Using Systems Consultation to Improve Opioid Prescribing in Primary Care: Protocol for a Sequential, Multiple-Assignment Randomized Trial (SMART)
Andrew Quanbeck, PhD
Department of Family Medicine and Community Health
University of Wisconsin
School of Medicine and Public Health
ABSTRACT:
Background (context and purpose of the study) Health care systems are notoriously slow to adopt clinical guidelines and other evidence-based practices, in part because the literature offers little help about which implementation strategies work best in different clinical settings and how strategies could be tailored to maximize their effectiveness in different contexts. This study tests a blended implementation strategy called systems consultation to improve concordance with clinical guideline for opioid prescribing in primary care. Systems consultation consists of the following theoretically and empirically proven strategies: (1) an educational meeting followed by audit and feedback, (2) practice facilitation, and (3) physician peer consulting. The study aims to discover the most cost-effective sequence and combination of strategies for improving opioid prescribing practices in diverse primary care clinics.
Methods (how the study will be performed) The study is a hybrid type 3 cluster-randomized sequential multiple-assignment randomized trial (SMART) that randomizes clinics at two timepoints, months 3 and 6 of an 18-month intervention period. The study will compare the effect on morphine-milligram equivalent dose of the elements of systems consultation. Four combinations of implementation strategies will be assessed: an educational meeting and audit and feedback alone (AF), AF plus practice facilitation (PF), AF + PF plus physician peer consulting (PPC), and AF + PPC. In addition, an assessment of system-, clinic-, and prescriber-level contextual factors will be developed and tested to build a tool for tailoring strategies to different clinics, and a cost estimate will be conducted of the strategies that make up systems consultation. The study aims to enroll up to 38 clinics from three health systems. Mixed methods will be used to evaluate systems consultation using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Clinics will be the primary unit of analysis.
Discussion (summary and potential implications) Systems consultation is a practical blend of evidence-based strategies, in this case used to improve opioid prescribing practices in primary care. The blend offers a range of strategies from minimally to substantially intensive to make available the most cost-effective strategy(ies) for specific clinical contexts. Systems consultation and the adaptive approach used to deliver the strategy may generalize to the adoption of other evidence-based practices as well.
