High-risk Prescribing Research Articles

Clinical Decision Support to Increase Emergency Department Naloxone Coprescribing: Implementation Report.

Coprescribing naloxone with opioid analgesics is a Centers for Disease Control and Prevention (CDC) best practice to mitigate the risk of fatal opioid overdose, yet coprescription by emergency medicine clinicians is rare, occurring less than 5% of the time it is indicated. Clinical decision support (CDS) has been associated with increased naloxone prescribing; however, key CDS design characteristics and pragmatic outcome measures necessary to understand replicability and effectiveness have not been reported. This study aimed to rigorously evaluate and quantify the impact of CDS designed to improve emergency department (ED) naloxone coprescribing. We hypothesized CDS would increase naloxone coprescribing and the number of naloxone prescriptions filled by patients discharged from EDs in a large health care system. Following user-centered design principles, we designed and implemented a fully automated, interruptive, electronic health record-based CDS to nudge clinicians to coprescribe naloxone with high-risk opioid prescriptions. "High-risk" opioid prescriptions were defined as any opioid analgesic prescription ≥90 total morphine milligram equivalents per day or for patients with a prior diagnosis of opioid use disorder or opioid overdose. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to evaluate pragmatic CDS outcomes of reach, effectiveness, adoption, implementation, and maintenance. Effectiveness was the primary outcome of interest and was assessed by (1) constructing a Bayesian structural time-series model of the number of ED visits with naloxone coprescriptions before and after CDS implementation and (2) calculating the percentage of naloxone prescriptions associated with CDS that were filled at an outpatient pharmacy. Mann-Kendall tests were used to evaluate longitudinal trends in CDS adoption. All outcomes were analyzed in R (version 4.2.2; R Core Team). Between November 2019 and July 2023, there were 1,994,994 ED visits. CDS reached clinicians in 0.83% (16,566/1,994,994) of all visits and 15.99% (16,566/103,606) of ED visits where an opioid was prescribed at discharge. Clinicians adopted CDS, coprescribing naloxone in 34.36% (6613/19,246) of alerts. CDS was effective, increasing naloxone coprescribing from baseline by 18.1 (95% CI 17.9-18.3) coprescriptions per week or 2,327% (95% CI 3390-3490). Patients filled 43.80% (1989/4541) of naloxone coprescriptions. The CDS was implemented simultaneously at every ED and no adaptations were made to CDS postimplementation. CDS was maintained beyond the study period and maintained its effect, with adoption increasing over time (τ=0.454; P<.001). Our findings advance the evidence that electronic health record-based CDS increases the number of naloxone coprescriptions and improves the distribution of naloxone. Our time series analysis controls for secular trends and strongly suggests that minimally interruptive CDS significantly improves process outcomes.

425 Predictors of High-Risk Opioid Prescribing in the Emergency Department at an Academic Medical Center

425 Predictors of High-Risk Opioid Prescribing in the Emergency Department at an Academic Medical Center

Effectiveness of Audit and Feedback and Academic Detailing Interventions to Support Safer Opioid Prescribing in Primary Care

BackgroundOpioids, prescribed to manage pain, are associated with safety risks. Quality improvement strategies such as audit and feedback and academic detailing may improve prescribing in primary care. MethodsWe used a matched-cohort design with claims databases. Participants were family physicians practicing in Ontario, Canada. The interventions were a voluntary audit and feedback report with or without academic detailing sessions. Physicians in the control group received neither intervention. The primary outcome was mean rate of high-risk opioid prescriptions per 100 patients per month. Data were analyzed comparing monthly percentage change in slope over 12 months before and 18 months after the intervention. Additional analyses considered only the subgroup of higher-prescribing physicians. ResultsThere were 1469 (25%) physicians in the audit and feedback group, 245 (4%) in the audit and feedback + academic detailing group, and 4211 (71%) matched controls. All groups showed a significant preintervention decline in opioid prescribing. There were no significant between-group differences in opioid prescribing postintervention. Among high-prescribing physicians, there was a significant reduction in the audit and feedback group (% change in slope = –0.37, 95% CI = –0.65 to –0.09, P < .01), but not in the academic detailing group (% change in slope = 0.19, 95% CI = –0.52 to 0.91, P = .59). ConclusionsThis study demonstrated declining secular trends in prescribing and suggests that two large-scale initiatives had limited additional benefits. We found some additional reductions after audit and feedback among the highest-volume opioid prescribers. Future interventions should focus on these physicians for the greatest benefit.

