Marcus A Bachhuber1,2, Denis Nash3,4, William N Southern5, Moonseong Heo1,6, Matthew Berger7, Mark Schepis7, Manu Thakral8, Chinazo O Cunningham1. 1. Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York. 2. Now with Section of Community and Population Medicine, Louisiana State University Health Sciences Center-New Orleans. 3. Institute for Implementation Science in Population Health, City University of New York, New York. 4. Graduate School of Public Health and Health Policy, Department of Epidemiology and Biostatistics, City University of New York, New York, New York. 5. Division of Hospital Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York. 6. Now with College of Behavioral, Social and Health Sciences, Department of Public Health Sciences, Clemson University, Clemson, South Carolina. 7. Montefiore Information Technology, Montefiore Medical Center, Bronx, New York. 8. College of Nursing and Health Sciences, University of Massachusetts Boston, Boston.
Abstract
Importance: Interventions to improve judicious prescribing of opioid analgesics for acute pain are needed owing to the risks of diversion, misuse, and overdose. Objective: To assess the effect of modifying opioid analgesic prescribing defaults in the electronic health record (EHR) on prescribing and health service use. Design, Setting, and Participants: A cluster randomized clinical trial with 2 parallel arms was conducted between June 13, 2016, and June 13, 2018, in a large urban health care system comprising 32 primary care and 4 emergency department (ED) sites in the Bronx, New York. Data were analyzed using a difference-in-differences method from 6 months before implementation through 18 months after implementation. Data were analyzed from January 2019 to February 2020. Interventions: A default dispense quantity for new opioid analgesic prescriptions of 10 tablets (intervention) vs no change (control) in the EHR. Main Outcomes and Measures: The primary outcome was the quantity of opioid analgesics prescribed with the new default prescription. Secondary outcomes were opioid analgesic reorders and health service use within 30 days after the new prescription. Intention-to-treat analysis was conducted. Results: Overall, 21 331 patients received a new opioid analgesic prescription from 490 prescribers. Comparing the intervention and control arms, site, prescriber, and patient characteristics were similar. For the new prescription, compared with the control arm, patients in the intervention arm had significantly more prescriptions for 10 tablets or fewer (7.6 percentage points; 95% CI, 6.1-9.2 percentage points), a lower number of tablets prescribed (-2.1 tablets; 95% CI, -3.3 to -0.9 tablets), and lower morphine milligram equivalents (MME) prescribed (-14.6 MME; 95% CI, -22.6 to -6.6 MME). Within 30 days after the new prescription, significant differences remained in the number of tablets prescribed (-2.7 tablets; 95% CI, -4.8 to -0.6 tablets), but not MME (-15.8 MME; 95% CI, -33.8 to 2.2 MME). Within this 30-day period, there were no significant differences between the arms in health service use. Conclusions and Relevance: In this study, implementation of a uniform reduced default dispense quantity of 10 tablets for opioid analgesic prescriptions led to a modest reduction in the quantity prescribed initially, without significantly increasing health service use. However, during 30 days after implementation, the influence on prescribing was mixed. Reducing EHR default dispense quantities for opioid analgesics is a feasible strategy that can be widely disseminated and may modestly reduce prescribing. Trial Registration: ClinicalTrials.gov Identifier: NCT03003832.
RCT Entities:
Importance: Interventions to improve judicious prescribing of opioid analgesics for acute pain are needed owing to the risks of diversion, misuse, and overdose. Objective: To assess the effect of modifying opioid analgesic prescribing defaults in the electronic health record (EHR) on prescribing and health service use. Design, Setting, and Participants: A cluster randomized clinical trial with 2 parallel arms was conducted between June 13, 2016, and June 13, 2018, in a large urban health care system comprising 32 primary care and 4 emergency department (ED) sites in the Bronx, New York. Data were analyzed using a difference-in-differences method from 6 months before implementation through 18 months after implementation. Data were analyzed from January 2019 to February 2020. Interventions: A default dispense quantity for new opioid analgesic prescriptions of 10 tablets (intervention) vs no change (control) in the EHR. Main Outcomes and Measures: The primary outcome was the quantity of opioid analgesics prescribed with the new default prescription. Secondary outcomes were opioid analgesic reorders and health service use within 30 days after the new prescription. Intention-to-treat analysis was conducted. Results: Overall, 21 331 patients received a new opioid analgesic prescription from 490 prescribers. Comparing the intervention and control arms, site, prescriber, and patient characteristics were similar. For the new prescription, compared with the control arm, patients in the intervention arm had significantly more prescriptions for 10 tablets or fewer (7.6 percentage points; 95% CI, 6.1-9.2 percentage points), a lower number of tablets prescribed (-2.1 tablets; 95% CI, -3.3 to -0.9 tablets), and lower morphine milligram equivalents (MME) prescribed (-14.6 MME; 95% CI, -22.6 to -6.6 MME). Within 30 days after the new prescription, significant differences remained in the number of tablets prescribed (-2.7 tablets; 95% CI, -4.8 to -0.6 tablets), but not MME (-15.8 MME; 95% CI, -33.8 to 2.2 MME). Within this 30-day period, there were no significant differences between the arms in health service use. Conclusions and Relevance: In this study, implementation of a uniform reduced default dispense quantity of 10 tablets for opioid analgesic prescriptions led to a modest reduction in the quantity prescribed initially, without significantly increasing health service use. However, during 30 days after implementation, the influence on prescribing was mixed. Reducing EHR default dispense quantities for opioid analgesics is a feasible strategy that can be widely disseminated and may modestly reduce prescribing. Trial Registration: ClinicalTrials.gov Identifier: NCT03003832.