Non-pharmacological Options in postoperative Hospital-based And Rehabilitation pain Management (NOHARM) pragmatic clinical trial

摘要 术后麻醉性止痛处方导致意外延长阿片类药物使用时间 成千上万的美国人。这一趋势助长了阿片类药物的过剩供应， 在全国范围内导致依赖、上瘾、转移注意力和吸毒过量。非- 药理学疼痛护理是有效的，并被围手术期疼痛指南推荐 同时提供更有利的风险收益比。然而，非药理学的疼痛护理是 很少用于手术后的一线或二线治疗。患者和临床医生的决策支持 干预措施在鼓励以患者为中心和与指南一致的护理方面是有效的，但 这些策略并没有在每天的术后疼痛中作为捆绑包进行实际测试 关心。NOHARM试验将首先确认面向患者和临床医生的可行性。 面对嵌入电子病历的循证捆绑包的决策支持部分(目标1)。 然后，我们将在4个Health的18个站点进行阶梯式群组随机试验，测试我们的捆绑包 系统(AIM 2)隶属于一个使用公共电子病历的国家医疗保健组织 站台。我们将测试一个可持续的系统战略，该战略可能会改变 围术期疼痛管理转向非药物选择，以保护 患者功能，尊重患者价值，并将阿片类药物的供应作为最后手段。这 可以作为全国医疗保健组织的典范，并可以传播 通过我们机构与全国最大的电子病历供应商的持续伙伴关系。为了确保 我们的方法是可持续的，我们还将研究在所有研究地点哪些有效，哪些没有 (目标3)，重点关注母组织中表达了高- 致力于解决阿片类药物危机。

ABSTRACT Prescriptions for narcotic pain relief after surgery result in unintended prolonged opioid use for hundreds of thousands of Americans. That trend fuels an excess supply of opioids that can lead to dependence, addiction, diversion, and overdoses on a national scale. Non- pharmacological pain care is effective and recommended by guidelines for perioperative pain while offering a more favorable risk benefit ratio. However, nonpharmacological pain care is rarely used as first or second-line therapy after surgery. Patient and clinician decision support interventions are effective in encouraging patient centered and guideline-concordant care, but these strategies have not been tested pragmatically as a bundle in every day postoperative pain care. The NOHARM trial will first confirmed the feasibility of patient-facing as well as clinician- facing decision support components of an EHR-imbedded evidence-based bundle (Aim 1). Then we will test our bundle in a step-wedge, cluster randomized trial at 18 sites in 4 Health Systems (Aim 2) affiliated with one national healthcare organization that uses a common EHR platform. We will test a sustainable system strategy that could change the paradigm of perioperative pain management toward nonpharmacological options in a manner that preserves patient function, honors patient values and maintains availability of opioids as a last resort. This could serve as a model for healthcare organizations nationally and could be disseminated through our institution’s ongoing partnership with the largest national EHR vendor. To ensure our approach is sustainable, we will also study what worked and what did not at all study sites (Aim 3), focusing on high-risk patients within a parent organization that has expressed a high- level commitment to addressing the opioid crisis.