Abstract
BackgroundThis paper reports on the feasibility, acceptability, and effectiveness of an innovative implementation strategy named “systems consultation” aimed at improving adherence to clinical guidelines for opioid prescribing in primary care. While clinical guidelines for opioid prescribing have been developed, they have not been widely implemented, even as opioid abuse reaches epidemic levels.MethodsWe tested a blended implementation strategy consisting of several discrete implementation strategies, including audit and feedback, academic detailing, and external facilitation. The study compares four intervention clinics to four control clinics in a randomized matched-pairs design. Each systems consultant aided clinics on implementing the guidelines during a 6-month intervention consisting of monthly site visits and teleconferences/videoconferences. The mixed-methods evaluation employs the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Quantitative outcomes are compared using time series analysis. Qualitative methods included focus groups, structured interviews, and ethnographic field techniques.ResultsSeven clinics were randomly approached to recruit four intervention clinics. Each clinic designated a project team consisting of six to eight staff members, each with at least one prescriber. Attendance at intervention meetings was 83%. More than 80% of staff respondents agreed or strongly agreed with the statements: “I am more familiar with guidelines for safe opioid prescribing” and “My clinic’s workflow for opioid prescribing is easier.” At 6 months, statistically significant improvements were noted in intervention clinics in the percentage of patients with mental health screens, treatment agreements, urine drug tests, and opioid-benzodiazepine co-prescribing. At 12 months, morphine-equivalent daily dose was significantly reduced in intervention clinics compared to controls. The cost to deliver the strategy was $7345 per clinic. Adaptations were required to make the strategy more acceptable for primary care. Qualitatively, intervention clinics reported that chronic pain was now treated using approaches similar to those employed for other chronic conditions, such as hypertension and diabetes.ConclusionsThe systems consultation implementation strategy demonstrated feasibility, acceptability, and effectiveness in a study involving eight primary care clinics. This multi-disciplinary strategy holds potential to mitigate the prevalence of opioid addiction and ultimately may help to improve implementation of clinical guidelines across healthcare.Trial registrationClinicalTrials.gov (NCT02433496). https://clinicaltrials.gov/ct2/show/NCT02433496Registered May 5, 2015
Highlights
This paper reports on the feasibility, acceptability, and effectiveness of an innovative implementation strategy named “systems consultation” aimed at improving adherence to clinical guidelines for opioid prescribing in primary care
More than 80% of staff respondents agreed or strongly agreed with the statements: “I am more familiar with guidelines for safe opioid prescribing” and “My clinic’s workflow for opioid prescribing is easier.”
Intervention clinics reported that chronic pain was treated using approaches similar to those employed for other chronic conditions, such as hypertension and diabetes
Summary
This paper reports on the feasibility, acceptability, and effectiveness of an innovative implementation strategy named “systems consultation” aimed at improving adherence to clinical guidelines for opioid prescribing in primary care. Implementing clinical guidelines in healthcare organizations Healthcare adopts evidence-based practices (EBPs) notoriously slowly [1]. Traditional approaches to improving medical practice have relied upon experts producing and publishing clinical guidelines in academic journals. Much has been published about the problem of clinical guideline uptake and possible solutions to it [6,7,8,9,10]. Various explanations of the problem and possible solutions have been identified—e.g., relating the process of developing guidelines to their uptake, or changing the methods used to disseminate the guidelines, or determining how implementable the guidelines are. The best approaches to bridging the gap between medical research and clinical practice are not yet known
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