Cluster-Randomized Comparative Effectiveness Trial of Physician-Directed Clinical Decision Support Versus Patient-Directed Education to Promote Appropriate Use of Opioids for Chronic Pain - 25/09/23
, Garth Fuller ⁎, Xiaoyu Liu ⁎, Taylor Dupuy ⁎, Tom Norris †, Roger Bolus ‡, Rebecca Gale ⁎, Itai Danovitch §, Sam Eberlein ⁎, Alma Jusufagic ¶, Teryl Nuckols ∥, Penney Cowan †Abstract |
We compared the effectiveness of physician-directed clinical decision support (CDS) administered via electronic health record versus patient-directed education to promote the appropriate use of opioids by conducting a cluster-randomized trial involving 82 primary care physicians and 951 of their patients with chronic pain. Primary outcomes were satisfaction with patient-physician communication consumer assessment of health care providers and system clinician and group survey (CG-CAHPS) and pain interference patient-reported outcomes measurement information system. Secondary outcomes included physical function (patient-reported outcomes measurement information system), depression (PHQ-9), high-risk opioid prescribing (>90 morphine milligram equivalents per day [≥90 mg morphine equivalent/day]), and co-prescription of opioids and benzodiazepines. We used multi-level regression to compare longitudinal difference-in-difference scores between arms. The odds of achieving the maximum CG-CAHPS score were 2.65 times higher in the patient education versus the CDS arm (P = .044; 95% confidence interval [CI] 1.03–6.80). However, baseline CG-CAHPS scores were dissimilar between arms, making these results challenging to interpret definitively. No difference in pain interference was found between groups (Coef = −0.64, 95% CI −2.66 to 1.38). The patient education arm experienced higher odds of Rx ≥ 90 milligrams morphine equivalent/day (odds ratio = 1.63; P = .010; 95% CI 1.13, 2.36). There were no differences between groups in physical function, depression, or co-prescription of opioids and benzodiazepines. These results suggest that patient-directed education may have the potential to improve satisfaction with patient-physician communication, whereas physician-directed CDS via electronic health records may have greater potential to reduce high-risk opioid dosing. More evidence is needed to ascertain the relative cost-effectiveness between strategies.
Perspective |
This article presents the results of a comparative-effectiveness study of 2 broadly used communication strategies to catalyze dialog between patients and primary care physicians around chronic pain. The results add to the decision-making literature and offer insights about the relative benefits of physician-directed versus patient-directed interventions to promote the appropriate use of opioids.
Le texte complet de cet article est disponible en PDF.Highlights |
• | We compared patient education versus clinical decision support for managing opioids. |
• | Patient education improved overall satisfaction with patient-physician communication. |
• | No difference was found in pain interference between the 2 groups. |
• | Clinical decision support showed greater potential to reduce high-dose opioid prescribing. |
• | The two strategies were otherwise equivalent in most other study outcomes. |
Keywords : Chronic pain, Opioids, Clinical decision support, Patient education, Communication
Plan
| ☆ | Trial Registration: NCT03301623. |
| This study was funded by The PCORI (CDR-1602-34521) and registered on ClinicalTrials.gov registration (NCT03301623). All the authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. |
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| Supplementary data accompanying this article are available online at www.jpain.org and www.sciencedirect.com. |
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| Address reprint requests to Brennan M.R. Spiegel, MD, MSHS, Director of Health Services Research, Cedars-Sinai, Pacific Theatre Building, 116 N. Robertson Blvd, 8th Floor, Los Angeles, CA 90048. |
Vol 24 - N° 10
P. 1745-1758 - octobre 2023 Retour au numéro
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