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

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.

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Decline in primary care providers’ prescribing of Schedule II opioids following the implementation of federal and state guidelines

Journal of Opioid Management ◽

10.5055/jom.2019.0492 ◽

2019 ◽

Vol 15 (2) ◽

pp. 111-118 ◽

Cited By ~ 1

Author(s):

Lisa B. E. Shields, MD ◽

Timothy A. Johnson, BS ◽

James P. Murphy, MD ◽

Douglas J. Lorenz, PhD ◽

Alisha Bell, MSN, RN, CPN ◽

...

Keyword(s):

Primary Care ◽

Primary Care Providers ◽

The United States ◽

Prescription Opioid ◽

Care Practice ◽

Evidence Based ◽

Care Providers ◽

Prescribing Practices ◽

Prescription Opioid Misuse ◽

Morphine Equivalent

Objective: Prescription opioid misuse represents a social and economic dilemma in the United States. The authors evaluated primary care providers’ (PCPs) prescribing of Schedule II opioids at our institution in Kentucky.Design: Prospective evaluation of PCPs’ prescribing practices over a 3-year period (October 1, 2014 to September 30, 2017) in an outpatient setting.Methods: An analysis of Schedule II opioid prescribing following the implementation of federal and state guidelines and evidence-based standards. Special attention focused on Schedule II opioid prescriptions with a quantity 90, Opana/ Oxycontin, and morphine equivalent daily dosage.Results: A statistically significant increase in the total number of PCPs and PCPs who prescribed Schedule II opioids was observed, while there was a concurrent significant decrease in the average number of Schedule II opioid pills prescribed per PCP, Schedule II opioid prescriptions per PCP, Schedule II opioid pills prescribed per patient by PCPs, Schedule II opioid prescriptions with a quantity 90 per PCP, and Opana/Oxycontin prescriptions per PCP. A statistically significant decline in the average morphine equivalent daily dosage of Schedule II opioids per PCP was noted.Conclusions: This study reports the benefit of incorporating federal and state regulations and institutional evidence-based guidelines into primary care practice to decrease the number of Schedule II opioids prescribed. Further preventive measures include selecting alternative treatments to opioids and reducing the rates of opioid nonmedical use and overdose while maintaining access to prescription opioids when indicated.

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Do primary care providers who prescribe more opioids have higher patient panel satisfaction scores?

SAGE Open Medicine ◽

10.1177/2050312118782547 ◽

2018 ◽

Vol 6 ◽

pp. 205031211878254 ◽

Cited By ~ 6

Author(s):

Frederick North ◽

Sarah J Crane ◽

Jon O Ebbert ◽

Sidna M Tulledge-Scheitel

Keyword(s):

Primary Care ◽

Patient Satisfaction ◽

Pain Management ◽

Primary Care Providers ◽

The United States ◽

Care Providers ◽

Opioid Prescription ◽

Opioid Prescribing ◽

Patient Complexity ◽

Satisfaction Measures

Objectives: Opioid prescribing in the United States has tripled since 1999. At the same time, there has been increasing attention to patient satisfaction. It has been suggested that providers concerned about patient satisfaction may be more likely to treat pain with opioids. We examined primary care providers’ opioid prescribing practices to determine if higher provider opioid prescribing was associated with higher patient satisfaction. Methods: For 77 primary care providers, we compared each provider’s opioid prescription count and amount prescribed to each provider’s patient panel satisfaction measures. Satisfaction measures were obtained from surveys following office visits and consisted of Likert-type scale answers concerning satisfaction for pain management and other provider satisfaction domains. Satisfaction surveys were generated independent of patient complaint of pain and had the aim of overall assessment of patient satisfaction with the provider and the healthcare system. We assessed the correlation between opioid prescribing and patient panel pain management satisfaction using linear regression models with and without adjustment for patient complexity. Results: We observed no statistically significant correlation between patient panel satisfaction with their provider and the quantity of opioids that the provider prescribed (R2 = 0.006; p = 0.52). There was also no correlation between patient panel satisfaction and the number of opioid prescriptions written by their provider (R2 = 0.005; p = 0.54). Additional multivariate analysis after adjusting for patient complexity also demonstrated no correlation of pain management satisfaction with opioids prescribed. Although the quantity of opioid prescriptions was not correlated with pain management satisfaction, several other patient satisfaction measures correlated significantly with pain management satisfaction. Conclusion: Primary care providers with a greater rate of opioid prescribing did not have higher patient panel satisfaction scores for pain management. In primary care, providers who want to improve patient satisfaction should focus on other components of patient care besides opioid-based pain management.

