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）是阿片类药物治疗慢性疼痛的主要处方者，但很少有提供者遵循有关评估和监测的标准实践指南。 我们提出了一个新的系统变化，在提供初级保健服务，以减少滥用和成瘾的处方阿片类药物的慢性疼痛患者。我们将建立在慢性病护理模式，初级保健系统的变化，以实施慢性病（如糖尿病，抑郁症）的指导方针，并最终改善患者的结果。 我们提出的干预措施包括护士管理的登记处，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人群进行基于人群的护理。 我们将完善电子病历中的工具，以促进遵守指南。 这些工具包括经过验证的仪器，用于筛查活性物质使用，抑郁症以及评估疼痛和功能，并将提示临床医生进行尿液药物测试。最后，向临床医生提供学术细节是改善护理的另一种有效方法。 在这些访问中，受过培训的个人访问他们执业的临床医生，并为他们提供改变实践的信息。 所提供的信息也可帮助初级专业人员克服变革的障碍。 我们将评估实施策略，以整合管理接受慢性阿片类药物治疗慢性疼痛患者的最佳现有证据。 我们提出了一个随机对照试验，在4个波士顿联邦合格的社区卫生中心（CHCs）。 我们选择在CHCs进行这项研究，这些CHCs可能成为其他CHCs的护理模式，因为根据《平价医疗法案》，它们的作用扩大到覆盖数百万低收入人群。 此外，社区卫生中心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随机分为以下两种情况之一：干预（护士护理管理，注册表，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的12个月内对这两种情况下的患者和提供者进行随访。我们的主要结果是PCP对慢性阿片类药物治疗指南的依从性和患者中的阿片类药物滥用。

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.