Clinical Effectiveness of Decision Support for Prescribing Opioids for Chronic Noncancer Pain: A Prospective Cohort Study
Clinical Effectiveness of Decision Support for Prescribing Opioids for Chronic Noncancer Pain: A Prospective Cohort Study
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DOI：
10.1016/j.jval.2019.09.2748
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发表时间：
2020-02-01
期刊：
影响因子：
4.5
通讯作者：
Bazzano, Lydia
中科院分区：
文献类型：
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作者：
Price-Haywood, Eboni G.;Burton, Jeffrey;Bazzano, Lydia
目的：这项前瞻性队列研究考察了电子病历临床决策支持(EMR CDS)对阿片类药物处方的临床有效性。方法：数据分析包括2017年1月至2018年10月路易斯安那州综合医疗服务系统中因非癌症疼痛而接受慢性阿片类药物治疗的初级保健患者。EMR CDS纳入了一个阿片类药物健康维护工具，以显示风险缓解的状态，药物订单中嵌入了吗啡当量日剂量(Medd)计算器和路易斯安那州药房药物监测计划的超级链接。结果：在14221名患者中，9%的患者开过处方，平均药物用量为90 mg。EMR CDS实施后MED无明显变化。年龄增加、Charlson共病指数评分、女性、非西班牙裔黑人、非阿片类止痛药联合处方和专科转诊与Medd&>=90(大剂量阈值)的几率较低相关。医疗保险或自付、药物滥用史和疼痛协议与超过这一高剂量阈值的处方几率增加有关。合并EMR CDS后，患者的尿药筛查率(17%比7%)和纳洛酮处方率(3%比1%，均P<；.001)更高。此外，在干预后期间，转诊到物理或职业治疗、矫形外科、神经病学、精神病学或心理学的专业转诊增加。尽管急诊科使用率下降(比率比0.92；95%可信区间0.89-0.95)，住院率没有变化。结论：EMR CDS提高了对阿片类药物风险缓解策略的遵从性。需要进一步研究哪些实践重新设计干预措施能有效减少大剂量阿片类药物处方。
Objectives: This prospective cohort study examines the clinical effectiveness of electronic medical record clinical decision support (EMR CDS) for opioid prescribing.Methods: Data analysis included primary care patients with chronic opioid therapy for noncancer pain seen within an integrated health delivery system in Louisiana between January 2017 and October 2018. EMR CDS incorporated an opioid health maintenance tool to display the status of risk mitigation, and the medication order embedded the morphine equivalent daily dose (MEDD) calculator and a hyperlink to the Louisiana pharmacy drug monitoring program. Outcome measures included change in the average MEDD and rates of opioid risk mitigation, hospitalization, and emergency department use.Results: Among 14 221 patients, 9% had prescriptions with an average MEDD >= 90 mg. There were no significant changes in MEDD after EMR CDS implementation. Increasing age, Charlson Comorbidity Index score, female sex, black non-Hispanic race, non-opioid pain medication co-prescriptions, and specialty referrals were associated with a lower odds of MEDD >= 90 (high-dose threshold). Medicare or self-pay, substance abuse history, and pain agreements were associated with increased odds of prescribing above this high-dose threshold. After incorporation of EMR CDS, patients had higher rates of urine drug screens (17% vs 7%) and naloxone prescriptions (3% vs 1%, all P < .001). In addition, specialty referrals to physical or occupational therapy, orthopedics, neurology, and psychiatry or psychology increased in the postintervention period. Although emergency department use decreased (rate ratio 0.92; 95% confidence interval 0.89-0.95), hospitalization rates did not change.Conclusions: EMR CDS improved adherence to opioid risk mitigation strategies. Further research examining which practice redesign interventions effectively reduce high-dose opioid prescribing is needed.