 (5–15) 42 (2–11) Ownership Health system 5 5 3 Independent group or solo 3 1 1 FQHC 2 1 6 Primary Driver To Participate Champion in clinic came forward 6 5 6 Corporate decision to improve opioid prescribing 3 2 3 Medical practice board investigation 1 0 1 n, number of clinics in trial; PC, primary care; FQHC, Federally Qualified Health Center.
Team Process Measures Trial 1 (n = 10 clinics) Trial 2 (n = 7) Trial 3 (n = 10) Average # meetings (min, max) 6.0 (3, 10) 7.3 (2, 11)* n/a† Average # team hours (min, max) 9.1 (2, 12) 8.7 (2, 13)* n/a† Average # months from start to finish (min, max) 3.0 (1, 7) 7.7 (4, 15) n/a† Average # strategies selected (min, max) 8.9 (3, 13) 8.6 (1, 13) 3.7 (3, 10) # Strategies presented to each clinic to choose from 15 16 28 # Strategies related to regulatory compliance (%) 32 (36) 21 (35) 4 (11) # Strategies related to streamlining workflow (%) 28 (31) 19 (32) 2 (5) # Strategies related to providing peer support (%) 20 (22) 12 (20) 30 (81) # Strategies related to responding to patients at risk (%) 9 (10) 8 (13) 1 (3) - Table 4.
Pre- and Postproject Change in Provider and Staff Assessment of Opioid Prescribing for Trial 1 (2012 to 2013)
Team Outcome Measures* Pre project (%) Post project (%) P value Providers satisfied with opioid management 42 96 <.01 Staff satisfied with opioid management 54 81 .01 Clinic has clear policies on opioid prescription 58 80 <.01 Clinic has a roster of opioid patients 71 88 .02 Providers increased use of agreements 38 58 .03 Providers more confident in using agreements 62 85 .02 Providers more confident in drug testing 54 69 .04 Providers more confident in prescription database 69 88 .01 Providers more confident in prescribing Opioids 46 77 .01 ↵* Based on responses of “4-Agree” or “5-Strongly Agree” on a 5-point Likert scale.
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