A hospital discharge opioid taper support intervention to improve post-operative opioid prescribing

摘要 Justina Groeger博士的这份K23申请提出了一个指导性的研究和职业发展计划 这将推动她成为一名领先的医生调查员的目标，她测试卫生系统的战略， 最大限度地减少阿片类药物相关的危害，特别是老年人（年龄≥65岁）。术后护理是一个时间， 过量的阿片类药物处方会导致不必要的伤害，特别是对老年人和体弱者 成年人了EHR嵌入式、面向提供者、患者特定的阿片类药物减量支持（DOTS） 干预可能会减少术后过量的阿片类药物处方，但尚未经过严格的测试， 即使在EHR中提供，提供者和患者因素也可能影响提供者是否使用 对患者的干预。拟议研究的首要目标是严格测试DOTS， 干预有三个组成部分：1）基于以下内容的患者特定阿片类药物逐渐减少时间表的建议： 患者出院前使用阿片类药物，2）基于患者出院前使用阿片类药物的自动默认出院阿片类药物处方， 建议减量时间表; 3）出院后加强对患者的电话支持。我们将 随机选择42名提供者接受DOTS或单独电话支持（TS）15个月，收集电子健康信息 记录1890例骨科手术患者的数据，从一个子集收集患者报告的结局 100名（每组50名来自提供者），并对21名DOTS提供者进行定性研究。具体 目的是：1）确定DOTS减少骨科术后过量阿片类药物处方的有效性 2）测试DOTS对患者报告的术后结局（包括疼痛强度）的影响， 身体功能，和紧急手术后护理;和3）确定供应商使用DOTS的决定因素。 我们假设，与TS提供者的患者相比，DOTS提供者的患者将具有有利的 结果包括减少过量阿片类药物处方和改善术后疼痛和功能。通过 完成拟议的研究和职业发展计划，Groeger博士将获得1）设计和 进行随机对照试验，2）开发和实施EHR嵌入式干预措施， 3)定性研究方法; 4）先进的纵向数据分析。这项研究将导致 到R 01应用程序，以严格测试DOTS在其他医院和未来的试验测试DOTS在医院 因其他（非骨科）急性疼痛原因出院。随着这些活动的完成， 在多学科导师团队的指导下，Groeger博士将获得实现她的目标所需的技能。 职业目标是成为一名领先的医生调查员，测试卫生系统战略，以尽量减少阿片类药物， 相关危害，尤其是老年人。

ABSTRACT This K23 application from Dr. Justina Groeger proposes a mentored research and career development plan that will advance her goal of becoming a leading physician-investigator who tests health systems strategies to minimize opioid-related harms, particularly among older adults (age ≥65). Post-operative care is a time when excessive opioid prescribing occurs which can result in unnecessary harms, particularly to older and frail adults. An EHR-embedded, provider-facing, patient-specific, discharge opioid taper support (DOTS) intervention may reduce excessive post-operative opioid prescribing, but has not been rigorously tested, and even if made available in the EHR, provider- and patient- factors are likely to influence whether providers use the intervention for patients. The overarching goal of the proposed research is to rigorously test DOTS, an intervention with three components: 1) a recommendation for a patient-specific opioid taper schedule based on patient opioid use prior to discharge, 2) an automated default discharge opioid prescription based on the recommended taper schedule, and 3) post-discharge enhanced telephonic support for patients. We will randomize 42 providers to DOTS or telephonic support alone (TS) for 15-months, collect electronic health record data for their 1890 patients having orthopedic surgery, collect patient-reported outcomes from a subset of 100 (50 from providers in each group), and conduct a qualitative study of 21 DOTS providers. The specific aims are to: 1) determine the effectiveness of DOTS for reducing excessive opioid prescribing after orthopedic surgery, 2) test the impact of DOTS on patient-reported post-operative outcomes including pain intensity, physical function, and emergency post-operative care; and 3) identify determinants of provider use of DOTS. We hypothesize that compared to patients of TS providers, patients of DOTS providers will have favorable outcomes including reduction in excessive opioid prescribing and improved pain and function after surgery. By completing the proposed research and career development plan, Dr. Groeger will gain skills in 1) design and conduct of randomized controlled trials, 2) development and implementation of EHR-embedded interventions, 3) qualitative research methods, and 4) advanced longitudinal data analysis. The proposed research will lead to an R01 application to rigorously test DOTS at other hospitals and future trials testing DOTS at hospital discharge for other (non-orthopedic) causes of acute pain. With the completion of these activities and with the guidance of a team of multi-disciplinary mentors, Dr. Groeger will obtain the skills necessary to achieve her career goal of become a leading physician-investigator who tests health systems strategies to minimize opioid- related harms, particularly among older adults.