scholarly journals Adoption of opioid-prescribing guidelines in primary care: a realist synthesis of contextual factors

BMJ Open ◽  
2021 ◽  
Vol 11 (12) ◽  
pp. e053816
Author(s):  
Nora Jacobson ◽  
Roberta A Johnson ◽  
Christie Schlabach ◽  
Jillian Incha ◽  
Lynn Madden ◽  
...  
Keyword(s):  
Primary Care ◽  
Contextual Factors ◽  
Static Model ◽  
Realist Synthesis ◽  
Prescribing Practices ◽  
Opioid Prescribing ◽  
Primary Care Settings ◽  
Registration Number ◽  
The Individual ◽  
Structural Mechanisms

ObjectiveAs part of an effort to design an implementation strategy tailoring tool, our research group sought to understand what is known about how contextual factors and prescriber characteristics affect the adoption of guideline-concordant opioid-prescribing practices in primary care settings.DesignWe conducted a realist synthesis of 71 articles.ResultsWe found that adoption is related to contextual factors at the individual, clinic, health system and environmental levels, which operate via intrapersonal, interpersonal, organisational and structural mechanisms.ConclusionA single static model cannot capture the complexity of the relationships between contexts, mechanisms and outcomes. Instead, a deeper understanding requires a dynamic model that conceptualises clusters of contextual factors and mechanisms that tend towards guideline concordance and clusters that tend toward non-concordance.Trail registration numberClinicalTrial.gov registration number NCT04044521.

scholarly journals Evaluating the implementation of a primary care intervention to reduce prescriptions of benzodiazepines (BENZORED IV)

2021 ◽  
Author(s):  
Isabel Socias ◽  
Alfonso Leiva ◽  
Haizea Pombo-Ramos ◽  
Ferran Bejarano ◽  
Ermengol Sempere-Verdú ◽  
...  
Keyword(s):  
Primary Care ◽  
Traffic Accidents ◽  
Implementation Strategies ◽  
Developed Countries ◽  
Successful Implementation ◽  
Implementation Climate ◽  
Primary Care Settings ◽  
The Individual

Abstract Background: General practitioners (GPs) in developed countries widely prescribe benzodiazepines (BZDs) for their anxiolytic, hypnotic, and muscle-relaxant effects. Treatment duration, however, is rarely limited and this results in a significant number of chronic users. Long-term BZD use is associated with cognitive impairment, falls with hip fractures, traffic accidents, and increased mortality. The BENZORED IV trial was a hybrid type 1 trial conducted to evaluate the effectiveness and implementation of an intervention to reduce BZD prescription in primary care. The purpose of this qualitative study was to analyze facilitator and barriers to implement the intervention to primary care settings.Methods: Focus group meetings with GPs from the intervention arm of the BENZORED IV trial were held at primary healthcare centers in the three districts. For sampling purposes, the GPs were classified as high or low implementers according to the success of the intervention measured at 12 months. The Consolidated Framework for Implementation Research (CFIR) was used to conduct the meetings and to code, rate and analyze the dataResults: Three of the 41 CFIR constructs strongly distinguished between high and low implementers: The complexity in the intervention, the individual Stage of Change and the key stakeholder’s engagement. Seven constructs weakly discriminated between the two groups: the adaptability in the intervention, the external policy and incentives, the implementation climate, the relative priority, the self-efficacy and formally appointed implementation leader engaging. Fourteen constructs did not discriminate between the two groups, six had insufficient data for evaluation, and eleven had no data for evaluation.Conclusion: We identified constructs that could explain the variation in the implementation of the intervention, this information is relevant to design successful implementation strategies to implement the intervention.

scholarly journals Using normalisation process theory to understand workflow implications of decision support implementation across diverse primary care settings

2019 ◽  
Vol 26 (1) ◽  
pp. e100088
Author(s):  
Rebecca G Mishuris ◽  
Joseph Palmisano ◽  
Lauren McCullagh ◽  
Rachel Hess ◽  
David A Feldstein ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Support ◽  
Clinical Decision ◽  
Process Theory ◽  
Normalisation Process Theory ◽  
Implementation Barriers ◽  
Clinical Workflow ◽  
Primary Care Settings ◽  
Registration Number

