|
BACKGROUND/RATIONALE:
It is estimated that one out of two Veterans are diagnosed with at least one type of chronic pain and approximately one-third of them are prescribed at least one opioid (Clark, 2002). The management of opioid therapy for chronic pain in the VA by primary care physicians presents a significant clinical problem due to under-trained providers in opioid therapy and the high prevalence of substance use disorders and other psychiatric comorbidities that complicate opioid therapy (Kandel et.al, 2001; Regier, et.al., 1990). Physician best practice must balance the need for pain relief against risks of over treatment and opioid misuse. An automated DSS based on the VA/DoD Clinical Practice Guidelines (CPG) that makes customized recommendations based on patient data will assist Primary Care Physicians and aims to reduce rates of opioid medication misuse, abuse, and addiction while improving pain relief.
OBJECTIVE(S):
The objectives of the proposed research project are: (1) To modify an existing VA DSS (used in managing hypertension) for new use in managing opioid therapy in chronic pain; (2) To assess and iteratively improve the new Chronic Pain DSS based on three types of testing: basic quality assurance and system testing, accuracy of practice recommendations testing, and provider usability testing; and (3) To evaluate and iteratively improve the DSS in a single-site pilot based on evaluations of: patient acceptability, provider feedback, and impact on provider behaviors and patient outcomes.
METHODS:
An expert panel of pain specialists, primary care physicians, a pharmacist, and a DSS expert will be used to guide and approve user specifications, guideline operationalizing, and design documents. Development of the DSS will be done in collaboration with the Stanford Medical Informatics (SMI) group at Stanford University. Experts from the SMI will update and revise where necessary a DSS technology that has been used successfully at the VAPAHCS over the last two years. The development work will include: (1) ensuring accurate patient data extraction and write-back to VistA, (2) developing a flexible updateable knowledge base with respect to prevention of opioid medication non-compliance, abuse, and addiction, (3) updating an inference engine that will interpret the patient data (over 100 data fields estimated), and (4) creating an easy to use and efficient user interface and experience. Once the technology has been successfully verified, a sample of 12 primary care physicians will pilot test the DSS.
FINDINGS/RESULTS:
We hypothesize that the Chronic Pain DSS practice recommendations will include provider behavior improvement: better screening for substance use disorders, increased use of a urine drug screen prior to prescribing opioid medications, improved continuity of care (i.e., care by the same provider), better documentation of pain and medical assessment before opioid prescribing and at regular follow-up intervals, improved appropriate prescribing (namely, titration rates consistent with the CPG and greater use of long-acting opioids) and patient outcome improvement: improved analgesia and decreased rates of opioid non-compliance including fewer early prescription renewals and better rates of appointment completions.
IMPACT:
This implementation project integrates work on substance use disorders and clinical decision-making that, heretofore, have been separate streams of work in CHCE. Full implementation of this project could result in significantly decreasing opioid medication non-compliance, abuse, and addiction while significantly increasing the rate in which these substance use problems and disorders are detected, while reducing chronic pain.
PUBLICATIONS:
None at this time.
DRA:
Health Services and Systems, Substance Abuse, Addictive Disorders
DRE:
Technology Development and Assessment, Quality of Care
Keywords:
Decision support, Drug abuse, Pain
MeSH Terms:
none
|
