Analgesic Prescribing Practices Can Be Improved by Low-Cost Point-of-Care Decision Support

Abstract

Context Codeine has become a controversial choice for analgesia in children compared to other commonly available drugs. Objectives To evaluate whether an educational campaign shifted resident prescribing patterns away from codeine toward more appropriate analgesics. Methods Our intervention consisted of a pocket-sized reference card given to all trainees and key staff on an inpatient pediatric acute care unit; pediatrics residents also had the option to attend a one-hour lecture. The pocket-card recommended against codeine (including rationale), and gave prescription guidance for our institution’s preferred formulary alternative analgesics, which included tramadol and hydrocodone. We used inpatient prescribing data to track the prescribing of codeine and alternative medications over time. Results Following the interventions, there was a significant decrease in the percentage of patients receiving codeine (13.5% of patients received the drug in the year before, 5.4% in the year after, P<0.0001). Use of hydrocodone-containing analgesics increased overall during the same period (7.4% to 16%, P<0.0001) as did tramadol use (0.2% to 2.6%, P<0.0001). There were no changes in pain management satisfaction scores. Conclusions A simple, low-cost educational campaign consisting primarily of a pocket guide to analgesics markedly improved analgesic prescribing patterns, and that improvement extended to services not targeted by the didactic component of our educational campaign. Point-of-care decision support via a pocket-card may be sufficient for effecting change in medication prescribing patterns of trainees.

Factors Associated With the Prophylactic Prescription of a Bowel Regimen to Prevent Opioid-Induced Constipation

“…Several previous studies have shown that low-cost point-of-care decision support tools in the form of a pocket cards can change prescribing practices. 11,13 Utilization of the PCA order set by our pain service is consistent with a study by Overhage et al that showed that embedding “corollary orders” into the computerized physician order entry system can decrease prescribing errors of omissions. 14 Our findings are consistent with previous studies that demonstrate changes in prescribing practices through various forms of clinical decision support.…”

“…Whereas Ury et al showed that an educational curriculum alone was unable to improve prescribing rates of an empirical bowel regimen among trainees, 12 Rosenbluth and colleagues demonstrated that the use of pocket-sized reference card was effective in changing opioid prescribing practices in both medical and surgical trainees. 11 Increasing the prescribing rates of prophylactic bowel regimen among the surgical services will likely need to involve other modalities, such as clinical decision support tools or changes to our electronic ordering system.…”

“…Several studies have examined the use of clinical decision support tools and educational modalities to improve opioid prescribing practices among trainees. 10,11 Clinical decision support tools may be useful in improving rates of prophylactic bowel regimens at the time of an opioid prescription.…”

National Patterns of Codeine Prescriptions for Children in the Emergency Department

“…A quality improvement initiative with resident physicians showed a statistically significant decrease in rate of codeine prescription from 13.5% to 5.4% with the introduction of a pocketsized analgesic reference card. 34 Other interventions may include removal of codeine from hospital formularies or electronic medical record-based decision support for providers. A study by O'Conner et al found formulary restriction, supported by education and computerized order entry, effectively eliminated analgesic meperidine use at a tertiary-care hospital.…”

Effect of an opioid management program for Colorado workers’ compensation providers on adherence to treatment guidelines for chronic pain

“…Preliminary evidence suggests that opioid dosing guidelines and/or physician training may reduce opioid dosage, as well as change opioid prescribing practices . However, this evidence is limited to a small number of states and a handful of clinics.…”