The Development and Evaluation of a Patient-Centered Opioid Discharge Prescribing Guideline within the Electronic Health Record of a Health System

项目摘要 从痛苦的手术中恢复过来的患者通常在住院期间和术后接受阿片类药物治疗。 帮助控制疼痛和启动恢复过程的手术期。尽管如此，手术后获得阿片类药物 使患者成为慢性使用者的风险增加。超过80%的外科患者在低风险后接受阿片类药物治疗 手术中，许多患者接受的阿片类药物超过了控制疼痛所需的量。过量开药 增加了转移和误用的风险。相反，处方不足可能会让许多患者面临 无法控制的疼痛和随后的紧急护理。目前的阿片类药物临床实践指南(CPGs)包括 降低最大出院缺省值、高级警告、与患者接受的程序挂钩的缺省值，或 基于先前阿片类药物使用的警告。然而，研究表明，术后疼痛管理应该是 基于个人疼痛体验和疼痛耐受性为每个患者量身定做。这些洞察力表明，一个病人- 术后需要以CPG为中心的疼痛管理。然而，以患者为中心的CPG是繁琐和 出院时从医院手工实施电子健康记录(EHR)耗时。2020年的全国 科学院、工程院和医学研究院的文件强调了寻找以患者为中心的阿片类药物的必要性 为急性疼痛开CPG处方。需要临床决策支持(CDS)工具来快速合成特定于患者的信息 来自电子健康记录的数据，以促进以患者为中心的阿片类药物放电CPG的使用。 为了实现这一目标，最近的三项研究为住院患者前一天使用阿片类药物提供了强有力的临床依据 出院时提供了个人疼痛体验和疼痛耐受性的可靠指标，以指导患者- 集中在出院后阿片类药物处方。南方普里斯玛健康中心普外科的外科医生 卡罗莱纳州利用这一原理开发了以患者为中心的阿片类药物释放CPG，并在他们的 该部于2018年3月提出。符合CPG阿片类药物出院处方的患者比例增加 实施后从10%下降到25.8%，59全部门平均阿片类药物排放水平下降，一般 外科医生轶事般地发现，这些减少几乎没有对患者产生负面反应。尽管有这些积极的结果， 普通外科医生报告说，在繁忙的实践中应用CPG所需的额外时间限制了其更广泛的范围 使用反映了文献中的发现。目前，以患者为中心的CPG要求提供者进行 手动详细分析患者病历，可为每位患者增加5-10分钟的出院时间。在……里面 此外，由于只有轶事可用，关于使用以患者为中心的CPG的患者结局的证据并不 当然了。我们相信，一种以患者为中心的阿片类药物处方工具(PCOPT)可以立即将患者- 从EHR到出院过程的特定信息将显著提高患者的依从性- 中枢阿片类药物放电CPG。此外，我们将使用有效性实施来实施PCOPT 为以患者为中心的CPG对患者的影响提供确凿证据的混合II型研究设计 使用骨科创伤患者下肢骨折对预后的影响。我们的建议书已在 对特别强调通知(SEN)的回应：AHRQ宣布对卫生服务研究感兴趣，以解决 阿片类药物危机(非HS-18-015)。

Project Summary Patients recovering from painful surgical procedures commonly receive opioids during their inpatient and post- operative periods to help manage pain and initiate the recovery process. Nonetheless, access to opioids after surgery puts patients at increased risk of becoming a chronic user. Over 80% of surgical patients receive opioids after low-risk surgery with many patients receiving opioids more than the amount needed to control pain. Overprescribing increases the risk of diversion and misuse. Conversely, under-prescribing may leave many patients open to uncontrolled pain and subsequent emergency care. Current opioid discharge clinical practice guidelines (CPGs) involve lowering maximum discharge defaults, high level warnings, defaults pegged to procedures received by patients, or warnings based on prior opioid utilization. However, research suggests that post-surgery pain management should be tailored to each patient based on individual pain experience and pain tolerance. These insights suggest that a patient- centered CPG for post-operative pain management is needed. However, patient-centered CPGs are cumbersome and time consuming to implement by hand from hospital electronic health records (EHR) at discharge. A 2020 National Academies of Sciences, Engineering, and Medicine document emphasized the need to find patient-centered opioid prescribing CPG for acute pain. A clinical decision support (CDS) tool is needed to quickly synthesize patient-specific data from the EHR to promote the use of patient-centered opioid discharge CPGs. Toward this goal, three recent studies provide a strong clinical rationale that inpatient opioid use the day before discharge affords a sound proxy for individual pain experience and pain tolerance at discharge to guide patient- centered post-discharge opioid prescribing. Surgeons in the General Surgery department at Prisma Health in South Carolina used this rationale to develop a patient-centered opioid discharge CPG that was implemented in their department in March 2018. The percentage of patients with CPG-compliant opioid discharge prescriptions increased from 10% to 25.8% after implementation,59 the department-wide average opioid discharge level fell, and the General Surgeons anecdotally found little negative patient response from these reductions. Despite these positive results, General Surgeons reported that the extra time required to apply the CPG within a busy practice limited its broader use which reflects findings in the literature. Currently, the patient-centered CPG requires providers to perform a detailed analysis of patient charts by hand that can add 5-10 minutes per patient to the discharge process. In addition, with only anecdote available, the evidence on patient outcomes from use of the patient-centered CPG is not definitive. We believe that a patient-centered opioid prescribing tool (PCOPT) that immediately incorporates patient- specific information from EHR into the discharge process will significantly increase compliance with the patient- centered opioid discharge CPG. In addition, we will implement the PCOPT using an effectiveness-implementation hybrid Type II study design to yield definitive evidence on the effects of the patient-centered CPG on patient outcomes on outcomes using orthopaedic trauma patients with a lower- extremity fracture. Our proposal is in response to the Special Emphasis Notice (SEN): AHRQ Announces Interest in Health Services Research to Address the Opioids Crisis (NOT-HS-18-015).