Enhancing Medication Safety with ML-Enhanced Decision Support Systems: A Comparative Analysis of Prescription Error Detection

Background: Medication prescription errors are a global issue, leading to significant morbidity and mortality. Traditional rule-based Medical Decision Support Systems (MDSS) are often ineffective, generating numerous false alerts and failing to detect all potential errors. This study assesses a new anomaly detection system integrated with Electronic Health Records (EHR) to improve the accuracy and utility of medication error warnings. Methods: Anomalous prescription detection was implemented alongside an existing MDSS in a real-world inpatient setting over 18 months. The new system utilized Machine Learning (ML) combined with a rule-based MDSS to analyze historical EHR data. It aimed to identify and flag high-risk prescriptions through real-time anomaly detection. The performance of this hybrid system was compared against traditional MDSS and multicriteria query (MQ) methods. A clinical pharmacist reviewed 415 patients (3401 prescriptions) to validate the effectiveness of the system, assessing notifications for accuracy, clinical relevance, and practicality. Results: The ML-enhanced MDSS demonstrated superior performance compared to traditional systems. It achieved a 76% interception rate for prescriptions needing pharmacist review and a precision rate of 75%. The hybrid system outperformed traditional MDSS and MQ methods, with areas under the ROC and PRC curves of 0.84 and 0.79, respectively, compared to 0.66 and 0.57 for MDSS and 0.7 and 0.58 for MQ approaches. Conclusion: Integrating ML with rule-based MDSS significantly improves the detection of high-risk medication prescriptions, reducing false alerts and enhancing accuracy. This hybrid approach offers a more effective tool for identifying potential medication errors and improving patient safety in inpatient settings.

Prevalence of actionable pharmacogenetic variants and high-risk drug prescriptions: A Swiss hospital-based cohort study.

Drug type and dosing recommendation have been designed and optimized based on average response in the general population. Yet, there is significant inter-individual variability in drug response, which results in treatment inefficacy or adverse drug reactions in a subset of patients. This is partly due to genetic factors that typically affect drug metabolism or clearance. To verify the relevance and applicability of international pharmacogenetic guidelines in the Swiss population, we genotyped 1533 patients from a hospital-based biobank who received at least 30 different drugs, as documented in their electronic health record. We then assessed the prevalence of clinically actionable variants in 13 high-risk pharmacogenes. We compared the allele frequencies obtained in the hospital-based cohort with those of a Swiss population-based cohort of 4791 individuals. The prevalence of clinically actionable variants was comparable between the two cohorts, with most study participants (97.3%) carrying at least one actionable pharmacogenetic variant. We then assessed the frequency of high-risk prescriptions due to actionable gene-drug interactions and observed that 31% of patients in the hospital-based cohort were prescribed at least one drug for which they carried a high-risk variant, and for which international guidelines recommend a change of drug or dosage. Our analysis confirms the high prevalence of actionable pharmacogenetic variants in the Swiss population. It also shows that a substantial minority of patients are exposed to drugs for which they carry potentially problematic variants. Implementing a genetically informed approach to drug prescribing could have a positive impact on the quality of healthcare delivery.

Changes in Primary Care Health Services During the COVID-19 Pandemic: A Longitudinal Analysis of Data From Ontario.

The COVID-19 pandemic significantly impacted primary care, but its effect on quality of care is not well understood. We used health administrative data to understand the changes in quality-of-care measures for primary care between October 2018 and April 2022. We examined the following domains: cancer screening, chronic disease (diabetes) management, high-risk prescribing, continuity of care and capacity of primary care services. Colorectal and breast cancer screenings declined after the pandemic and had not returned to baseline by study end. In patients living with diabetes, in-person visits and up-to-date retinopathy screening rates declined after the pandemic declaration and did not return to baseline by study end, while statin prescribing remained stable. High-risk opioid prescribing decreased over time and was not affected by the pandemic. Physician continuity remained stable, though new patient enrollments decreased over the pandemic but returned to baseline by study end. Existing disparities in colorectal cancer screening by income and recent registration widened during the pandemic. In summary, COVID-19 had a variable impact on primary care, with the strongest influence on preventive and chronic disease care that was dependent on in-person visits.

