Interrupted Time Series of User‐centered Clinical Decision Support Implementation for Emergency Department–initiated Buprenorphine for Opioid Use Disorder

Abstract

Objectives Adoption of emergency department (ED) initiation of buprenorphine (BUP) for opioid use disorder (OUD) into routine emergency care has been slow, partly due to clinicians’ unfamiliarity with this practice and perceptions that it is complicated and time‐consuming. To address these barriers and guide emergency clinicians through the process of BUP initiation, we implemented a user‐centered computerized clinical decision support system (CDS). This study was conducted to assess the feasibility of implementation and to evaluate the preliminary efficacy of the intervention to increase the rate of ED‐initiated BUP. Methods An interrupted time series study was conducted in an urban, academic ED from April 2018 to February 2019 (preimplementation phase), March 2019 to August 2019 (implementation phase), and September 2019 to December 2019 (maintenance phase) to study the effect of the intervention on adult ED patients identified by a validated electronic health record (EHR)‐based computable phenotype consisting of structured data consistent with potential cases of OUD who would benefit from BUP treatment. The intervention offers flexible CDS for identification of OUD, assessment of opioid withdrawal, and motivation of readiness to start treatment and automates EHR activities related to ED initiation of BUP (including documentation, orders, prescribing, and referral). The primary outcome was the rate of ED‐initiated BUP. Secondary outcomes were launch of the intervention, prescription for naloxone at ED discharge, and referral for ongoing addiction treatment. Results Of the 141,041 unique patients presenting to the ED over the preimplementation and implementation phases (i.e., the phases used in primary analysis), 906 (574 preimplementation and 332 implementation) met OUD phenotype and inclusion criteria. The rate of BUP initiation increased from 3.5% (20/574) in the preimplementation phase to 6.6% (22/332) in the implementation phase (p = 0.03). After the temporal trend of the number of physician's with X‐waiver training and other covariates were adjusted for, the relative risk of BUP initiation rate was 2.73 (95% confidence interval [CI] = 0.62 to 12.0, p = 0.18). Similarly, the number of unique attendings who initiated BUP increased modestly 7/53 (13.0%) to 13/57 (22.8%, p = 0.10) after offering just‐in‐time training during the implementation period. The rate of naloxone prescribed at discharge also increased (6.5% preimplementation and 11.5% implementation; p < 0.01). The intervention received a system usability scale score of 82.0 (95% CI = 76.7 to 87.2). Conclusion Implementation of user‐centered CDS at a single ED was feasible, acceptable, and associated with increased rates of ED‐initiated BUP and naloxone prescribing in patients with OUD and a doubling of the number of unique physicians adopting the practice. We have implemented this intervention across several health systems in an ongoing trial to assess its effectiveness, scalability, and generalizability.

Improving transitions of care for patients initiated on buprenorphine for opioid use disorder from the emergency departments in King County, Washington

“…However, 1 study found that the rate of ED-initiated buprenorphine only increased when waivered providers also received a clinical decision support system and just-in-time training. 27 Recently trained ED providers are also more likely to believe OUD is similar to other chronic diseases and approve of ED-initiated buprenorphine, highlighting the importance of education in expanding prescribing capacity. 6 Third, interviewees argued that transitions of care for patients with OUD should mirror other ED referrals for high-risk conditions with many suggesting the establishment of a central agency to streamline communication.…”

“…not yet have the capacity to schedule appointments.Previous work has leveraged the EHR to provide computerized clinical decision support systems, which have improved rates of buprenorphine prescribing in the ED for patients with untreated OUD 27. Additionally, patient privacy regulations surrounding health information, including patient records for the treatment of substance use disorders as guided by the 42 CFR Part 2 regulations, have recently been revised to facilitate coordination of care 29.…”

Misalignment of Stakeholder Incentives in the Opioid Crisis

“…To address this, one can benefit from points of access to patients to potentially initiating treatments. These include ED visit/hospital admission [ 138 , 139 , 140 , 141 , 142 ] and incarceration [ 143 , 144 , 145 , 146 , 147 , 148 , 149 ]. Employing techniques like screening, brief intervention, and referral to treatment (SBIRT) can also be helpful in this regard [ 75 ].…”

Clinician Perceptions About a Decision Support System to Identify and Manage Opioid Use Disorder

“…14 However, a group at Ochsner Clinic demonstrated that the implementation of such a tool in 36 clinics greatly increased the number of patients receiving OUD therapy, and a group at the University of Texas Southwestern has been testing whether an OUD CDS can increase the initiation of buprenorphine treatment in emergency departments. [15][16][17][18] A National Institute on Drug Abuse Center for the Clinical Trials Network (CTN) report in 2020 concluded that a CDS tool for OUD screening, assessment, and treatment might help address the opioid crisis. 19 Our team has extensive experience with building and testing CDS systems and has been working on a version aimed at the CTN recommendations.…”