Winning Abstracts from the 2013 Medical Student Abstract Competition: A Bundle Approach to Improving Opioid Treatment of Chronic Non-Cancer Pain in a Primary Care Setting
Author:
Justin R. Abbatemarco, University of South Florida College of
Medicine, Class of 2015
Introduction:
This project evaluated Plan-Do-Study-Act (PDSA) methodology in
changing opioid prescribing practice to comply with state
legislation while monitoring its effect on aberrant behaviors.
Methods:
National guidelines and new regulations were condensed into an
'opioid bundle' which included a treatment agreement, informed
consent, drug monitoring plan and one time look up in the Florida
Prescription drug database. PDSA methodology was utilized to
implement the 'opioid bundle' and improve individual provider
adherence with new regulations. Adult patients with an ICD-9 code
of muscular or neuropathic pain who had been prescribed more than
90 days of opioid therapy within the General Internal Medicine
Department of the University of South Florida were included in the
project. Five PDSA cycles were conducted to improve adherence with
the 'opioid bundle'. The PDSA cycles were initiated sequentially to
allow for continuous assessment and improvement. Aberrant
behaviors, which included early refills, dose escalation,
unexpected results on urine drug screens and multiple prescribing
providers, were also tracked in all patients included in the study.
Following each PDSA cycle, the success of implementation of the
'opioid bundle' and the presence of aberrant behaviors was assessed
through chart review. A p control chart was used to track the
'opioid bundle' implementation after each PDSA cycle. To determine
the effect of the 'opioid bundle' on aberrant behaviors, the
results were compared before and after implementation of the
'opioid bundle' utilizing a Mann-Whitney test.
Results:
A total of 97 chronic noncancer pain (CNCP) patients were included
in the analysis. After five PDSA cycles, the bundle was implemented
in 60.0% of CNCP patients. Aberrant behavior was observed in 52%
(25/48) of CNCP patients pre-bundle and 16% (8/49) of CNCP patients
post-bundle. There was not a statistical difference in early
refills (p=0.3920) or unexpected results in urine drug screen
(p=0.3046) but there were statistically significant decreases in
dose escalation (p=0.0462) and patients with more than one opioid
prescriber (p=0.0260).
Conclusion:
The PDSA methodology enabled implementation of the 'opioid bundle'
and offered a practical model for small, outpatient clinics to
implement changes. This project required minimal resources and the
results are directly applicable to other outpatient clinics needing
to change opioid prescribing practice. Though aberrant behavior
decreased, it is difficult to conclude this was solely due to the
'opioid bundle'.