BackgroundEffective implementation of technologies into clinical workflow is hampered by lack of integration into daily activities. Normalisation process theory (NPT) can be used to describe the kinds of ‘work’ necessary to implement and embed complex new practices. We determined the suitability of NPT to assess the facilitators, barriers and ‘work’ of implementation of two clinical decision support (CDS) tools across diverse care settings.MethodsWe conducted baseline and 6-month follow-up quantitative surveys of clinic leadership at two academic institutions’ primary care clinics randomised to the intervention arm of a larger study. The survey was adapted from the NPT toolkit, analysing four implementation domains: sense-making, participation, action, monitoring. Domains were summarised among completed responses (n=60) and examined by role, institution, and time.ResultsThe median score for each NPT domain was the same across roles and institutions at baseline, and decreased at 6 months. At 6 months, clinic managers’ participation domain (p=0.003), and all domains for medical directors (p<0.003) declined. At 6 months, the action domain decreased among Utah respondents (p=0.03), and all domains decreased among Wisconsin respondents (p≤0.008).ConclusionsThis study employed NPT to longitudinally assess the implementation barriers of new CDS. The consistency of results across participant roles suggests similarities in the work each role took on during implementation. The decline in engagement over time suggests the need for more frequent contact to maintain momentum. Using NPT to evaluate this implementation provides insight into domains which can be addressed with participants to improve success of new electronic health record technologies.Trial registration numberNCT02534987.

scholarly journals Primary Care Providers’ Knowledge, Attitudes, and Beliefs About HIV Pre-Exposure Prophylaxis (PrEP): Informing Network-Based Interventions

2021 ◽  
Vol 33 (4) ◽  
pp. 325-344
Author(s):  
Erik D. Storholm ◽  
Allison J. Ober ◽  
Matthew L. Mizel ◽  
Luke Matthews ◽  
Matthew Sargent ◽  
...  
Keyword(s):  
Primary Care ◽  
Claims Data ◽  
Primary Care Providers ◽  
Attitudes And Beliefs ◽  
Care Providers ◽  
Provider Education ◽  
Prescribing Practices ◽  
Sexually Transmitted ◽  
Primary Care Settings ◽  
Exposure Prophylaxis

Increasing access to pre-exposure prophylaxis (PrEP) in primary care settings for patients who may be at risk for HIV could help to increase PrEP uptake, which has remained low among certain key risk populations. The current study conducted interviews with primary care providers identified from national claims data as having either high or low likelihood of serving PrEP-eligible patients based on their prescribing practices for other sexually transmitted infections. The study yielded important information about primary care providers’ knowledge, attitudes, and beliefs about PrEP, as well as the barriers and facilitators to prescribing PrEP. Key recommendations for a provider-focused intervention to increase PrEP prescribing among primary care providers, including increasing patient education to increase demand from providers, enhancing provider education, leveraging technology, and instituting standardized sexual health checks, are provided with the goal of informing network-based interventions.

Exploring the social ecology for appropriate antibiotic prescribing and stewardship in primary care: presenting the VALUE driven model of practice derived from qualitative analysis of public and private care settings in Singapore

2021 ◽  
Author(s):  
Huiling Guo ◽  
Zoe Jane-Lara Hildon ◽  
Victor Weng Keong Loh ◽  
Meena Sundram ◽  
Muhamad Alif Bin Ibrahim ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Making ◽  
Care Delivery ◽  
Antibiotic Prescribing ◽  
Publicly Funded ◽  
Prescribing Practices ◽  
National Guidelines ◽  
Optimal Care ◽  
Public And Private ◽  
Primary Care Settings

Abstract Background: Singapore’s healthcare system allows both antibiotic prescribing and dispensing across public and private primary care settings, presenting an ideal context to learn from systems where dispensing is closely tied to diverse operational models and funding mechanisms. Aim: To explore processes underpinning decision-making for antibiotic prescribing by primary care doctors in Singapore, by examining doctors’ experiences in different primary care settings. Methods: Thirty semi-structured interviews were conducted with 17 doctors working in publicly funded primary care clinics (polyclinics) and 13 doctors working in private general practitioner (GP) clinics (solo, small group and large group practices). Interviews were audio-recorded and transcribed verbatim. Data were analysed using applied thematic analysis. Results: Given the lack of National Guidelines for antibiotic prescribing in the Singapore context, this practice is currently non-standardised in both private and publicly funded primary care settings. Themes contributing to best practice narratives relate to having independent funding sources and control over drug formulary orders, and valuing reduction in antimicrobial resistance (AMR). The existence of trusting patient-doctor relationships, and reasonable patient loads were observed to allow joint participatory and informed decision-making that further enabled appropriate prescribing. The importance of monitoring and application of data/evaluations to inform practice was a minority theme, nevertheless underpinning all levels of optimal care delivery.Conclusions: A model for appropriate antibiotic prescribing-related interventions needs to prioritise addressing and shaping organisational and personal Valuing of AMR reduction. These values have to also Align with wider systemic constraints experienced in publicly funded institutions, operational management of private clinics and interactions with patients at the interpersonal level. The overcoming of such constraints and allowing time for patient Liaison and trust building will crystalise these earlier initiatives. Use of data to monitor and Evaluate antibiotic prescribing, informing optimal delivery systems should be routinely shared for transparency and to improve prescribing practices. These dimensions are summarised in the VALUE model for appropriate antibiotic prescribing and stewardship in primary care, which is recommended as transferable to diverse contexts.