Estimating the economic effect of harm associated with high risk prescribing of oral non-steroidal anti-inflammatory drugs in England: population based cohort and economic modelling study

ObjectivesTo quantify prevalence, harms, and NHS costs in England of problematic oral non-steroidal anti-inflammatory drug (NSAID) prescribing in high risk groups.DesignPopulation based cohort and economic modelling study.SettingEconomic models estimating patient...

Protocol for the development and validation of a Polypharmacy Assessment Score

BackgroundAn increasing number of people are using multiple medications each day, named polypharmacy. This is driven by an ageing population, increasing multimorbidity, and single disease-focussed guidelines. Medications carry obvious benefits, yet polypharmacy is also linked to adverse consequences including adverse drug events, drug-drug and drug-disease interactions, poor patient experience and wasted resources. Problematic polypharmacy is ‘the prescribing of multiple medicines inappropriately, or where the intended benefits are not realised’. Identifying people with problematic polypharmacy is complex, as multiple medicines can be suitable for people with several chronic conditions requiring more treatment. Hence, polypharmacy is often potentially problematic, rather than always inappropriate, dependent on clinical context and individual benefit vs risk. There is a need to improve how we identify and evaluate these patients by extending beyond simple counts of medicines to include individual factors and long-term conditions.AimTo produce a Polypharmacy Assessment Score to identify a population with unusual levels of prescribing who may be at risk of potentially problematic polypharmacy.MethodsAnalyses will be performed in three parts:1. A prediction model will be constructed using observed medications count as the dependent variable, with age, gender and long-term conditions as independent variables. A ‘Polypharmacy Assessment Score’ will then be constructed through calculating the differences between the observed and expected count of prescribed medications, thereby highlighting people that have unexpected levels of prescribing.Parts 2 and 3 will examine different aspects of validity of the Polypharmacy Assessment Score:2. To assess ‘construct validity’, cross-sectional analyses will evaluate high-risk prescribing within populations defined by a range of Polypharmacy Assessment Scores, using both explicit (STOPP/START criteria) and implicit (Medication Appropriateness Index) measures of inappropriate prescribing.3. To assess ‘predictive validity’, a retrospective cohort study will explore differences in clinical outcomes (adverse drug reactions, unplanned hospitalisation and all-cause mortality) between differing scores.DiscussionDeveloping a cross-cutting measure of polypharmacy may allow healthcare professionals to prioritise and risk stratify patients with polypharmacy using unusual levels of prescribing. This would be an improvement from current approaches of either using simple cutoffs or narrow prescribing criteria.

T140 - The Effect of Mental Illness on High-Risk Opioid Prescribing for Clients With Comorbid Pain and Alcohol Use Disorder in New York State

T140 - The Effect of Mental Illness on High-Risk Opioid Prescribing for Clients With Comorbid Pain and Alcohol Use Disorder in New York State

Community pharmacists' attitudes towards checking prescriptions: a cross-sectional survey.

The final prescription check is a mandatory but time-consuming process in Dutch community pharmacies. A safer dispensing process may have made the final prescription check obsolete. To describe the final prescription check in Dutch community pharmacies and explore pharmacists' attitudes towards changing this. A cross-sectional survey among Dutch community pharmacists. The online questionnaire was based on literature and previous qualitative research, piloted in three pharmacies, and took 10 min to complete. Results were analysed descriptively. A total of 409 pharmacists participated. They saw the final prescription check as an important quality assurance of the dispensing process. Nevertheless, most pharmacists agreed that the final prescription check could be optimized as they thought that the time invested outweighed the benefits. Automation of the dispensing process, only checking selected high-risk prescriptions, and more in-process checks could reduce the need for an extensive final prescription check, rather than delegating the task to assistants. To implement changes, most pharmacists felt current dispensing guidelines needed to be adapted. There was a widespread consensus that optimizing the final prescription check could enhance efficiency and allow more time for person-centred care. Most pharmacists expressed a preference for updated guidelines before implementing such changes.

