Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care: A Cluster-Randomized Clinical Trial.
Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care: A Cluster-Randomized Clinical Trial.
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DOI：
10.1001/jamainternmed.2017.2468
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发表时间：
2017-09-01
影响因子：
39
通讯作者：
Lasser KE
中科院分区：
文献类型：
--
作者：
Liebschutz JM;Xuan Z;Shanahan CW;LaRochelle M;Keosaian J;Beers D;Guara G;O'Connor K;Alford DP;Parker V;Weiss RD;Samet JH;Crosson J;Cushman PA;Lasser KE
处方阿片类药物滥用是一个国家危机。很少有干预措施提高了对阿片类药物处方指南的依从性。确定多组分干预，即初级保健中阿片类药物处方的转变（TOPCARE; http：//mytopcare.org/），是否在降低阿片类药物滥用风险的同时提高了指南依从性。在53名初级保健临床医生（PCC）及其985名接受长期阿片类药物治疗疼痛的患者中进行的随机临床试验。该研究于2014年1月至2016年3月在4个安全网初级保健实践中进行。干预PCC接受护士护理管理，电子注册表，1对1学术细节和安全阿片类药物处方的电子决策工具。控制PCC仅收到电子决策工具。主要结局包括12个月内指南一致性治疗的记录（电子健康记录中的患者-PCC协议和至少1次尿液药物检测[UDT]）和2次或更多次早期阿片类药物再填充。次要结局包括阿片类药物剂量降低（即，试验结束时吗啡等效日剂量[MEDD]降低10%）和阿片类药物治疗中止。调整后的结果控制不同的基线患者特征：物质使用诊断，精神健康诊断和语言。在985例参与患者中，519例为男性，466例为女性（平均[SD]患者年龄，54.7 [11.5]岁）。患者接受的平均（SD）MEDD为57.8（78.5）mg。在1年时，干预患者比对照组更有可能接受与指南一致的护理（65.9% vs 37.8%; P <0.001;校正比值比[AOR]，6.0; 95% CI，3.6-10.2），患者-PCC一致性（在376例基线无一致性的患者中，53.8% vs 6.0%; P < .001; AOR，11.9; 95% CI，4.4-32.2），并接受至少1次UDT（74.6% vs 57.9%; P <0.001; AOR，3.0; 95% CI，1.8-5.0）。两组之间早期再灌注的几率没有差异（20.7% vs 20.1%; AOR，1.1; 95% CI，0.7-1.8）。与对照组相比，干预组患者更有可能减少10%的剂量或停止阿片类药物治疗（AOR，1.6; 95% CI，1.3-2.1; P < .001）。在校正分析中，干预组患者的平均（SE）MEDD比对照组低6.8（1.6）mg（P <0.001）。多组分干预改善了指南一致性护理，但没有减少早期阿片类药物再填充。clinicaltrials.gov标识符：NCT 01909076
Prescription opioid misuse is a national crisis. Few interventions have improved adherence to opioid-prescribing guidelines. To determine whether a multicomponent intervention, Transforming Opioid Prescribing in Primary Care (TOPCARE; http://mytopcare.org/), improves guideline adherence while decreasing opioid misuse risk. Cluster-randomized clinical trial among 53 primary care clinicians (PCCs) and their 985 patients receiving long-term opioid therapy for pain. The study was conducted from January 2014 to March 2016 in 4 safety-net primary care practices. Intervention PCCs received nurse care management, an electronic registry, 1-on-1 academic detailing, and electronic decision tools for safe opioid prescribing. Control PCCs received electronic decision tools only. Primary outcomes included documentation of guideline-concordant care (both a patient-PCC agreement in the electronic health record and at least 1 urine drug test [UDT]) over 12 months and 2 or more early opioid refills. Secondary outcomes included opioid dose reduction (ie, 10% decrease in morphine-equivalent daily dose [MEDD] at trial end) and opioid treatment discontinuation. Adjusted outcomes controlled for differing baseline patient characteristics: substance use diagnosis, mental health diagnoses, and language. Of the 985 participating patients, 519 were men, and 466 were women (mean [SD] patient age, 54.7 [11.5] years). Patients received a mean (SD) MEDD of 57.8 (78.5) mg. At 1 year, intervention patients were more likely than controls to receive guideline-concordant care (65.9% vs 37.8%; P < .001; adjusted odds ratio [AOR], 6.0; 95% CI, 3.6–10.2), to have a patient-PCC agreement (of the 376 without an agreement at baseline, 53.8% vs 6.0%; P < .001; AOR, 11.9; 95% CI, 4.4–32.2), and to undergo at least 1 UDT (74.6% vs 57.9%; P < .001; AOR, 3.0; 95% CI, 1.8–5.0). There was no difference in odds of early refill receipt between groups (20.7% vs 20.1%; AOR, 1.1; 95% CI, 0.7–1.8). Intervention patients were more likely than controls to have either a 10% dose reduction or opioid treatment discontinuation (AOR, 1.6; 95% CI, 1.3–2.1; P < .001). In adjusted analyses, intervention patients had a mean (SE) MEDD 6.8 (1.6) mg lower than controls (P < .001). A multicomponent intervention improved guideline-concordant care but did not decrease early opioid refills. clinicaltrials.gov Identifier: NCT01909076
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发表时间：
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CDC规定慢性疼痛的阿片类药物的指南 - 美国，2016年。
DOI：
10.1001/jama.2016.1464
发表时间：
2016-04-19
期刊：
JAMA
影响因子：
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作者：
Dowell D;Haegerich TM;Chou R
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