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

项目概要/摘要 处方阿片类药物危机需要灵活但可推广的系统级实施策略 广泛改进处方实践。关于更安全的处方做法已经达成共识，但是 确定如何实施所需的变革仍然是一个挑战。拟议的研究将测试 落实这一共识的创新方式是适应性系统磋商。该研究旨在确定 哪种实施策略的顺序和组合能够最有效地促进实践 不同初级保健诊所的变化。该研究服务于学习如何优化的长期目标 促进初级保健机构循证实践的实施战略。该提案建立在 一项试点研究在 4 个初级保健诊所测试了系统咨询，结果发现系统咨询 在减少患者平均阿片类药物剂量方面是可行、可接受且有效的（与结果直接相关） 过量死亡的风险）。拟议的研究测试了该策略的自适应版本 不同级别（卫生系统、诊所、处方医生）。干预从学术细节开始，一个系统—— 级别策略包括专家主导的培训课程和远程后续行动。这个策略 持续18个月并作为对照条件。 3个月后，一半的诊所将被随机分配 接受实践便利化，这是一项旨在改进与阿片类药物处方相关流程的诊所级战略。 6 个月时，将评估处方者的指南一致性，一半的非指南一致性 处方者将被随机接受医师同伴辅导，这是一种处方者级别的策略，其中 医师专家为处方者提供一对一的建议，以管理患者的长期阿片类药物 治疗。这 3 种策略将通过一项序贯、多任务随机试验在 38 家诊所进行 来自威斯康星州 3 个卫生系统。该研究比较了吗啡对平均吗啡毫克剂量的影响 自适应系统咨询实施策略（干预组）与单独的学术细节 （对照组）。该研究将回答有关杰出企业的比较有效性的问题 实施策略（学术细节、实践促进和医师同伴辅导）在一个单一的、 高效率的学习。该研究还对影响影响的背景因素进行了评估 不同实施策略的有效性并估算提供 4 种不同序列的成本 以及实施策略的组合。这项研究将通过测试 可以定制多层次的实施策略来评估影响的背景因素 实施。这些基础知识可用于帮助缓解阿片类药物危机并优化 选择和部署实施战略，以促进采用许多经过验证但仍 整个医疗保健实践未得到充分利用。

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.