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Variation in Diabetes Management: A National Assessment of Primary Care Providers

Journal of Diabetes Science and Technology ◽

10.1177/1932296819861662 ◽

2019 ◽

Vol 14 (1) ◽

pp. 70-76

Author(s):

John W. Peabody ◽

Enrico de Belen ◽

Jeffrey R. Dahlen ◽

Maria Czarina Acelajado ◽

Mary T. Tran ◽

...

Keyword(s):

Primary Care ◽

Glycemic Control ◽

Diabetes Management ◽

Glycemic Variability ◽

Primary Care Providers ◽

The United States ◽

Poor Glycemic Control ◽

Simulated Patients ◽

Evidence Based ◽

Care Providers

Background:Glucose control is monitored primarily through ordering HbA1c levels, which is problematic in patients with glycemic variability. Herein, we report on the management of these patients by board-certified primary care providers (PCPs) in the United States.Methods:We measured provider practice in a representative sample of 156 PCPs. All providers cared for simulated patients with diabetes presenting with symptoms of glycemic variability. Provider responses were reviewed by trained clinicians against evidence-based care standards and accepted standard of care protocols.Results:Care varied widely—overall quality of care averaged 51.3%±10.6%—with providers performing just over half the evidence-based practices necessary for their cases. More worryingly, provider identified the underlying etiology of the poor glycemic control only 36.3% of the time. HbA1c was routinely ordered in 91.3% of all cases but often (59.5%) inappropriately. Ordering other tests of glycemic control (done in 15% of cases) led to significant increases in identifying the etiology of the hyperglycemia. Correctly modifying their patient’s treatment was more likely to occur if doctors first identified the underlying etiology (65.9% vs 49.0%, P<0.001). We conservatively estimated a US $65/patient/visit in unnecessary testing and US $389 annually in additional care costs when the etiology was missed, translating potentially into millions of dollars of wasteful spending.Conclusion:Despite established evidence that HbA1c misses short-term changes in diabetes, we found PCPs consistently ordered HbA1c, rarely using other available blood tests. However, if the factors leading to poor glycemic control were recognized, PCPs were more likely to correctly alter their patient’s hypoglycemic therapy.

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Measuring and Improving Evidence-Based Patient Care Using a Web-Based Gamified Approach in Primary Care (QualityIQ): Randomized Controlled Trial (Preprint)

10.2196/preprints.31042 ◽

2021 ◽

Author(s):

Trever Burgon ◽

Linda Casebeer ◽

Holly Aasen ◽

Czarlota Valdenor ◽

Diana Tamondong-Lachica ◽

...

Keyword(s):

