Prescribing Patterns and Use of Risk-Reduction Tools After Implementing an Opioid-Prescribing Protocol

BACKGROUND

The literature on results from primary care-based opioid-prescribing protocols is small and results have been mixed. To advance this field, we evaluated whether opioid prescribing changed after a comprehensive protocol was implemented and whether change was associated with the number and type of risk reduction tools adopted.

METHODS

Electronic medical record data were obtained for 2607 patients. Demographics, Patient Health Questionnaire-9 scores, body mass index, and utilization levels of protocol elements were measured for 24 months prior and 18 months post implementation of an opioid-prescribing protocol within a federally qualified health center. χ² and t-tests were computed to estimate change in opioid prescribing, morphine-equivalent dose, comedication prescribing, and number and type of protocol elements utilized.

RESULTS

The opioid protocol was associated with an increase in urine drug screens from 18.3% to 26.8% from pre to postimplementation (P < .0001). There was no significant increase in opioid treatment agreements. Tramadol (21.4% to 16.8%, P = .0006) and antidepressant (56.0% to 51.6%, P = .012) prescribing significantly decreased. Total opioid prescriptions and maximum morphine-equivalent doses were similar from pre to postimplementation. Protocol elements were more often used when patients had a higher opioid dose and were receiving benzodiazepines.

CONCLUSIONS

Implementing a multi-faceted opioid-prescribing protocol was not associated with change in number or dose of opioid prescriptions but was associated with greater use of urine drug screens, and risk reduction tools were used more often in high-risk patients. Implementation research is needed to identify barriers to maximizing adherence to opioid protocols.

Health Care Utilization and Pain Outcomes Following Early Imaging for Low Back Pain in Older Adults

BACKGROUND

Professional societies have provided inconsistent guidance regarding whether older patients should receive early imaging for low back pain, in the absence of clinical indications. The study assesses the implications of early imaging by evaluating its association with downstream utilization in an elderly population.

METHODS

Patients were included if they had a Medicare Advantage plan, had claims-based evidence of low back pain in 2014, and lacked conditions justifying early imaging. The outcomes examined were short-term, nonchronic, and chronic opioid use, steroid injections, and spinal surgery in the following 730 days, and persistent low back pain at 180 to 365 days. Morphine dose equivalents of opioid use was used as a measure of intensity. Logistic and γ regressions were used to assess the association between imaging in the first 6 weeks and the outcomes.

RESULTS

Among the 57,293 patients meeting inclusion criteria, the mean age was 71.2, and 26,606 (46.4%) received early imaging. Early imaging was associated with increased adjusted odds of short-term (odds ratio [OR], 1.21; 95% CI, 1.15 to 1.28), nonchronic (OR, 1.78; 95% CI, 1.69 to 1.88), and chronic (OR, 1.13; 95% CI, 1.07 to 1.18) opioid use, as well as steroid injections (OR, 2.55; 95% CI, 2.28 to 2.85) and spinal surgery (OR, 3.40; 95% CI, 2.97 to 3.90). Patients that received early imaging were more likely to experience persistent pain (OR, 1.09; 95% CI, 1.05 to 1.14) and used significantly more morphine dose equivalents if they had nonchronic opioid use.

CONCLUSIONS

Early imaging for low back pain in older individuals was common, and was associated with greater utilization of downstream services and persistent pain.

[Clinical Judgment: the scientific method applied to medical attention]

Medical care based on technical rationality, along with "Evidence-Based Medicine", converted the doctor in an operative technician and relegated the participation of the patient, only with his disease. The health-disease phenomenon results from the complex patient-environment interaction over time. The management of this intricate situation led the development of Clinical Judgment -scientific method applied to the clinic- and is described in the "Architecture of Clinical Research". Dr. Alvan R. Feinstein wrote, "There is nothing in such description [of the concepts] that a sensible physician, experienced in health care, does not know, or cannot understand".

A Qualitative Analysis of Implementing EvidenceNOW to Improve Cardiovascular Care

PURPOSE

The Heart of Virginia Health care (HVH) was a regional cooperative under the EvidenceNOW initiative to assist primary care practices in implementing evidence-based cardiovascular care and building capacity for quality improvement. The HVH implementation team included individuals from multiple universities, quality improvement organizations, and consulting firms. The goal of this study was to understand HVH team member viewpoints on the challenges, strengths, and lessons learned in each phase of the project.

