Implementing Opioid Risk Reduction Strategies into Primary Care Practice

描述（由申请人提供）：处方阿片类药物滥用是一个重大的公共卫生问题，也是一个患者安全问题。初级保健提供者（pcp）是慢性疼痛阿片类药物的主要处方者，但很少有提供者遵循有关评估和监测的标准实践指南。我们提出了一种新的初级保健服务系统改变，以减少慢性疼痛患者对处方阿片类药物的滥用和成瘾。我们将在慢性病护理模式的基础上，对初级保健系统进行改革，以实施慢性病（如糖尿病、抑郁症）指南，并最终改善患者的预后。我们建议的干预措施包括一个护士管理的登记处，用于规划个体患者护理，并对接受阿片类药物治疗慢性疼痛的患者进行基于人群的护理。我们将改进电子病历中的工具，以促进指南的遵守。这些工具包括经过验证的仪器，用于筛查活性物质使用、抑郁、评估疼痛和功能，并将促使临床医生要求进行尿检。最后，向临床医生提供学术细节是另一种改善护理的有效方法。在这些访问中，受过培训的个人访问他们执业的临床医生，并向他们提供改变实践的信息。所提供的信息也可以帮助pcp克服变革的障碍。我们将评估实施策略，将现有的最佳证据整合到初级保健机构中，以管理接受慢性阿片类药物治疗慢性疼痛的患者。我们建议在4个波士顿联邦认证的社区卫生中心（CHCs）进行随机对照试验。我们选择在CHCs进行研究，这可能成为其他CHCs的护理模式，因为它们的作用扩大到根据《平价医疗法案》覆盖数百万低收入人群。此外，chc是采用以患者为中心的医疗之家的临床站点的先锋。我们将56名pcp随机分配到以下两种条件之一：干预条件（护士护理管理、注册、电子决策支持工具和学术细节）或控制条件（电子决策支持工具）。我们将在干预开始后对两种情况下的患者和提供者进行12个月的随访。我们的主要结果是PCP患者对慢性阿片类药物治疗指南的依从性和阿片类药物滥用。

DESCRIPTION (provided by applicant): Prescription opioid misuse is a significant public health problem as well as a patient safety concern. Primary care providers (PCPs) are the leading prescribers of opioids for chronic pain, yet few providers follow standard practice guidelines regarding assessment and monitoring. We propose a novel system change in delivery of primary care services to decrease misuse of and addiction to prescription opioids for patients with chronic pain. We will build on the Chronic Care Model, primary care system change to implement guidelines for chronic disease (e.g. diabetes, depression) and ultimately, to improve patient outcomes. Our proposed intervention includes a nurse-managed registry for planning individual patient care and conducting population- based care for a population of patients receiving opioids for chronic pain. We will refine tools within the electronic medical record to facilitate guideline adherence. These tools include validated instruments to screen for active substance use, depression and to assess pain and function, and will prompt clinicians to order urine drug tests. Finally, academic detailing to clinicians is another effective way to improve care. In these visits, trained individuals visit clinicians where they practice and provid them with information to change practice. The information given may also assist PCPs in overcoming obstacles to change. We will evaluate implementation strategies to integrate the best available evidence for managing patients receiving chronic opioid therapy for chronic pain into primary care settings. We propose a randomized controlled trial in 4 Boston federally qualified community health centers (CHCs). We chose to conduct the study at CHCs that could become a model for care at other CHCs as their roles expand to cover many millions of low-income populations under the Affordable Care Act. Further, CHCs are in the vanguard of clinical sites adopting the patient centered medical home. We will randomize 56 PCPs to one of the two following conditions: intervention (nurse care management, registry, electronic decision support tools, and academic detailing) or control condition (electronic decision support tools). We will follow patients and providers in both conditions for 12 months after the initiation of the intervention. Our primary outcomes are PCP adherence to chronic opioid therapy guidelines and opioid misuse among patients.