Promoting the implementation of clinical guidelines for opioid prescribing in primary care using systems consultation

项目摘要/摘要 处方阿片类药物危机迫切需要一种灵活但可推广的系统一级实施战略来 广泛改进处方做法。关于更安全的处方做法已经形成了共识，但 确定如何实施必要的改革仍然是一个挑战。拟议中的研究将测试一个 以创新的方式落实这一共识，适应性制度协商。这项研究旨在确定 哪种实施战略的顺序和组合在促进实践方面最有效 在不同的初级保健诊所发生变化。这项研究服务于学习如何优化的长期目标 在初级保健环境中促进循证实践的实施战略。这项建议的基础是 一项在4家初级保健诊所测试系统咨询的试点研究发现，系统咨询 在减少患者的平均阿片类药物剂量方面是可行的、可接受的和有效的(结果直接相关 对过量死亡的风险)。这项拟议的研究测试了一种适应版本的战略，该战略是为 不同层次(卫生系统、诊所、处方者)。干预始于学术细节，一个系统- 一级战略，包括由专家领导的培训课程和基于远程的后续行动。这一战略 持续18个月，并作为控制条件。在3个月后，一半的诊所将被随机分配 为了获得实践便利化，这是一项临床一级的战略，旨在改善与阿片类药物处方有关的流程。 在6个月后，处方者将接受指南一致性评估，而非指南一致性的患者将有一半接受评估 处方者将随机接受医生同行指导，这是一种处方者级别的策略，在这种策略中， 医生专家向处方医生提供一对一的建议，帮助他们管理长期服用阿片类药物的患者 心理治疗。这3种策略将在38家诊所进行顺序、多重分配的随机试验 来自威斯康星州的3个医疗系统。该研究比较了安慰剂对吗啡平均毫克剂量的影响 适应性系统咨询实施策略(干预组)与单独的学术细节 (对照组)。这项研究将回答有关突出的比较有效性的问题 实施策略(学术细节、实践促进和医生同行指导) 高效学习。这项研究还评估了影响这一问题的背景因素 不同实施策略的有效性，并估算交付4种不同序列的成本 以及实施战略的组合。这项研究将通过测试一个 多层次实施战略，可量身定做以评估影响 实施。这一基本知识可用于帮助缓解阿片类药物危机和优化 选择和部署实施战略，以促进采用许多经过验证但 在整个医疗保健过程中未充分利用的做法。

Project Summary/Abstract The prescription opioids crisis begs for a flexible but generalizable systems-level implementation strategy to widely improve prescribing practices. A consensus has emerged about safer prescribing practices, but determining how to implement needed changes remains a challenge. The proposed research will test an innovative way to implement that consensus, adaptive systems consultation. The research aims to identify which sequence and combination of implementation strategies works most effectively in promoting practice change in different primary care clinics. The research serves the long-term goal of learning how to optimize implementation strategies to promote evidence-based practice in primary care settings. This proposal builds on a pilot study that tested systems consultation in 4 primary care clinics, which found that systems consultation was feasible, acceptable, and effective in reducing patients’ average opioid dose (an outcome directly related to the risk of overdose death). The proposed research tests an adaptive version of the strategy tailored to different levels (health system, clinic, prescriber). The intervention starts with academic detailing, a systems- level strategy consisting of an expert-led training session plus distance-based follow-up. This strategy continues for 18 months and serves as the control condition. At 3 months, half of the clinics will be randomized to receive practice facilitation, a clinic-level strategy aimed at improving processes related to opioid prescribing. At 6 months, prescribers will be assessed for guideline concordance, and half of non-guideline concordant prescribers will be randomized to receive physician peer coaching, a prescriber-level strategy, in which a physician expert gives one-on-one advice to prescribers in managing their patients on long-term opioid therapy. These 3 strategies will be delivered in a sequential, multiple-assignment randomized trial to 38 clinics from 3 Wisconsin health systems. The study compares the effect on average morphine milligram dose of an adaptive systems consultation implementation strategy (the intervention group) vs. academic detailing alone (the control group). The study will answer questions about the comparative effectiveness of prominent implementation strategies (academic detailing, practice facilitation, and physician peer coaching) in a single, highly efficient study. The study also develops an assessment of the contextual factors that influence the effectiveness of different implementation strategies and estimates the costs of delivering 4 different sequences and combinations of implementation strategies. This study will advance implementation science by testing a multi-level implementation strategy that can be tailored to assess contextual factors influencing implementation. This fundamental knowledge could be used to help mitigate the opioid crisis and in optimizing the selection and deployment of implementation strategies used to promote the uptake of many proven but underused practices throughout healthcare.