Primary Care ◽

Real Time ◽

Primary Care Physicians ◽

Primary Care Providers ◽

The United States ◽

Physician Satisfaction ◽

Evidence Based ◽

Clinical Decisions ◽

Care Providers ◽

Evidence Based Care

BACKGROUND Unwarranted variability in clinical practice is a challenging problem in practice today, leading to poor outcomes for patients and low-value care for providers, payers, and patients. OBJECTIVE In this study, we introduced a novel tool, QualityIQ, and determined the extent to which it helps primary care physicians to align care decisions with the latest best practices included in the Merit-Based Incentive Payment System (MIPS). METHODS We developed the fully automated QualityIQ patient simulation platform with real-time evidence-based feedback and gamified peer benchmarking. Each case included workup, diagnosis, and management questions with explicit evidence-based scoring criteria. We recruited practicing primary care physicians across the United States into the study via the web and conducted a cross-sectional study of clinical decisions among a national sample of primary care physicians, randomized to continuing medical education (CME) and non-CME study arms. Physicians “cared” for 8 weekly cases that covered typical primary care scenarios. We measured participation rates, changes in quality scores (including MIPS scores), self-reported practice change, and physician satisfaction with the tool. The primary outcomes for this study were evidence-based care scores within each case, adherence to MIPS measures, and variation in clinical decision-making among the primary care providers caring for the same patient. RESULTS We found strong, scalable engagement with the tool, with 75% of participants (61 non-CME and 59 CME) completing at least 6 of 8 total cases. We saw significant improvement in evidence-based clinical decisions across multiple conditions, such as diabetes (+8.3%, P<.001) and osteoarthritis (+7.6%, P=.003) and with MIPS-related quality measures, such as diabetes eye examinations (+22%, P<.001), depression screening (+11%, P<.001), and asthma medications (+33%, P<.001). Although the CME availability did not increase enrollment in the study, participants who were offered CME credits were more likely to complete at least 6 of the 8 cases. CONCLUSIONS Although CME availability did not prove to be important, the short, clinically detailed case simulations with real-time feedback and gamified peer benchmarking did lead to significant improvements in evidence-based care decisions among all practicing physicians. CLINICALTRIAL ClinicalTrials.gov NCT03800901; https://clinicaltrials.gov/ct2/show/NCT03800901

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Identification of barriers to safe opioid prescribing in primary care: a qualitative analysis of field notes collected through academic detailing

British Journal of General Practice ◽

10.3399/bjgp20x711737 ◽

2020 ◽

Vol 70 (697) ◽

pp. e589-e597 ◽

Cited By ~ 2

Author(s):

Christopher D Saffore ◽

Sarette T Tilton ◽

Stephanie Y Crawford ◽

Michael A Fischer ◽

Todd A Lee ◽

...

Keyword(s):

Primary Care ◽

Pain Management ◽

Qualitative Analysis ◽

Health System ◽

Primary Care Providers ◽

Academic Detailing ◽

Care Providers ◽

Opioid Prescribing ◽

Field Notes ◽

Safe Opioid Prescribing

Background Understanding barriers to safe opioid prescribing in primary care is critical amid the epidemic of prescription opioid abuse, misuse, and overdose in the US. Educational outreach strategies, such as academic detailing (AD), provide a forum for identification of barriers to, and strategies to facilitate, safe opioid prescribing in primary care.AimTo identify barriers to safe opioid prescribing among primary care providers (PCPs) through AD.Design and settingQualitative analysis of data was collected through an existing AD intervention to improve safe opioid prescribing in primary care. The AD intervention was delivered from June 2018 to August 2018 to licensed PCPs with prescriptive authority within a large independent health system in the metropolitan Chicagoland area.MethodThe AD intervention involved visits by trained detailers to PCPs who contemporaneously documented details from each visit via field notes. Using qualitative analysis, field notes were analysed to identify recurring themes related to opioid prescribing barriers.ResultsDetailer-entered field notes from 186 AD visits with PCPs were analysed. Barriers to safe opioid prescribing were organised into six themes: 1) gaps in knowledge; 2) lack of prescription monitoring programme (PMP) utilisation; 3) patient pressures to prescribe opioids; 4) insurance coverage policies; 5) provider beliefs; and 6) health system pain management practices.ConclusionBarriers to safe opioid prescribing in primary care, identified through AD visits among this large group of PCPs, support the need for continued efforts to enhance pain-management education, maximise PMP utilisation, and increase access to, and affordability of, non-opioid treatments.

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Influenza Antiviral Prescribing Practices and the Influence of Rapid Testing Among Primary Care Providers in the US, 2009–2016

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz192 ◽

2019 ◽

Vol 6 (6) ◽

Cited By ~ 3

Author(s):

Ashley L Fowlkes ◽

Andrea Steffens ◽

Carrie Reed ◽

Jonathan L Temte ◽

Angela P Campbell ◽

...