METHODS

Qualitative methods were used to facilitate reflection on the implementation and dissemination of the EvidenceNOW initiative in Virginia. In-depth interviews were conducted at the end of the project with 22 HVH team members. A nonparticipant, multidisciplinary research team completed thematic analysis of interview transcripts.

RESULTS

Positive attributes of the HVH initiative included diverse team member skills and areas of expertise, a well-received kick-off event, and a comprehensive set of practice improvement resources. Major challenges included recruiting primary care practices, varying types and capabilities of electronic health records, and working with practices at different transformation stages, with different objectives for participating and involvement in other government initiatives.

CONCLUSIONS

Study findings provide insights for future dissemination research and implementation of evidence-based practices in primary care. Challenges experienced in project development can result in a domino effect that could change the project timeline, type of practices recruited for study participation, resource allocation, and planned activities for quality improvement. Effectiveness of external quality improvement support may depend on practice engagement, preexisting organizational structures and processes, availability of resources, and length and continuity of practice facilitation.

Improving medication optimisation in left ventricular systolic dysfunction after acute myocardial infarction

Glasgow city has the highest cardiovascular disease (CVD) mortality rate in the UK. Patients with left ventricular systolic dysfunction after acute myocardial infarction represent a ‘high-risk’ cohort for adverse CVD outcomes. The optimisation of secondary prevention medication in this group is often suboptimal. Our aim was to improve the use and target dosing of ACE inhibitors (ACEI), angiotensin II receptor blockers (ARBs) and beta-blockers in such patients, through pharmacist-led clinics and cardiology multidisciplinary team collaboration. Retrospective audits characterised baseline care. Prospective pharmacist-led clinics were piloted and rolled out across seven hospitals and primary care localities over four Plan–Do–Study–Act cycles. ‘Hub’ and ‘spoke’ clinics utilised independent prescribing pharmacists with different levels of cardiology experience. Pharmacists were trained through a bespoke training programme—‘Teach and Treat’. Consultant cardiologists provided senior support and governance. Patients attending prospective pharmacist-led clinics were more likely to be prescribed an ACEI (or ARB) and beta-blocker (n=856/885 (97%) vs n=233/255 (91%), p<0.001 and n=813/885 (92%) vs n=224/255 (88%), p=0.048, respectively) and be on target dose of ACEI (or ARB) and beta-blocker (n=585/885 (66%) vs n=64/255 (25%), p<0.001 and n=218/885 (25%) vs n=17/255 (7%), p<0.001, respectively) compared with baseline. The mean dose of ACEI (or ARB) and beta-blocker was also higher (79% vs 48% of target dose, p<0.001% and 48% vs 33% of target dose, p<0.001, respectively) compared with baseline. Use of secondary prevention medication was significantly improved by pharmacist and cardiology collaboration. These improvements were sustained across a 4-year period, supported by a novel approach called ‘Teach and Treat’ which linked training to defined clinical service delivery. Further work is needed to assess the impact of the programme on long-term CVD outcomes.

Pretraining to Recognize PICO Elements from Randomized Controlled Trial Literature

PICO (Population/problem, Intervention, Comparison, and Outcome) is widely adopted for formulating clinical questions to retrieve evidence from the literature. It plays a crucial role in Evidence-Based Medicine (EBM). This paper contributes a scalable deep learning method to extract PICO statements from RCT articles. It was trained on a small set of richly annotated PubMed abstracts using an LSTM-CRF model. By initializing our model with pretrained parameters from a large related corpus, we improved the model performance significantly with a minimal feature set. Our method has advantages in minimizing the need for laborious feature handcrafting and in avoiding the need for large shared annotated data by reusing related corpora in pretraining with a deep neural network.