Reduction in Schedule II opioid prescribing by primary care providers, orthopedic and general surgeons, and pain management specialists following the implementation of a State House Bill and an Institutional Controlled Substance Task Force

2021 ◽  
Vol 17 (2) ◽  
pp. 155-167
Author(s):  
Lisa B. E. Shields, MD ◽  
Timothy A. Johnson, BS ◽  
Michael W. Daniels, MS ◽  
Alisha Bell, MSN, RN, CPN ◽  
Diane M. Siemens, PharmD ◽  
...  
Keyword(s):  
Primary Care ◽  
Pain Management ◽  
Primary Care Providers ◽  
The United States ◽  
Prescription Opioid ◽  
Evidence Based ◽  
Care Providers ◽  
Prescribing Practices ◽  
Opioid Prescribing ◽  
General Surgeons

Objective: Prescription opioid misuse represents a social and economic challenge in the United States. We evaluated Schedule II opioid prescribing practices by primary care providers (PCPs), orthopedic and general surgeons, and pain management specialists.Design: Prospective evaluation of prescribing practices of PCPs, orthopedic and general surgeons, and pain management specialists over 5 years (October 1, 2014-September 30, 2019) in an outpatient setting.Methods: An analysis of Schedule II opioid prescribing following the implementation of federal and state guidelines and evidence-based standards at our institution. Results: There were significantly more PCPs, orthopedic and general surgeons, and pain management specialists with a significantly increased number who prescribed Schedule II opioids, whereas there was a simultaneous significant decline in the average number of Schedule II opioid prescriptions per provider, Schedule II opioid pills prescribed per provider, and Schedule II opioid pills prescribed per patient by providers. The average number of Schedule II opioid prescriptions with a quantity 90 and Opana/Oxycontin prescriptions per PCP, orthopedic surgeon, and pain management specialist significantly decreased. The total morphine milligram equivalent (MME)/day of Schedule II opioids ordered by PCPs, orthopedic and general surgeons, and pain management specialists significantly declined. The ages of the providers remained consistent throughout the study. Conclusions: This study reports the implementation of federal and state regulations and institutional evidence-based guidelines into primary care and medical specialty practices to reduce the number of Schedule II opioids prescribed. Further research is warranted to determine alternative therapies to Schedule II opioids that may alleviate a patient’s pain without initiating or exacerbating a potentially lethal opioid addiction.

Novel peer review method for improving controlled substance prescribing in primary care

2016 ◽  
Vol 12 (4) ◽  
pp. 269 ◽  
Author(s):  
Brian Penti, MD, MS ◽  
Jane M. Liebschutz, MD, MPH, FACP ◽  
Brian Kopcza, PharmD, BCACP ◽  
Ziming Xuan, ScD ◽  
Christine Odell, MD, MSc ◽  
...  
Keyword(s):  
Primary Care ◽  
Family Medicine ◽  
Teaching Hospital ◽  
Chart Review ◽  
Peer Feedback ◽  
Safety Net ◽  
Prescribing Practices ◽  
Opioid Prescribing ◽  
Medicine Clinic ◽  
Urban Safety