Improving Naloxone Co-prescribing Through Clinical Decision Support.

Despite national guidelines recommending naloxone co-prescription with high-risk medications, rates remain low nationally.This was reflected atour institution with remarkably low naloxone prescribing rates.We sought to determine if a clinical decision support (CDS) tool could increase rates of naloxone co-prescribing with high-risk prescriptions. An alert in the electronic health record was triggered upon signing an order for a high-risk opioid medication without a naloxone co-prescription.We examined all opioid prescriptions written by family and general internal medicine practitioners at the University of Iowa Hospitals and Clinics in outpatient encounters between November 30, 2020, and February 28, 2022.Once triggered by a high-risk prescription, the CDS tool had the option to choose an order set with an automatically selected co-prescription for naloxone along with patient instructions automatically added to the patient's after-visit summary (AVS).We examined the monthly percentage of patients receiving Schedule II opioid prescriptions ≥90 morphine milliequivalents (MME)/day who received concurrent naloxone prescriptions in the 12 months before the CDS went live and the three months following go-live. Concurrent naloxone prescriptions increased from 1.1% in the 12 months prior to implementation in November 2021 to 9.4% (p<0.001) during the post-intervention period across eight family medicine and internal medicine clinics. This single-center quality improvement project with retrospective analysis demonstrates the potential efficacy of a single CDS tool in increasing the rate of naloxone prescription.The impact of such prescribing on overall mortality requires further research. The CDS tool was easy to implement and improved rates of appropriate naloxone co-prescribing.

The 340B Program and High-Risk Prescribing of Oral Targeted Therapies for Advanced Prostate Cancer.

The use of expensive oral targeted agents for advanced prostate cancer can be influenced by those who stand to gain from their use. The 340B drug pricing program allows eligible hospitals to purchase medications at steep discounts, generating millions of dollars in savings. The extent to which hospitals engage in higher-risk prescribing due to program incentives is unclear. Medicare claims were used to perform a retrospective study of men with advanced prostate cancer. The primary outcome was targeted therapy use in men with high noncancer mortality risk. Secondary outcomes included androgen biosynthesis inhibitor use in men with cardiovascular history, androgen receptor inhibitor use in men with neurocognitive history, and therapy within 14 days of death. Proportional hazards models were used to assess time-to-event outcomes, while logistic regression was used for binary outcomes. In men with high noncancer mortality risk, targeted therapy use did not differ at 340B participating compared to nonparticipating hospitals (hazard ratio [HR] 1.1, 95% CI 0.67-1.5). There was no difference in androgen biosynthesis inhibitor use in men with a prior cardiac event (HR 0.96, 95% CI 0.70-1.3) or androgen receptor inhibitor use in men with a prior neurocognitive event (HR 1.5, 95% CI 0.65-3.4) in those treated at 340B participating compared to nonparticipating hospitals. Therapy use in the last 14 days of life did not vary by 340B participation (odds ratio 1.3, 95% CI 0.86-1.9). In men with advanced prostate cancer, high-risk prescribing and futility measures did not vary by participation in the 340B drug pricing program.

Effects of state opioid prescribing laws on rates of fatal crashes in the USA

BackgroundState opioid prescribing cap laws, mandatory prescription drug monitoring programme query or enrolment laws and pill mill laws have been implemented across US states to curb high-risk opioid prescribing. Previous...

Pragmatic trial evaluating the impact of simulation training on high-risk prescribing to older adults by junior physicians.

