NIATx in Primary Care: Pilot study examines ways to improve opioid prescribing practices

 “Early indicators suggest that the NIATx approach, with some modification, translates well to primary care,” says Andrew Quanbeck, Associate Scientist at the Center for Health Enhancement Systems Studies.

Quanbeck is leading a pilot project (Using Systems Consulting to Promote Evidence-Based Practices in Primary Care) that is testing a version of the NIATx model in primary care settings. The three-year NIDA-funded study is addressing what medical directors and staff at all levels of primary care clinics recognize as a key problem: opioid prescribing. (See link to published article.)

Quanbeck has worked on several NIATx projects over the past decade, including NIATx 200, Advancing Recovery, and STAR-SI. His current research focuses on accelerating the adoption of evidence-based practices in healthcare.

The study team includes NIATx coach Lynn Madden, along with Dr. Randy Brown and Dr. Aleksandra Zgierska, both of the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health. Drs. Brown and Zgierska are both family physicians with expertise in addiction. They will serve as “systems consultants,” providing peer-to-peer support to physicians and other clinical staff members involved in the pilot. 

“This pilot project foreshadows a long-term plan to do a larger follow-up study,” says Quanbeck. “In the pilot, we’re investigating use of a systems approach to institute a set of universal precautions for opioid prescribing,” he explains. “The ultimate goal is to create a system that will minimize the chance that people and communities end up at risk for opioid misuse.”  

Four primary clinics recruited from UW Health community-based family medicine clinics are participating in the pilot.

 “NIATx principles and tools are very much a part of the pilot study design,” says Quanbeck.

Participating clinics complete a walk-through in advance of a site visit from the study team. The walk-through results are translated into a flow chart that’s shared with the study team. The clinic participants use the Nominal Group Technique to address issues identified in the walk-through and flow chart.

The project incorporates another NIATx principle, “Get ideas from outside the organization or field” in the use of a checklist—a long-standing safety tool in aviation and other industries. The checklist in this study is based on published guidelines for opioid prescribing. It emerged from a group decision process that included clinical guideline writers, primary care physicians, and systems engineers.  

The validated checklist will allow doctors to prescribe in concordance with the guidelines and will also standardize the opioid prescribing practice in a particular clinic.

It will be especially helpful, says Quanbeck, for busy primary care physicians pressed for time. “Reading through a 40-page article on prescribing guidelines can be tough for physicians, given the many constraints on their time.”

Adds Quanbeck, “The checklist is a way to condense and prioritize the recommendations that a physician would otherwise have to search for within the published clinical guidelines. It provides a set of items that are discrete, measureable, and lend themselves well to PDSA cycles.”

The checklist will also alert prescribers to factors shown to put someone at high risk of opioid misuse: 1) a high opioid dosage; 2) co-prescription of benzodiazepines; and 3) absence of monitoring, such as regular follow-up visits with the prescribing physician, urine drug tests, and checking the prescription drug monitoring program.

“The prescription opioid epidemic is a problem that has developed over decades, and it’s clear that there will be no quick fix to the problem,” says Quanbeck. “With this study, we are trying to build systems that going forward can minimize the long-term risk of opioid misuse.”

For more information about Using Systems Consulting to Promote Evidence-Based Practices in Primary Care, contact Andrew Quanbeck at andrew.quanbeck@chess.wisc.edu

Interested in learning how to use the NIATx model in your agency or in a primary care setting? Attend the Spring 2016 NIATx Change Leader Academy in Madison, WI!