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

摘要 这份来自Justina Groeger博士的K23申请书提出了一个有指导的研究和职业发展计划 这将推进她的目标，成为一名领先的医生兼研究员，测试卫生系统战略，以 尽量减少与阿片类药物相关的危害，特别是在老年人中(65岁的≥)。术后护理是指 过量的阿片类药物处方可能会导致不必要的伤害，特别是对年老和虚弱的人 成年人。嵌入电子病历、面向提供者、特定于患者的出院阿片类药物锥度支持(DOTS) 干预可能会减少术后过量的阿片类药物处方，但尚未经过严格测试，以及 即使在电子病历中提供，提供者和患者的因素也可能影响提供者是否使用 对患者的干预。这项拟议研究的首要目标是严格测试DOTS，以及 包括三个组成部分的干预：1)基于以下内容的针对患者的阿片类药物逐渐减少时间表的建议 患者在出院前使用阿片类药物，2)基于以下条件的自动默认阿片类药物处方 推荐的逐渐减少的计划，以及3)出院后加强对患者的电话支持。我们会 随机对42个提供商进行DOTS或电话支持(TS)，为期15个月，收集电子健康 记录他们的1890名接受整形外科手术的患者的数据，从子集收集患者报告的结果 100人(每组提供者50人)，并对21家DOTS提供者进行定性研究。具体的 目的是：1)确定DOTS在减少骨科术后过量阿片类药物处方方面的有效性 手术，2)测试DOTS对患者报告的术后结果的影响，包括疼痛强度， 身体功能和术后紧急护理；以及3)确定提供者使用DOTS的决定因素。 我们假设，与TS提供者的患者相比，DOTS提供者的患者将有更有利的 结果包括减少过量的阿片类药物处方以及术后疼痛和功能的改善。通过 完成拟议的研究和职业发展计划后，格罗格博士将获得设计和职业发展方面的技能 进行随机对照试验，2)开发和实施植入EHR的干预措施， 3)质的研究方法；4)先进的纵向数据分析。拟议的研究将导致 R01应用程序在其他医院严格测试DOTS，以及未来在医院测试DOTS的试验 因其他(非骨科)原因引起的急性疼痛而出院。随着这些活动的完成和 在一个多学科导师团队的指导下，格罗格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，测试卫生系统策略，将阿片类药物降至最低- 相关的危害，特别是在老年人中。

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.