High-risk medications like benzodiazepines, sedative hypnotics, and antipsychotics are commonly prescribed for hospitalized older adults, despite guidelines recommending avoidance. Prior interventions have not fully addressed how physicians make such prescribing decisions, particularly when experiencing stress or cognitive overload. Simulation training may help improve prescribing decision-making but has not been evaluated for overprescribing. In this two-arm pragmatic trial, we randomized 40 first-year medical resident physicians (i.e., interns) on inpatient general medicine services at an academic medical center to either intervention (a 40-minute immersive simulation training) or control (online educational training) groups. The primary outcome was the number of new benzodiazepine, sedative hypnotic, or antipsychotic orders for treatment-naïve older adults during hospitalization. Secondary outcomes included the same outcome by all providers, being discharged on one of the medications, and orders for related or control medications. Outcomes were measured using electronic health record data over each intern's service period (~2 weeks). Outcomes were evaluated using generalized estimating equations, adjusting for clustering. In total, 522 treatment-naïve older adult patients were included in analyses. Over follow-up, interns prescribed ≥1 high-risk medication for 13 (4.9%) intervention patients and 13 (5.0%) control patients. The intervention led to no difference in the number of new prescriptions (Rate Ratio [RR]: 0.85, 95%CI: 0.31-2.35) versus control and no difference in secondary outcomes. In secondary analyses, intervention interns wrote significantly fewer "as-needed" ("PRN") order types for the high-risk medications (RR: 0.29, 95%CI: 0.08-0.99), and instead tended to write more "one-time" orders than control interns, though this difference was not statistically significant (RR: 2.20, 95%CI: 0.60-7.99). Although this simulation intervention did not impact total high-risk prescribing for hospitalized older adults, it did influence how the interns prescribed, resulting in fewer PRN orders, suggesting possibly greater ownership of care. Future interventions should consider this insight and implementation lessons raised. Clinicaltrials.gov(NCT04668248).

Influence of Implementing an Opioid Stewardship Team in the Primary Care Setting.

Background: The Updated 2022 Centers for Disease Control (CDC) Clinical Practice Guideline for Prescribing Opioids for Pain highlights the importance of shared decision making and provider-patient relationships. Interprofessional teams may be helpful in supporting providers and patients. A large, multi-site primary care department created an interprofessional primary care opioid stewardship team to target high-risk opioid prescribing and improve practice alignment with CDC recommendations through dashboard reporting and education. Objective: The primary objective was to assess reduction in morphine milligram equivalents (MME) from baseline to 6 months in patients on opioid doses ≥90 MME daily. The secondary objective assessed change in number of naloxone prescriptions from baseline to 6 months after education. Methods: The study was conducted across 30 primary care sites of one health system within Michigan from 2021 to 2022. The opioid stewardship team included 2 physicians, 3 pharmacists, a project operations manager, and IT support. Interventions included creation of a dashboard, provider education, dissemination of policy, and chart audits. Using the electronic health record (EHR) dashboard, patients on chronic opioid doses ≥90 MME daily or missing an active naloxone prescription were identified. Primary care providers (PCP) were provided with an individual list of patients for whom to consider intervention. Support was provided for prescribers, but the team did not interact with patients directly. Results: Baseline analysis identified 290 patients on doses ≥ 90 MME daily. There was reduction in median daily MME from baseline to 6 months in the overall study population (140 [105 240] vs 120 [90 240], P < .001). At 6 months 181 (62.4%) of patients had been given a prescription for naloxone versus 108 (37.2%) who had one at baseline, P < .001. Conclusion: The initiatives implemented by the opioid stewardship team resulted in statistically significant reductions in MME and an increase in naloxone prescribing from baseline to 6 months post-education.

Medicines Regimens Charted for Older People Living in Residential Aged Care: A Repeated Cross-Sectional Study Describing the Number of Medicines, Regimen Complexity, High-Risk Prescribing, and Potential Underprescribing