[Choosing Wisely Portugal: The View of Portuguese Doctors]

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Development and Usability of Mobile-based Healthcare Protocols in Kenya

Healthcare protocols have been shown to improve the quality of health service delivery by offering explicit guidelines and recommendations for clinicians who are uncertain about how to proceed in a given clinical situation. While various modalities are used to implement protocols, few rigorous evaluations of protocol use exist in low-resource clinical settings. This study aimed to develop mobile-based protocols (MBPs) and test their usability against currently used paper-based protocol (PBPs). Satisfaction, efficiency and effectiveness of the protocols were evaluated through a think-aloud usability exercise, in-depth interviews, and through a questionnaire. Compared to PBPs, satisfaction scores were higher with MBPs (83.8 versus 66.8, p=0.0498), number of errors lower with MBPs (2/25 versus 5/25, p=0.1089), with average time for task completion higher with MBPs (23.3s versus21.6s, p=0.7394). MBPs offer more satisfaction and trend towards being more effective as a dissemination modality for healthcare protocols in low-resource settings.

Patient Safety In Inpatient Psychiatry: A Remaining Frontier For Health Policy

Behavioral health care has been slow to take up robust efforts to improve patient safety. This lag is especially apparent in inpatient psychiatry, where there is risk for physical and psychological harm. Recent investigative journalism has provoked public concern about instances of alleged abuse, negligence, understaffing, sexual assault, inappropriate medication use, patient self-harm, poor sanitation, and inappropriate restraint and seclusion. However, empirical evidence describing the scope of unsafe experiences is limited. While evidence-based inpatient psychiatry requires care to be trauma-informed, market failures and a lack of payment alignment with patient-centered care leave patients vulnerable to harm. Existing regulatory mechanisms attempt to provide accountability; however, these mechanisms are imperfect. Furthermore, research is sparse. Few health services researchers study inpatient psychiatry, the issue has not been a priority among research funders, and data on inpatient psychiatry is excluded from national surveys of quality. Several policy levers could begin to address these deficiencies. These include aligning incentives with patient-centered care, building trauma-informed care into accreditation and monitoring, conducting trend analyses of critical incidents, and improving research capacity.

One In Five Fewer Heart Attacks: Impact, Savings, And Sustainability In San Diego County Collaborative

Before 2011 rates of hospitalization for heart attacks were about the same in San Diego County as they were in the rest of California. In 2011 a multistakeholder population health collaborative consisting of partners at the federal, state, and local levels launched Be There San Diego. The collaborative's goal was to reduce cardiovascular events through the spread of best practices aimed at improving control of hypertension, lipid levels, and blood sugar and through patient and medical community activation. Using hospital discharge data for the period 2007-16, we compared acute myocardial infarction (AMI) hospitalization rates in San Diego County and the rest of the state before and after the demonstration project started. AMI hospitalization rates decreased by 22 percent in San Diego County versus 8 percent in the rest of the state, with an estimated 3,826 AMI hospitalizations avoided and $86 million in savings in San Diego. Results show that a science-based health collaborative can improve outcomes while lowering costs, and efforts are under way to ensure the collaborative's sustainability.

[Endovascular therapy for acute stroke-An important role of neurologists]

Previous randomized clinical trials have revealed significant benefit of the endovascular thrombectomy for the patients with acute ischemic stroke. In this short communication, I would like to introduce the history of endovascular treatment for acute ischemic stroke in Japan, and give a positive message to the neurologists who might contribute to the treatment for acute ischemic stroke.

A collaborative process for a program redesign for education in evidence-based health care

OBJECTIVE:

We outline the framework of a collaborative process to redesign an existing 5-year health education program, which may prove useful to other similar institutions. The aim was to strengthen evidence-based practice and curriculum alignment.

METHODS:

A whole-of-program approach was used to restructure the existing courses into 3 "streams": professional practice, clinical research, and clinical science. The process incorporated a series of facilitated workshops organized by the department director of learning and teaching and the faculty facilitation team, and it was inclusive of all available members of the department, a clinic supervisor, a sessional (casual teaching) staff member, and a recent graduate of the program.

RESULTS:

Unit content and assessments were restructured to progress the program learning outcomes from year to year. The undergraduate program was redesigned to create a more logical learning pathway for students. Consolidation of subject topics in the postgraduate program allowed for the development of stand-alone research-only units.