Keyword(s):

Primary Care ◽

Antiviral Treatment ◽

Multivariable Analysis ◽

Age Groups ◽

Primary Care Providers ◽

The United States ◽

Care Providers ◽

Prescribing Practices ◽

Surveillance Network ◽

Illness Onset

Abstract Background Early influenza antiviral treatment within 2 days of illness onset can reduce illness severity and duration. Reliance on low sensitivity rapid influenza diagnostic tests (RIDTs) to guide antiviral prescribing has been reported. We describe antiviral prescribing practices among primary care providers from a large surveillance network in the United States. Methods From 2009–2016, a network of 36 to 68 outpatient clinics per year collected respiratory specimens and clinical data for patients with influenza-like illness (ILI). Specimens were tested for influenza using polymerase chain reaction (PCR). We used multivariable logistic regression to assess factors influencing antiviral prescribing. Results Among 13 540 patients with ILI, 2766 (20%) were prescribed antivirals. In age groups recommended to receive empiric antiviral treatment for suspected influenza, 11% of children <2 years and 23% of adults ≥65 years received a prescription. Among 3681 patients with a positive PCR test for influenza, 40% tested negative by RIDT. In multivariable analysis, prescription receipt was strongly associated with a positive RIDT (adjusted odds ratio [aOR] 12, 95% CI 11–14) and symptom onset ≤2 days before visit (aOR 4.3, 95% CI 3.8–4.9). Antiviral prescribing was also more frequent among pediatric and private family practice clinics compared with community health centers (aOR 1.9, 95% CI 1.6–2.2, and 1.3, 95% CI 1.1–1.5, respectively). Conclusion Primary care providers were more likely to prescribe antivirals to patients with a positive RIDT, but antivirals were prescribed infrequently even to patients in high-risk age groups. Understanding patient and provider characteristics associated with antiviral prescribing is important for communicating treatment recommendations.

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Measuring and Improving Evidence-Based Patient Care Using a Web-Based Gamified Approach in Primary Care (QualityIQ): Randomized Controlled Trial

Journal of Medical Internet Research ◽

10.2196/31042 ◽

2021 ◽

Vol 23 (12) ◽

pp. e31042

Author(s):

Trever Burgon ◽

Linda Casebeer ◽

Holly Aasen ◽

Czarlota Valdenor ◽

Diana Tamondong-Lachica ◽

...

Keyword(s):

Primary Care ◽

Real Time ◽

Primary Care Physicians ◽

Primary Care Providers ◽

The United States ◽

Physician Satisfaction ◽

Evidence Based ◽

Clinical Decisions ◽

Care Providers ◽

Evidence Based Care

Background Unwarranted variability in clinical practice is a challenging problem in practice today, leading to poor outcomes for patients and low-value care for providers, payers, and patients. Objective In this study, we introduced a novel tool, QualityIQ, and determined the extent to which it helps primary care physicians to align care decisions with the latest best practices included in the Merit-Based Incentive Payment System (MIPS). Methods We developed the fully automated QualityIQ patient simulation platform with real-time evidence-based feedback and gamified peer benchmarking. Each case included workup, diagnosis, and management questions with explicit evidence-based scoring criteria. We recruited practicing primary care physicians across the United States into the study via the web and conducted a cross-sectional study of clinical decisions among a national sample of primary care physicians, randomized to continuing medical education (CME) and non-CME study arms. Physicians “cared” for 8 weekly cases that covered typical primary care scenarios. We measured participation rates, changes in quality scores (including MIPS scores), self-reported practice change, and physician satisfaction with the tool. The primary outcomes for this study were evidence-based care scores within each case, adherence to MIPS measures, and variation in clinical decision-making among the primary care providers caring for the same patient. Results We found strong, scalable engagement with the tool, with 75% of participants (61 non-CME and 59 CME) completing at least 6 of 8 total cases. We saw significant improvement in evidence-based clinical decisions across multiple conditions, such as diabetes (+8.3%, P<.001) and osteoarthritis (+7.6%, P=.003) and with MIPS-related quality measures, such as diabetes eye examinations (+22%, P<.001), depression screening (+11%, P<.001), and asthma medications (+33%, P<.001). Although the CME availability did not increase enrollment in the study, participants who were offered CME credits were more likely to complete at least 6 of the 8 cases. Conclusions Although CME availability did not prove to be important, the short, clinically detailed case simulations with real-time feedback and gamified peer benchmarking did lead to significant improvements in evidence-based care decisions among all practicing physicians. Trial Registration ClinicalTrials.gov NCT03800901; https://clinicaltrials.gov/ct2/show/NCT03800901