ObjectiveWe aimed to explore medicines regimens charted for older people living in residential aged care facilities (RACFs). DesignRepeated cross-sectional study using routinely collected data sampled in a cross-sectional manner at 11 time points (day of admission, then at 1, 3, 7, 14, and 30 days, and 3, 6, 12, 18, and 24 months post admission). Setting and ParticipantsThe cohort is set in 34 RACFs managed by a single Australasian provider. People aged ≥65 years admitted to permanent care between January 1, 2017, and October 1, 2021, with medicines charted on the date of admission. MethodsMedicines charted were evaluated for potentially suboptimal prescribing including number of medicines, high-risk prescribing (eg, potentially inappropriate medicines, anticholinergic burden), and potential underprescribing. ResultsThe 3802 residents in the final cohort had a mean age of 84.9 ± 7.2 years at admission. At least 1 example of suboptimal prescribing was identified in 3479 (92%) residents at admission increasing to 1410 (97%) at 24 months. The number of medicines charted for each resident increased over time from 6.0 ± 3.8 regular and 2.8 ± 2.7 as required medicines at admission to 8.9 ± 4.1 regular and 8.1 ± 3.7 as required medicines at 24 months. Anticholinergic drug burden increased from 1.6 ± 2.4 at admission to 3.0 ± 2.8 at 24 months. Half the residents (2173; 57%) used at least 1 potentially inappropriate medicine at admission, which rose to nearly three-quarters (1060; 73%) at 24 months admission. Conclusion and ImplicationsThe total number of medicines charted for older adults living in RACFs increases with length of stay, with charted as required medicines nearly tripling. Effective interventions to optimize medicines use in this vulnerable population are required.

Unraveling Medication Complexity in the Elderly: A Critical Assessment of Adherence Implications

Background: Chronic illnesses often affect grown-ups over 60 years of age, leading to inadequate and impecunious medication adherence, which increases the risk of bleakness, hospitalization, and mortality, despite the irrefutably factual benefits of certain medications. Aim and Objectives: To appraise the degree of drug intricacy in older patients with chronic diseases and to break down the factors impacting drug adherence among them. Methodology: A 10-month study involving 676 patients was carried out at the general medicine department of a tertiary hospital. Information was gathered for the study using the Morisky Medication Adherence Scale (MMAS) and the Medicine Regimen Complexity Index (MRCI). Results: A sample size of 676 on the whole, with 393 male patients surmounting 283 female patients. The level of intricacy was higher for the larger part of prescriptions. On the off chance that around 645 patients were prescribed more than 5 drugs. The greater part of the populace has shown good adherence (59%), trailed by moderate adherence (23%), and ultimately low adherence (18%). The intricacy of the prescription was recognized as the essential driver of non-adherence in 314 patients, and upon analyzing the responses from MRCI and MMAS scores, it was found that 156 patients on less complicated regimens exhibited moderate and 399 patients had great adherence among the total populace. Conclusion: To further develop drug adherence in more seasoned adults, doctors ought to consider medicine class numbers, high-risk prescriptions, and multi-layered systems, including age-related, natural, and social variables.

Academic detailing to improve appropriate opioid prescribing: a mixed-methods process evaluation.

Academic detailing, an educational outreach service for family physicians, was funded by the Ontario government to address gaps in opioid prescribing and pain management. We sought to evaluate the impact of academic detailing on opioid prescribing, and to understand how and why academic detailing may have influenced opioid prescribing. In this mixed-methods study, we collected quantitative and qualitative data concurrently from 2017 to 2019 in Ontario, Canada. We analyzed prescribing outcomes descriptively for a sample of participating physicians and compared them with a matched control group. We invited physicians to participate in qualitative interviews to discuss their experiences in academic detailing. Development and analysis of qualitative interviews was informed by the Theoretical Domains Framework. We triangulated qualitative and quantitative findings to understand the mechanisms that drove changes in opioid prescribing. Physicians receiving academic detailing (n = 238) achieved a greater reduction in opioid prescribing than matched controls (n = 238). Seventeen physicians completed interviews and reported that academic detailing addressed barriers to pain care, including lack of confidence, difficult interactions with patients and prescribing and tapering decisions. Academic detailing reinforced knowledge about opioid prescribing and pain management. Discussion of complex patients and talking points to use during challenging conversations were described as key drivers of practice change. The findings of this real-world, mixed-methods evaluation explain how an academic detailing service addressed key barriers and enablers to limit high-risk opioid prescribing in primary care. This nuanced understanding will be used to inform, spread and scale academic detailing.

The Association of Cognitive Status and Post-Operative Opioid Prescribing in Older Adults.