CONCLUSION:

The mechanism of curriculum mapping allowed for discussion about the flow of information from year to year and how evidenced knowledge and understanding can be developed. It is necessary that everyone participates and understands the importance of program goals as developed by the process. Because drift in curriculum can occur incrementally over the years, to be effective, the program requires ongoing monitoring and regular collaboration to continue improvements.

Preventative and medical treatment of ear disease in remote or resource-constrained environments

BACKGROUND

Important ear problems can affect the outer ear, the middle ear and the inner ear. Globally, the greatest burden of disease is due to ear conditions that are associated with otorrhoea and hearing loss.

METHODS

This study reviewed the literature on the prevention and treatment of common ear conditions that are most relevant to settings with high rates of ear disease and limited resources. The grading of recommendations assessment, development and evaluation ('GRADE') approach was utilised to assess interventions.

RESULTS

Accurate diagnosis of ear disease is challenging. Much of the preventable burden of ear disease is associated with otitis media. Nine otitis media interventions for which there is moderate to high certainty of effect were identified. While most interventions only provide modest benefit, the impact of treatment is more substantial in children with acute otitis media with perforation and chronic suppurative otitis media.

CONCLUSION

Disease prevention through good hygiene practices, breastfeeding, reducing smoke exposure, immunisation and limiting noise exposure is recommended. Children with acute otitis media with perforation, chronic suppurative otitis media, complications of otitis media, and significant hearing loss should be prioritised for medical treatment.

Road Map For Diffusion Of Innovation In Health Care

New scientific knowledge and innovation are often slow to disseminate. In other cases, providers rush into adopting what appears to be a clinically relevant innovation, based on a single clinical trial. In reality, adopting innovations without appropriate translation and repeated testing of practical application is problematic. In this article we provide examples of clinical innovations (for example, tight glucose control in critically ill patients) that were adopted inappropriately and that caused what we term a malfunction. To address the issue of malfunctions, we review various examples and suggest frameworks for the diffusion of knowledge leading to the adoption of useful innovations. The resulting model is termed an integrated road map for coordinating knowledge transformation and innovation adoption. We make recommendations for the targeted development of practice change procedures, practice change assessment, structured descriptions of tested interventions, intelligent knowledge management technologies, and policy support for knowledge transformation, including further standardization to facilitate sharing among institutions.

Few Americans Receive All High-Priority, Appropriate Clinical Preventive Services

As of 2015, only 8 percent of US adults ages thirty-five and older had received all of the high-priority, appropriate clinical preventive services recommended for them. Nearly 5 percent of adults did not receive any such services. Further delivery system-level efforts are needed to increase the use of preventive services.

An Interactive Workshop Reviewing Basic Biostatistics and Applying Bayes' Theorem to Diagnostic Testing and Clinical Decision-Making

INTRODUCTION

Sensitivity, specificity, and predictive values-the basic statistics behind using and interpreting screening and diagnostic tests-are taught in all medical schools, yet studies have shown that a majority of physicians cannot correctly define and apply these concepts. Previous work has not rigorously examined this disconnect and attempted to address it.

METHODS

We used adult learning theory to design a case-based interactive workshop to review biostatistics and apply them to clinical decision-making using Bayes' theorem. Participants took an anonymous multiple-choice pretest, posttest, and delayed posttest on definitions and application of the concepts, and we compared the scores between the three tests. Several experiences with early iterations provided feedback to improve the workshop but were not included for analysis.

RESULTS

We conducted the finalized workshop with 54 pediatrics students, residents, and faculty. All learners completed the immediate pre- and posttests, and eight completed the delayed posttest. Average scores rose from 4.5/8 (56%) on the pretest to 6.5/8 (81%) on the posttest and 6.4/8 (80%) on the delayed posttest. Two-tailed t tests showed p < .001 for the difference between the pretest and both posttests, and post hoc power analysis showed a power of 99% to detect the observed differences. There was no significant difference (p = .8) between the posttest and delayed posttest.

DISCUSSION

Our work demonstrates that an interactive workshop reviewing basic biostatistics and teaching rational diagnostic testing using Bayes' theorem can be effective in connecting theoretical knowledge of biostatistics to evidence-based decision-making in real clinical practice.

