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Analysis

Opioid Rx Drop When Default EMR Settings Change

By MedPage Today  
   January 22, 2020

Electronic medical record defaults may influence emergency department prescribing.

This article was first published on Tuesday, January 21, 2019 in MedPage Today.

By Judy George, Senior Staff Writer, MedPage Today   

Clinicians prescribed fewer opioid pills when default settings in the electronic medical record (EMR) were lower, a prospective study of two large urban emergency departments showed.

Changing the default EMR setting also resulted in a lower proportion of patients discharged from emergency departments (EDs) with prescriptions exceeding CDC recommendations, reported Juan Carlos Montoy, MD, PhD, of the University of California, San Francisco (UCSF), and colleagues in JAMA Internal Medicine.

Though the intervention decreased the number of pills prescribed to patients, it "still let each doctor choose the appropriate quantity for each patient," Montoy explained.

"Doctors are trying to do the right thing when deciding how to treat patients who are in pain," he told MedPage Today. "But they are human and susceptible to the same mistakes in decision-making as everyone else.

"There is a large body of research on behavioral economics looking at how people make decisions for everything from quitting smoking to saving for retirement," Montoy continued. "Our findings extend this research to the practice of medicine and show we can use nudges that have been proven effective in other contexts to help doctors provide better care for patients."

In general, ED clinicians follow opioid prescribing guidelines and small changes, if baseline amounts already are low, may not have a huge effect on reducing risks associated with overprescribing, noted Kit Delgado, MD, MS, of the University of Pennsylvania in Philadelphia, who wasn't involved with the study.

"That being said, there's still some room to get EDs to lower their defaults," Delgado told MedPage Today. "We conducted a recent national survey and found that 10% of EDs had default amounts of 30 tablets which is way too high, suggesting that the EMR may be inadvertently encouraging marked overprescribing for many conditions."

In their study, Montoy and colleagues evaluated opioid prescribing at two EDs -- UCSF Medical Center and Highland Hospital, a trauma center and safety-net teaching hospital in Oakland, California -- between November 2016 and July 2017.

Over 20 weeks, they randomly changed the EMR default settings for commonly prescribed opioids such as oxycodone, combined oxycodone and acetaminophen (Percocet), and combined hydrocodone bitartrate and acetaminophen (Norco), for 4 weeks at a time. Before the study, the default dispensing settings were 20 tablets at UCSF and 12 tablets at Highland.

The researchers tested preset quantities of five, 10, and 15 pills, and null (a blank setting that required clinicians to enter a number) over five 4-week blocks. "There was some risk that after lowering the default to a lower number than the previous setting, patients may have been prescribed fewer pills than their doctor would have otherwise prescribed," Montoy noted. "This small risk was mitigated by always allowing the prescription to be changed to whatever quantity the doctor prescribed, rather than instituting a limit."

Over the course of the study, 104 physicians, nurse practitioners, and physician assistants wrote 4,320 opioid prescriptions. For each tablet increase in default quantity, 0.19 more opioid tablets (95% CI 0.15-0.22) were prescribed. Pairwise comparisons of default quantities (five vs 15 tablets, for example) showed that a lower default setting was associated with fewer pills prescribed in more than half of the comparisons.

The work builds on other research about EMR defaults and short-term opioid prescribing, both in EDs and other settings. A study of post-surgical patients discharged at Yale New Haven Health System, for example, showed that lowering default settings from 30 to 12 pills decreased the amount of opioids prescribed by more than 15%.

"Changing defaults can be a powerful tool to help reset a prescriber's mindset on what an appropriate opioid prescription should be," said Yale researcher Alexander Chiu, MD. "While data is beginning to show how much pain medication an average patient requires for various conditions, many clinicians are still prescribing based on anecdote and historical practice," he told MedPage Today.

Montoy and colleagues noted several limitations to their study. It did not investigate whether default settings affected the proportion of patients prescribed an opioid, the drug that was prescribed, or which patients received opioid prescriptions. Findings may not apply to non-ED clinicians or to other locales, they added. Importantly, the study did not track potential consequences of the intervention, such as undertreated pain or return visits due to inadequately treated pain.

The study was supported by the National Institutes of Health National Center for Advancing Translational Sciences (UCSF Clinical and Translational Institute).

Researchers disclosed relevant relationships with UCSF Clinical and Translational Institute, Par Pharmaceutical, California ED BRIDGE Program, and Collective Medical.

“Changing defaults can be a powerful tool to help reset a prescriber's mindset on what an appropriate opioid prescription should be.”


KEY TAKEAWAYS

Changing the default EMR setting also resulted in a lower proportion of patients discharged from EDs with prescriptions exceeding CDC recommendations.

Though the intervention decreased the number of pills prescribed to patients, it allowed doctors to choose the appropriate quantity for each patient.


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