Association of Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in Emergency Departments

Jcc, Montoy; Coralic, Zlatan; Aa, Herring; Ej, Clattenburg; Mc, Raven

doi:10.1001/jamainternmed.2019.6544

Cited by 41 publications

(66 citation statements)

References 28 publications

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“…RenderX demonstrated that each tablet increase in preset yielded an increase of 0.19 tablets prescribed, and lower default quantities were associated with lower number of pills in 8 of 15 pairwise comparisons [25]. These results support our approach that modifications to prescription presets are an effective way to enact change in opioid prescribing.…”

Section: Xsl • Fosupporting

confidence: 70%

“…Despite a number of publications demonstrating reductions in opioid prescribing through presets [22,23,25], to our knowledge this research is the first to demonstrate reduction in overall opioid prescribing and prescribing of multiple individual opioids for an entire hospital system. Our hospitals and ambulatory clinics are located in one of the most lethal counties in one of the most lethal states associated with the opioid epidemic [38][39][40].…”

Section: Xsl • Fomentioning

confidence: 76%

“…In order to curb overprescribing and reduce quantities of tablets, CPOE-linked interventions focus on preset defaulted prescription settings [22][23][24]. Previous studies have shown that the introduction or modification of opioid prescription presets has demonstrated reductions of tablet quantities and prescription MME for postsurgical patients [22], as well as significant reductions in the number of tablet quantities dispensed in the emergency department (ED) [23,25]. These studies suggest that modification of EHR-linked CPOE settings is a simple, inexpensive, and effective method of reducing the number of tablets associated with opioid prescriptions.…”

Section: Introductionmentioning

confidence: 99%

“…These studies suggest that modification of EHR-linked CPOE settings is a simple, inexpensive, and effective method of reducing the number of tablets associated with opioid prescriptions. However, all previous studies have focused on isolated emergency [23][24][25][26][27] or surgery departments [22]. We are unaware of any research examining the effects of modifications to opioid presets across an entire hospital system.…”

Section: Introductionmentioning

confidence: 99%

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Reduction in Hospital System Opioid Prescribing for Acute Pain Through Default Prescription Preference Settings: Pre–Post Study (Preprint)

Slovis¹,

Riggio²,

Girondo³

et al. 2020

Preprint

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BACKGROUND The United States is in an opioid epidemic. Passive decision support in the electronic health record (EHR) through opioid prescription presets may aid in curbing opioid dependence. OBJECTIVE The objective of this study is to determine whether modification of opioid prescribing presets in the EHR could change prescribing patterns for an entire hospital system. METHODS We performed a quasi-experimental retrospective pre–post analysis of a 24-month period before and after modifications to our EHR’s opioid prescription presets to match Centers for Disease Control and Prevention guidelines. We included all opioid prescriptions prescribed at our institution for nonchronic pain. Our modifications to the EHR include (1) making duration of treatment for an opioid prescription mandatory, (2) adding a quick button for 3 days’ duration while removing others, and (3) setting the default quantity of all oral opioid formulations to 10 tablets. We examined the quantity in tablets, duration in days, and proportion of prescriptions greater than 90 morphine milligram equivalents/day for our hospital system, and compared these values before and after our intervention for effect. RESULTS There were 78,246 prescriptions included in our study written on 30,975 unique patients. There was a significant reduction for all opioid prescriptions pre versus post in (1) the overall median quantity of tablets dispensed (54 [IQR 40-120] vs 42 [IQR 18-90]; P<.001), (2) median duration of treatment (10.5 days [IQR 5.0-30] vs 7.5 days [IQR 3.0-30]; P<.001), and (3) proportion of prescriptions greater than 90 morphine milligram equivalents/day (27.46% [10,704/38,976; 95% CI 27.02%-27.91%] vs 22.86% [8979/39,270; 95% CI 22.45%-23.28%]; P<.001). CONCLUSIONS Modifications of opioid prescribing presets in the EHR can improve prescribing practice patterns. Reducing duration and quantity of opioid prescriptions could reduce the risk of dependence and overdose.

