Use of chart review tool and peer feedback to influence physician prescribing of controlled substances

PURPOSE: Develop and evaluate a chart review tool (CRT) to improve the safety and effectiveness of prescribing controlled substances in a primary care setting. METHODS: A Controlled Substance Review Committee, consisting of volunteer primary care physicians and a clinical pharmacist, developed a CRT to assess compliance with a primary care clinic’s controlled substance prescribing policy and effectiveness of therapy. The CRT was based on existing clinic policies and American Pain Society/American Academy of Pain Medicine clinical guidelines for opioid prescribing. Every month, committee physicians used the CRT to review medical records of patients prescribed controlled substances chronically. The CRT tracked factors from the previous 6 months, including morphine equivalent dose (MED) prescribed, indication for treatment, documentation of treatment effectiveness, the Opioid Risk Tool score (ORT score), results from urine drug testing (UDT) and patient violations of the clinic’s controlled substance policy. These findings are used to provide the treating physician constructive, non-punitive feedback. We also assessed if the use of the CRT resulted in change in MED prescribed. RESULTS: Ninety-nine patient charts from 14 different physicians were reviewed over 1 year. Eighty-eight of these patients were receiving opioids for chronic pain, with an average dose in MED 72.6 mg/day (SD 89). Twenty-nine percent of charts had documentation that the controlled substance was improving the patient’s quality of life or decreasing their pain. Sixty percent of patients had at least one violation of the clinic’s controlled substance treatment agreement in the prior 6 months, and half of the violations were due to missed appointments with specialists to help manage pain. Patients were more likely to have a violation of controlled substance policy in the past 6 months if they were prescribed both a benzodiazepine (BZD) and an opioid (p=0.04), had a documented treatment agreement (p=0.002), or were high risk per ORT score (p=0.001). The mean dose of opioids, for the 88 patients who were prescribed opioids, decreased 2.6 mg/day MED from time of chart review until the end of study (mean duration 6.3 months), compared to a 6.9 mg/day MED increase that occurred from 12 months prior to chart review to the time of chart review (p=0.01). CONCLUSION: Development and implementation of a CRT in an urban primary care clinic provided helpful insight on prescribing practices, and has promise to improve quality of opioid prescribing. The most common violation of the clinic policy was missed appointments with specialists, and patients prescribed both BZD and an opioid or were high risk per ORT were most likely to have violations. Documentation of effectiveness of therapy was lacking

Reducing Preconception Risks Among African American Women with Conversational Agent Technology

BACKGROUND: Systems and tools are needed to identify and mitigate preconception health (PCH) risks, particularly for African American (AA) women, given persistent health disparities. We developed and tested Gabby, an online preconception conversational agent system. METHODS: One hundred nongravid AA women 18-34 years of age were screened for over 100 PCH risks and randomized to the Gabby or control group. The Gabby group interacted with the system for up to six months; the control group received a letter indicating their health risks with a recommendation to talk with their clinician. The numbers, proportions, and types of risks were compared between groups. RESULTS: There were 23.7 (SD 5.9) risks identified per participant. Eighty-five percent (77 of 91) provided 6 month follow up data. The Gabby group had greater reductions in the number (8.3 vs. 5.5 risks, P \u3c .05) and the proportion (27.8% vs 20.5%, P \u3c 0.01) of risks compared to controls. The Gabby group averaged 63.7 minutes of interaction time. Seventy-eight percent reported that it was easy to talk to Gabby and 64% used information from Gabby to improve their health. CONCLUSION: Gabby was significantly associated with preconception risk reduction. More research is needed to determine if Gabby can benefit higher risk populations and if risk reduction is clinically significant

Lessons Learned and Strategies for Recruitment of Diverse, Low-income Patients into an Integrative Medical Group Visit Clinical Trial

OBJECTIVE: Description of recruitment methods and lessons learned in a randomized controlled trial of underserved patients using an integrative medical group visits intervention. METHODS: Comparison of the demographic characteristics of participants screened and consented to the study as well as description of recruitment methods used. OUTCOME MEASURES: This paper examines the characteristics of patients who were eligible compared to those who were not, characteristics of patients at the different sites, and patient characteristics over time (by comparing various cohorts) based on our experiences recruiting underserved patients. RESULTS: We screened 338 patients, with 205 (60.6%) meeting eligibility criteria and 159 patients randomized and consented. 133 patients were found ineligible, with the most common reasons being low depression scores (n=20), manic symptoms (n=20), and psychotic symptoms (n=19), and alcohol use (n=15). We found demographic differences in patients recruited by different methods and at different sites- patients referred by provider letter were older than those referred by self-referral or provider referral (mean age/SD vs. mean age/SD, p=0.0001). For site-specific differences, patients at DH were older (53 SD=12.3) than those at the Boston Medical Center (49 SD=11.3) and CSHC (p=0.048) in pair-wise comparisons. Patients at DH were also more likely to be white (25%) as compared to BMC (18%) and DH (7%), while those at CSHC were more likely to be black (70%) (p=0.008)