Medical Record Alert Associated with Reduced Opioid and Benzodiazepine Co-prescribing
BACKGROUND:
The 2014 VA Opioid Safety Initiative (OSI) prioritized reductions in opioid and benzodiazepine co-prescribing and other non-recommended opioid prescribing practices. This implementation project evaluated the effectiveness of an advanced medication alert designed to reduce opioid and benzodiazepine co-prescribing among Veterans with high-risk conditions (substance use disorder, sleep apnea, suicide risk, and age >e; 65) at one VA healthcare system (VA Puget Sound). Primary outcomes were population-level changes in the proportion of patients co-prescribed opioids and benzodiazepines in the 12 months before and after alert launch for each of the four risk conditions. Alert site trends were compared to those of a similar VA healthcare system without the alert. Secondary outcomes included: 1) change in proportion of patients with each risk condition prescribed opioids before and after alert launch; 2) change in proportion of patients with each risk condition prescribed benzodiazepines before and after alert launch; and 3) among patients activating the alert, changes in prescribing patterns in the 6 months after patients' initial alert activation.
FINDINGS:
- Proportions of patients with concurrent prescriptions decreased significantly post-alert launch among Veterans with substance use (25%), sleep apnea (39%), and suicide risk (62%), with greater decreases at the alert site relative to the comparison site in sleep apnea and suicide-risk cohorts. Significant decreases in benzodiazepine prescribing were observed at the alert site only.
- Over 12 months, the alert activated for 1,332 Veterans, activating a median of 3 times per patient, with the most common reason for activation being age, followed by sleep apnea and substance use disorder – and small numbers (<5%) for suicide risk.
- Most long-term users (≥ 90 days of both medications in prior 6 months) with an activated alert continued to be co-prescribed these medications six months later.
IMPLICATIONS:
- Future work should examine whether combining medication alerts with other interventions (e.g. greater availability of behavioral supports for tapering and/or pain management, academic detailing) further decreases risky medication combinations.
- Efforts that involve multiple prescriber groups (e.g. primary care and mental health) may lead to greater reductions in co-prescribing than involvement of a single group.
LIMITATIONS:
- Investigators could not determine whether the medication alert resulted in cancelled benzodiazepine or opioid prescriptions, as these data were not available.
- Investigators were unable to capture all prescriptions received outside VA.
AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D's Quality Enhancement Research Initiative (RRP 12-527). Ms. Malte and Ms. Achtmeyer, and Drs. Saxon and Hawkins are part of HSR&D's Center of Innovation for Veteran-Centered and Value-Drive Care and the VA Puget Sound Center of Excellence in Substance Abuse Treatment and Education.
Malte C, Berger D, Saxon A, Hagedorn H, Achtmeyer C, Mariano A, and Hawkins E. Electronic Medical Record Alert Associated with Reduced Opioid and Benzodiazepine Co-prescribing in High-Risk Veteran Patients. Medical Care. December 28, 2017;e-pub ahead of print.
