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Association of Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in Emergency Departments: A Randomized Quality Improvement Study.
JAMA Intern Med. 2020 04 01; 180(4):487-493.JIM

Abstract

Importance

Prescription opioids play a significant role in the ongoing opioid crisis. Guidelines and physician education have had mixed success in curbing opioid prescriptions, highlighting the need for other tools that can change prescriber behavior, including nudges based in behavioral economics.

Objective

To determine whether and to what extent changes in the default settings in the electronic medical record (EMR) are associated with opioid prescriptions for patients discharged from emergency departments (EDs).

Design, Setting, and Participants

This quality improvement study randomly altered, during a series of five 4-week blocks, the prepopulated dispense quantities of discharge prescriptions for commonly prescribed opioids at 2 large, urban EDs. These changes were made without announcement, and prescribers were not informed of the study itself. Participants included all health care professionals (physicians, nurse practitioners, and physician assistants) working clinically in either of the 2 EDs. Data were collected from November 28, 2016, through July 9, 2017, and analyzed from July 16, 2017, through May 14, 2018.

Interventions

Default quantities for opioids were changed from status quo quantities of 12 and 20 tablets to null, 5, 10, and 15 tablets according to a block randomization scheme. Regardless of the default quantity, each health care professional decided for whom to prescribe opioids and could modify the quantity prescribed without restriction.

Main Outcomes and Measures

The primary outcome was the number of tablets of opioid-containing medications prescribed under each default setting.

Results

A total of 104 health care professionals wrote 4320 prescriptions for opioids during the study period. Using linear regression, an increase of 0.19 tablets prescribed (95% CI, 0.15-0.22) was found for each tablet increase in default quantity. When evaluating each of the 15 pairwise comparisons of default quantities (eg, 5 vs 15 tablets), a lower default was associated with a lower number of pills prescribed in more than half (8 of the 15) of the pairwise comparisons; there was a higher quantity in 1 and no difference in 6 comparisons.

Conclusions and Relevance

These findings suggest that default settings in the EMR may influence the quantity of opioids prescribed by health care professionals. This low-cost, easily implementable, EMR-based intervention could have far-reaching implications for opioid prescribing and could be used as a tool to help combat the opioid epidemic.

Trial Registration

ClinicalTrials.gov identifier: NCT04155229.

Authors+Show Affiliations

Department of Emergency Medicine, University of California, San Francisco.Department of Emergency Medicine, University of California, San Francisco.Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, California.Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, California. Tuba City Regional Health Care Corporation, Tuba City, Arizona.Department of Emergency Medicine, University of California, San Francisco.

Pub Type(s)

Journal Article
Randomized Controlled Trial
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

31961377

Citation

Montoy, Juan Carlos C., et al. "Association of Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in Emergency Departments: a Randomized Quality Improvement Study." JAMA Internal Medicine, vol. 180, no. 4, 2020, pp. 487-493.
Montoy JCC, Coralic Z, Herring AA, et al. Association of Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in Emergency Departments: A Randomized Quality Improvement Study. JAMA Intern Med. 2020;180(4):487-493.
Montoy, J. C. C., Coralic, Z., Herring, A. A., Clattenburg, E. J., & Raven, M. C. (2020). Association of Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in Emergency Departments: A Randomized Quality Improvement Study. JAMA Internal Medicine, 180(4), 487-493. https://doi.org/10.1001/jamainternmed.2019.6544
Montoy JCC, et al. Association of Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in Emergency Departments: a Randomized Quality Improvement Study. JAMA Intern Med. 2020 04 1;180(4):487-493. PubMed PMID: 31961377.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Association of Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in Emergency Departments: A Randomized Quality Improvement Study. AU - Montoy,Juan Carlos C, AU - Coralic,Zlatan, AU - Herring,Andrew A, AU - Clattenburg,Eben J, AU - Raven,Maria C, PY - 2020/1/22/pubmed PY - 2020/11/4/medline PY - 2020/1/22/entrez SP - 487 EP - 493 JF - JAMA internal medicine JO - JAMA Intern Med VL - 180 IS - 4 N2 - Importance: Prescription opioids play a significant role in the ongoing opioid crisis. Guidelines and physician education have had mixed success in curbing opioid prescriptions, highlighting the need for other tools that can change prescriber behavior, including nudges based in behavioral economics. Objective: To determine whether and to what extent changes in the default settings in the electronic medical record (EMR) are associated with opioid prescriptions for patients discharged from emergency departments (EDs). Design, Setting, and Participants: This quality improvement study randomly altered, during a series of five 4-week blocks, the prepopulated dispense quantities of discharge prescriptions for commonly prescribed opioids at 2 large, urban EDs. These changes were made without announcement, and prescribers were not informed of the study itself. Participants included all health care professionals (physicians, nurse practitioners, and physician assistants) working clinically in either of the 2 EDs. Data were collected from November 28, 2016, through July 9, 2017, and analyzed from July 16, 2017, through May 14, 2018. Interventions: Default quantities for opioids were changed from status quo quantities of 12 and 20 tablets to null, 5, 10, and 15 tablets according to a block randomization scheme. Regardless of the default quantity, each health care professional decided for whom to prescribe opioids and could modify the quantity prescribed without restriction. Main Outcomes and Measures: The primary outcome was the number of tablets of opioid-containing medications prescribed under each default setting. Results: A total of 104 health care professionals wrote 4320 prescriptions for opioids during the study period. Using linear regression, an increase of 0.19 tablets prescribed (95% CI, 0.15-0.22) was found for each tablet increase in default quantity. When evaluating each of the 15 pairwise comparisons of default quantities (eg, 5 vs 15 tablets), a lower default was associated with a lower number of pills prescribed in more than half (8 of the 15) of the pairwise comparisons; there was a higher quantity in 1 and no difference in 6 comparisons. Conclusions and Relevance: These findings suggest that default settings in the EMR may influence the quantity of opioids prescribed by health care professionals. This low-cost, easily implementable, EMR-based intervention could have far-reaching implications for opioid prescribing and could be used as a tool to help combat the opioid epidemic. Trial Registration: ClinicalTrials.gov identifier: NCT04155229. SN - 2168-6114 UR - https://www.unboundmedicine.com/medline/citation/31961377/Association_of_Default_Electronic_Medical_Record_Settings_With_Health_Care_Professional_Patterns_of_Opioid_Prescribing_in_Emergency_Departments:_A_Randomized_Quality_Improvement_Study_ L2 - https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2019.6544 DB - PRIME DP - Unbound Medicine ER -