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严重的公共卫生问题，也是一个患者安全问题。初级保健提供者(PCP)是治疗慢性疼痛的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提供初级保健服务的制度改革，以减少慢性疼痛患者滥用和上瘾处方阿片类药物。我们将在慢性护理模式、初级保健系统改革的基础上，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护士管理的登记，用于规划个人患者护理，并为接受阿片类药物治疗慢性疼痛的患者群体进行基于人群的护理。我们将完善电子病历中的工具，以促进指南的遵守。这些工具包括经过验证的仪器，用于筛选活性物质使用、抑郁以及评估疼痛和功能，并将促使临床医生下令进行尿液药物测试。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式。在这些访问中，训练有素的个人访问他们执业的临床医生，并向他们提供信息以改变做法。所提供的信息还可能有助于方案执行方案克服变革的障碍。我们将评估实施策略，以将接受慢性阿片类药物治疗慢性疼痛的患者的最佳可用证据整合到初级保健环境中。我们建议在4个波士顿联邦合格的社区卫生中心(CHC)进行随机对照试验。我们选择在社区卫生中心进行这项研究，这可能成为其他社区卫生中心护理的典范，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口。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随机分为以下两种情况之一：干预(护士护理管理、登记、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这两种情况下的患者和提供者进行为期12个月的跟踪。我们的主要结果是PCP遵守慢性阿片类药物治疗指南和患者滥用阿片类药物。

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.