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Section: Xsl • Fosupporting

confidence: 70%

Section: Xsl • Fomentioning

confidence: 76%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Reduction in Hospital System Opioid Prescribing for Acute Pain Through Default Prescription Preference Settings: Pre–Post Study (Preprint)

Slovis¹,

Riggio²,

Girondo³

et al. 2020

Preprint

View full text Add to dashboard Cite

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“…In 10 recent studies, implementing a new or lower default dispense quantity for opioid analgesics, either alone or as part of a package of interventions, was associated with reductions in the quantity of new prescriptions. 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 In 2 studies, removing defaults, and therefore requiring prescribers to make an active choice with each prescription, yielded mixed results. 23 , 25 …”

Section: Introductionmentioning

confidence: 99%

Effect of Changing Electronic Health Record Opioid Analgesic Dispense Quantity Defaults on the Quantity Prescribed

et al. 2021

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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 PARTICIPANTSA 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 RELEVANCEIn 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 (continued) Key Points Question Does reducing the default number of tablets for opioid analgesic prescriptions in the electronic health record influence prescribing or other outcomes? Findings In this cluster randomized clinical trial of 32 primary care and 4 emergency department sites, with a total of 21 331 prescriptions, a reduced uniform default dispense quantity of 10 tablets led to an increase in the percentage of prescriptions for 10 tablets or fewer (7.6 percentage points). No significant difference in health service use was noted. Meaning Find...

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Effect of Pharmacist Email Alerts on Concurrent Prescribing of Opioids and Benzodiazepines by Prescribers and Primary Care Managers

et al. 2022

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ImportancePolicy makers have sought to discourage concurrent prescribing of opioids and benzodiazepines (coprescribing) because it is associated with overdose. Email alerts sent by pharmacists may reduce coprescribing, but this intervention lacks randomized evidence.ObjectiveTo investigate whether pharmacist emails to practitioners caring for patients who recently received opioids and benzodiazepines reduce coprescribing of these medications.Design, Setting, and ParticipantsRandomized clinical trial (intention to treat) conducted in 2019-2021 of patients and their practitioners (prescribers and primary care managers) in the National Capital Region of the Military Health System. Participants were 2237 patients who were recently coprescribed opioids and benzodiazepines. These patients had 789 practitioners eligible for emails.InterventionsPatients were randomized to email alerts to their practitioners or as-usual care. Clinical pharmacists sent the email alert. Messages were standardized and designed to facilitate coordination between practitioners, increase awareness of guidelines, and provide action steps and resources.Main Outcomes and MeasuresThe primary outcomes were patients’ days received of opioids, benzodiazepines, and concurrent opioids and benzodiazepines during the 90 days following enrollment evaluated using 1-sided hypothesis tests. Secondary outcomes included total prescribing of opioids and benzodiazepines by patients’ practitioners, including to patients outside the study, to test for broader outcomes on their prescribing.ResultsOf 2237 patients, 1187 were assigned to treatment and 1050 to control; 1275 (57%) were women. Patients received a mean (SD) of 31 (44) days of opioids and 33 (34) days of benzodiazepines in the 90 days before enrollment. There were no detected differences in the primary end points, including patients’ receipt of opioids (adjusted difference, 1.1 days; 95% CI, -∞ to 3.0; P = .81), benzodiazepines (adjusted difference, −0.6 days; 95% CI, -∞ to 1.4; P = .30), and opioids and benzodiazepines together (adjusted difference, −0.1 days; 95% CI, -∞ to 0.7; P = .41). Of 789 practitioners, 429 were considered the treatment group, 325 were considered controls, and 35 were excluded. There were no detected differences in practitioners’ total prescribing of opioids, benzodiazepines, or both drug classes together.Conclusions and RelevanceIn this randomized clinical trial of pharmacist emails to practitioners, email alerts failed to detectably reduce coprescribing, highlighting the value of alternative approaches. Combining randomization with quality improvement activities may help stakeholders seeking evidence-based interventions to encourage guideline-concordant care.Trial RegistrationClinicalTrials.gov Identifier: NCT03887247

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Association of Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in Emergency Departments

Cited by 41 publications

References 28 publications

Reduction in Hospital System Opioid Prescribing for Acute Pain Through Default Prescription Preference Settings: Pre–Post Study (Preprint)

Reduction in Hospital System Opioid Prescribing for Acute Pain Through Default Prescription Preference Settings: Pre–Post Study (Preprint)

Effect of Changing Electronic Health Record Opioid Analgesic Dispense Quantity Defaults on the Quantity Prescribed

Effect of Pharmacist Email Alerts on Concurrent Prescribing of Opioids and Benzodiazepines by Prescribers and Primary Care Managers

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