To examine the differences in opioid prescribing by cognitive status following common elective surgical procedures among Medicare beneficiaries. Older individuals commonly experience changes in cognition with age. Although opioid prescribing is common after surgery, differences in opioid prescribing after surgery by cognitive status are poorly understood. We conducted a retrospective analysis of patients ≥65 years participating in the Health and Retirement Study (HRS) linked with Medicare claims data who underwent surgeries between January 2007 and November 2016 and had cognitive assessments before the index operation. Cognitive status was defined as normal cognition, mild cognitive impairment (MCI), or dementia. Outcomes assessed were initial perioperative opioid fill rates, refill rates, and high-risk prescriptions fill rates. The total amount of opioids filled during the 30-day postdischarge period was also assessed. Adjusted rates were estimated for patient factors using the Cochran-Armitage test for trend. Among the 1874 patients included in the analysis, 68% had normal cognition, 21.3% had MCI, and 10.7% had dementia. Patients with normal cognition (58.1%) and MCI (54.5%) had higher initial preoperative fill rates than patients with dementia (33.5%) (P < 0.001). Overall, patients with dementia had similar opioid refill rates (21%) to patients with normal cognition (24.1%) and MCI (26.5%) (P = 0.322). Although prior opioid exposure did not differ by cognitive status (P = 0.171), among patients with high chronic preoperative use, those with dementia had lower adjusted prescription sizes filled within 30 days following discharge (281 OME) than patients with normal cognition (2147 OME) and MCI (774 OME) (P < 0.001; P = 0.009 respectively). Among opioid-naive patients, patients with dementia also filled smaller prescription sizes (97 OME) compared to patients with normal cognition (205 OME) and patients with MCI (173 OME) (P < 0.001 and P = 0.019, respectively). Patients with dementia are less likely to receive postoperative prescriptions, less likely to refill prescriptions, and receive prescriptions of smaller sizes compared to patients with normal cognition or MCI. A cognitive assessment is an additional tool surgeons can use to determine a patient's individualized postoperative pain control plan.

Effects of an academic detailing service on benzodiazepine prescribing patterns in primary care.

Benzodiazepines are commonly used to treat anxiety and/or insomnia but are associated with substantial safety risks. Changes to prescribing patterns in primary care may be facilitated through tailored quality improvement strategies. Academic detailing (AD) may be an effective method of promoting safe benzodiazepine prescribing. The objective of this study was to evaluate the effectiveness of AD on benzodiazepine prescribing among family physicians. We used an interrupted time series matched cohort design using population-based administrative claims databases. Participants were family physicians practicing in Ontario, Canada. The intervention was a voluntary AD service which involves brief service-oriented educational outreach visits by a trained pharmacist. The focus was on key messages for safer benzodiazepine prescribing in primary care with an emphasis on judicious prescribing to older adults aged 65 and older. Physicians in the intervention group were those who received at least one AD visit on benzodiazepine use between June 2019 and February 2020. Physicians in the control group were included if they did not receive an AD visit during the study period. Intervention physicians were matched to control physicians 1:4, on a variety of characteristics. Physicians were excluded if they had inactive billing or billing of less than 100 unique patient visits in the calendar year prior to the index date. The primary outcome was mean total benzodiazepine prescriptions at the level of the physician. Secondary outcomes were rate (per 100) of patients with long-term prescriptions, high-risk prescriptions, newly started prescriptions, and benzodiazepine-related patient harms. Data were analyzed using a repeated measures pre-post comparison with an intention-to-treat. Analyses were then stratified to focus on effects within higher-prescribing physicians. There were 1337 physicians were included in the study; 237 who received AD and 1064 who did not. There was no significant change in benzodiazepine prescribing when considering all physicians in the intervention and matched control groups. Although not significant, a greater reduction in total benzodiazepine prescriptions was observed amongst the highest-volume prescribing physicians who received the intervention (% change in slope = -0.53, 95%CI = -2.34 to 1.30, p > .05). The main limitation of our study was the voluntary nature of the AD intervention, which may have introduced a self-selection bias of physicians most open to changing their prescribing. This study suggests that future AD interventions should focus on physicians with the greatest room for improvement to their prescribing.