[Choosing Wisely Portugal - Wise Health Decisions]

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How to Choose the Best Evidence?

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The Quality of EBM Sources Perceived By Belgian Family Physicians

BACKGROUND

Belgian family physicians use several local and international sources for evidence-based medicine (EBM).

AIM

This study aims to investigate the quality of these EBM sources according to the Belgian family physicians.

METHODS

A sample of Belgian family physicians completed a digital survey on the quality of EBM sources.

RESULTS

Respondents evaluated the quality of the information for the major part of the local and international EBM sources good to excellent. More than 50% of the respondents found in the major part of the sources an answer to the question. More than half of the respondents found the necessary information in less than 5 minutes in most of the sources. Younger participants self-evaluated their search skills better than older participants.

CONCLUSION

The quality of most frequently used EBM sources in Belgium is evaluated as good and client-friendly. More than half of the respondents found an answer to their questions in most of the sources and this within 5 minutes.

RELATION BETWEEN IMPACT FACTOR IN ORTHOPEDIC JOURNALS AND LEVEL OF EVIDENCE

Objective:

This study aims to assess the quality of articles published in the leading orthopedic surgery journals, by measuring the relation between the impact factor and the number studies with a high level of evidence.

Methods:

A literature review was performed of articles published in four previously selected journals. A score of journal evidence (RER - Relation between Randomized clinical trials and Systematic reviews) was calculated, considering the number of RCTs and SR published and the total number of full-text articles.

Results:

The selected journals were JBJS-Am, ASMJ, BJJ-Br and Arthroscopy, with Impact factors of 5.280, 4.362, 3.309 and 3.206 respectively in 2015. In the study, the RER Scores, in the same order, were 9.408, 6.153, 7.456 and 7.779.

Conclusion:

The journal JBJS-Am is the best available source of information on orthopedic surgery from this point of view. It has the highest Impact Factor and clearly the highest RER Score. On the other hand, we could conclude that the number of published RCT and good quality SR is very low, with less than 10% of all the articles. Level of evidence III, Analyses based on limited alternatives and costs, and poor estimates.

Explicit Bias Toward High-Income-Country Research: A Randomized, Blinded, Crossover Experiment Of English Clinicians

Unconscious bias may interfere with the interpretation of research from some settings, particularly from lower-income countries. Most studies of this phenomenon have relied on indirect outcomes such as article citation counts and publication rates; few have addressed or proven the effect of unconscious bias in evidence interpretation. In this randomized, blinded crossover experiment in a sample of 347 English clinicians, we demonstrate that changing the source of a research abstract from a low- to a high-income country significantly improves how it is viewed, all else being equal. Using fixed-effects models, we measured differences in ratings for strength of evidence, relevance, and likelihood of referral to a peer. Having a high-income-country source had a significant overall impact on respondents' ratings of relevance and recommendation to a peer. Unconscious bias can have far-reaching implications for the diffusion of knowledge and innovations from low-income countries.

Low-Cost, High-Volume Health Services Contribute The Most To Unnecessary Health Spending

An analysis of data for 2014 about forty-four low-value health services in the Virginia All Payer Claims Database revealed more than $586 million in unnecessary costs. Among these low-value services, those that were low and very low cost ($538 or less per service) were delivered far more frequently than services that were high and very high cost ($539 or more). The combined costs of the former group were nearly twice those of the latter (65 percent versus 35 percent).

Impact Of The YMCA Of The USA Diabetes Prevention Program On Medicare Spending And Utilization

The YMCA of the USA received a Health Care Innovation Award from the Centers for Medicare and Medicaid Services to provide a diabetes prevention program to Medicare beneficiaries with prediabetes in seventeen regional networks of participating YMCAs nationwide. The goal of the program is to help participants lose weight and increase physical activity. We tested whether the program reduced medical spending and utilization in the Medicare population. Using claims data to compute total medical costs for fee-for-service Medicare participants and a matched comparison group of nonparticipants, we found that the overall weighted average savings per member per quarter during the first three years of the intervention period was $278. Total decreases in inpatient admissions and emergency department (ED) visits were significant, with nine fewer inpatient stays and nine fewer ED visits per 1,000 participants per quarter. These results justify continued support of the model.