Objective: Determine if peer feedback through a chart review tool (CRT) can impact opioid prescribing for patients with chronic noncancer pain in an outpatient family medicine clinic at an urban, safety-net teaching hospital and to assess providing practices.Design: A quality improvement (QI) project, comparing preopioid and postopioid prescribing practices.Setting: Outpatient family medicine clinic at urban, safety-net teaching hospital. Patients, Participants: A convenience sample of 16 family medicine physicians. Interventions: A CRT was developed to allow physicians to give peer feedback to one another about their opioid prescribing practices as part of a 1-year QI project. We assessed the deidentified data gathered from the CRT.Main Outcome Measure(s): Primary study outcome measures were the amount of opioids prescribed at the end of the QI project compared to the time of initial chart review. We also describe overall prescribing practices.Results: Ninety-nine patient charts from 14 different physicians were reviewed over 1 year. Sixty percent of patients had at least one violation of the clinic's controlled substance prescribing policy in the prior 6 months, and half of the violations were due to missed appointments with specialists to help manage pain. The mean dose of opioids decreased 2.6 mg morphine equivalent dose (MED)/day from time of chart review until the end of project, compared to a 6.9 mg MED/day increase that occurred from 12 months prior to chart review to the time of chart review (p = 0.01). Fourteen patients (16 percent) of patients prescribed opioids were takenoff of opioids after the chart review.Conclusions: Use of a CRT in an urban primary care clinic provided helpful insight on prescribing practices and has promise to improve quality of opioid prescribing.

scholarly journals How French general practitioners adapt their care to patients with social difficulties?

2019 ◽  
Vol 7 (4) ◽  
pp. e000044
Author(s):  
Annie De Oliveira ◽  
Barbara Chavannes ◽  
Magali Steinecker ◽  
Mady Denantes ◽  
Julie Chastang ◽  
...  
Keyword(s):  
Primary Care ◽  
Focus Groups ◽  
General Practitioners ◽  
Social Inequalities ◽  
Pay For Performance ◽  
Health Sector ◽  
Primary Care Settings ◽  
The Social ◽  
Social Difficulties ◽  
The Individual

ObjectiveSeveral studies have shown the role of the primary care system in access to care and in reducing social inequalities in health. The objective of this study was to describe the practices of general practitioners (GPs) in taking into account the social environment of their patient, and the ways they adapted to social difficulties.DesignQualitative study comprising interviews and focus groups.SettingFrench primary care settings.ParticipantsTwenty semistructured interviews and two focus groups were conducted with 33 GPs. Sessions were audio recorded, transcribed verbatim and analysed using thematic analysis. The reporting of findings was guided by consolidated criteria for reporting qualitative research.ResultThis study identified adaptations at three levels: in the individual management of patients (alert system, full involvement in prevention, better communication, prioritised additional examinations, financial facilities, help in administrative tasks), in the collective management of patients in an office (consultation without appointment, pay-for-performance indicators, medical staffs, multidisciplinary protocols, medical practice in group, medical student), and in the community management (patients description, cooperation with associations, public health sector and politics).ConclusionIn France, GPs can take into account the social determinants of health in practice through simple or more complex actions.

scholarly journals Systems consultation for opioid prescribing in primary care: a qualitative study of adaptation

2018 ◽  
Vol 28 (5) ◽  
pp. 397-404 ◽  
Author(s):  
Nora Jacobson ◽  
Roberta Johnson ◽  
Bri Deyo ◽  
Esra Alagoz ◽  
Andrew Quanbeck
Keyword(s):  
Primary Care ◽  
Implementation Strategy ◽  
Descriptive Analysis ◽  
Hierarchical Structures ◽  
Organisational Change ◽  
Pilot Test ◽  
Prescribing Practices ◽  
Opioid Prescribing ◽  
Key Characteristics ◽  
Change Teams

BackgroundIn order to promote guideline-concordant opioid prescribing practices, a blended implementation strategy called systems consultation was pilot tested in four primary care clinics in one US health system.ObjectivesTo describe (1) how systems consultation worked during the pilot test and (2) the modifications necessary to adapt this implementation strategy to primary care.MethodsA team of investigators conducted observations (n=24), focus groups (n=4) and interviews (n=2). The team; kept contact logs documenting all interactions with the intervention clinics and preserved all work products resulting from the intervention. Initial analysis was concurrent with data collection and findings were used to modify the intervention in real time. At the conclusion of the pilot test, a pragmatic descriptive analysis of all data was performed to explore key modifications.ResultsTime constraints, entrenched hierarchical structures and a lack of quality improvement skills among clinical staff were the main barriers to implementing systems consultation. Modifications made to address these conditions included creating a consulting team, giving change teams more direction, revising process improvement tools, supporting the use of electronic health record (EHR) functionalities and providing opportunities for shared learning among clinics.Discussion and conclusionWith the lessons of this research in mind, our goal in future iterations of systems consultation is to give clinics a combination of clinical, organisational change and EHR expertise optimised according to their needs. We believe a streamlined process for assessing the key characteristics identified in this study can be used to develop a plan for this kind of optimisation, or tailoring, and we will be developing such a process as part of an upcoming clinical trial.

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