JMIR Publications

ABSTRACT

Background:

Co-prescribing naloxone with opioid analgesics is a Centers for Disease Control and Prevention best practice to mitigate the risk of fatal opioid overdose (OD), yet co-prescription by emergency medicine clinicians is rare, occurring less than 5% of the time it is indicated. Clinical decision support (CDS) has been associated with increased naloxone prescribing; however, key CDS design characteristics and pragmatic outcome measures necessary to understand replicability and effectiveness have not been reported.

Objective:

This study aimed to rigorously evaluate and quantify the impact of CDS designed to improve emergency department (ED) naloxone co-prescribing. We hypothesized CDS would increase naloxone co-prescribing and the number of naloxone prescriptions filled by patients discharged from EDs in a large healthcare system.

Methods:

Following user-centered design (UCD) principles, we designed and implemented an interruptive, electronic health record (EHR)-based CDS to nudge clinicians to co-prescribe naloxone with high-risk opioid prescriptions. “High-risk” opioid prescriptions were defined as any opioid analgesic prescription > 90 total morphine milligram equivalents (MMEs) per day or for patients with a prior diagnosis of opioid use disorder (OUD) or opioid overdose (OD). The RE-AIM framework was used to evaluate pragmatic CDS outcomes of reach, effectiveness, adoption, implementation, and maintenance. Effectiveness was the primary outcome of interest and was assessed by: 1) constructing a Bayesian structural time-series model of the number of ED visits with naloxone co-prescriptions before and after CDS implementation, and 2) calculating the percentage of naloxone prescriptions associated with CDS that were filled at an outpatient pharmacy. Mann-Kendall tests were used to evaluate longitudinal trends in CDS adoption. All outcomes were analyzed in R (version 4.2.2).

Results:

Between 11/2019 and 7/2023, there were 1,994,994 ED visits. CDS reached clinicians in 0.83% (16,566/1,994,994) of all visits and 16% (16,566/103,606) of ED visits where an opioid was prescribed at discharge. Clinicians adopted CDS, co-prescribing naloxone in 34% (6,613/19,246) of alerts. CDS was effective, increasing naloxone co-prescribing from baseline by 18.1 (95% CI 17.9-18.3) co-prescriptions per week or 2,327% (95% CI 3,390-3,490). Patients filled 44% (1,989/4,541) of naloxone co-prescriptions. The CDS was implemented simultaneously at every ED and no adaptations were made to CDS post-implementation. CDS was maintained beyond the study period and maintained its effect, with adoption increasing over time (tau=0.454, p<<0.001).

Conclusions:

Our findings advance the evidence that EHR-based CDS increase the number of naloxone co-prescriptions and improve the distribution of naloxone. Our time series analysis controls for secular trends and strongly suggests that minimally interruptive CDS significantly improves process outcomes. Clinical Trial: None.