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145. Monthly Antibiotic Prescribing Peer Comparison Combined with In-person Education Decreases Antibiotic Prescribing for Acute Respiratory Infections

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.190 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S83-S83

Author(s):

Shelby J Kolo ◽

David J Taber ◽

Ronald G Washburn ◽

Katherine A Pleasants

Keyword(s):

Primary Care ◽

Respiratory Infections ◽

Primary Care Providers ◽

The United States ◽

Delivery Mode ◽

Antibiotic Prescribing ◽

Acute Respiratory Infections ◽

Care Providers ◽

Intervention Period ◽

Provider Education

Abstract Background Inappropriate antibiotic prescribing is an important modifiable risk factor for antibiotic resistance. Approximately half of all antibiotics prescribed for acute respiratory infections (ARIs) in the United States may be inappropriate or unnecessary. The purpose of this quality improvement (QI) project was to evaluate the effect of three consecutive interventions on improving antibiotic prescribing for ARIs (i.e., pharyngitis, rhinosinusitis, bronchitis, common cold). Methods This was a pre-post analysis of an antimicrobial stewardship QI initiative to improve antibiotic prescribing for ARIs in six Veterans Affairs (VA) primary care clinics. Three distinct intervention phases occurred. Educational interventions included training on appropriate antibiotic prescribing for ARIs. During the first intervention period (8/2017-1/2019), education was presented virtually to primary care providers on a single occasion. In the second intervention period (2/2019-10/2019), in-person education with peer comparison was presented on a single occasion. In the third intervention period (11/2019-4/2020), education and prescribing feedback with peer comparison was presented once in-person followed by monthly emails of prescribing feedback with peer comparison. January 2016-July 2017 was used as a pre-intervention baseline period. The primary outcome was the antibiotic prescribing rate for all classifications of ARIs. Secondary outcomes included adherence to antibiotic prescribing guidance for pharyngitis and rhinosinusitis. Descriptive statistics and interrupted time series segmented regression were used to analyze the outcomes. Results Monthly antibiotic prescribing peer comparison emails in combination with in-person education was associated with a statistically significant 12.5% reduction in the rate of antibiotic prescribing for ARIs (p=0.0019). When provider education alone was used, the reduction in antibiotic prescribing was nonsignificant. Conclusion Education alone does not significantly reduce antibiotic prescribing for ARIs, regardless of the delivery mode. In contrast, education followed by monthly prescribing feedback with peer comparison was associated with a statistically significant reduction in ARI antibiotic prescribing rates. Disclosures All Authors: No reported disclosures

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Engaging primary care providers in managing pediatric eating disorders: a mixed methods study

Journal of Eating Disorders ◽

10.1186/s40337-020-00363-8 ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Jocelyn Lebow ◽

Cassandra Narr ◽

Angela Mattke ◽

Janna R. Gewirtz O’Brien ◽

Marcie Billings ◽

...

Keyword(s):

Primary Care ◽

Eating Disorders ◽

Mixed Methods ◽

Care Setting ◽

Primary Care Setting ◽

Primary Care Providers ◽

Mixed Methods Study ◽

Evidence Based ◽

Care Providers ◽

Evidence Based Treatment

Abstract Background The primary care setting offers an attractive opportunity for, not only the identification of pediatric eating disorders, but also the delivery of evidence-based treatment. However, constraints of this setting pose barriers for implementing treatment. For interventions to be successful, they need to take into consideration the perspectives of stakeholders. As such, the purpose of this study was to examine in-depth primary care providers’ perspective of challenges to identifying and managing eating disorders in the primary care setting. Methods This mixed methods study surveyed 60 Pediatric and Family Medicine providers across 6 primary care practices. Sixteen of these providers were further interviewed using a qualitative, semi-structured interview. Results Providers (n = 60, response rate of 45%) acknowledged the potential of primary care as a point of contact for early identification and treatment of pediatric eating disorders. They also expressed that this was an area of need in their practices. They identified numerous barriers to successful implementation of evidence-based treatment in this setting including scarcity of time, knowledge, and resources. Conclusions Investigations seeking to build capacities in primary care settings to address eating disorders must address these barriers.

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