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
Justin R. Abbatemarco, University of South Florida College of Medicine, Class of 2015
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.
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.
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).
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'.