Association of Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in Emergency Departments: A Randomized Quality Improvement Study

Abstract

Importance: Prescription opioids play a significant role in the ongoing opioid crisis. Guidelines and physician education have had mixed success in curbing opioid prescriptions, highlighting the need for other tools that can change prescriber behavior, including nudges based in behavioral economics.

Objective: To determine whether and to what extent changes in the default settings in the electronic medical record (EMR) are associated with opioid prescriptions for patients discharged from emergency departments (EDs).

Design, setting, and participants: This quality improvement study randomly altered, during a series of five 4-week blocks, the prepopulated dispense quantities of discharge prescriptions for commonly prescribed opioids at 2 large, urban EDs. These changes were made without announcement, and prescribers were not informed of the study itself. Participants included all health care professionals (physicians, nurse practitioners, and physician assistants) working clinically in either of the 2 EDs. Data were collected from November 28, 2016, through July 9, 2017, and analyzed from July 16, 2017, through May 14, 2018.

Interventions: Default quantities for opioids were changed from status quo quantities of 12 and 20 tablets to null, 5, 10, and 15 tablets according to a block randomization scheme. Regardless of the default quantity, each health care professional decided for whom to prescribe opioids and could modify the quantity prescribed without restriction.

Main outcomes and measures: The primary outcome was the number of tablets of opioid-containing medications prescribed under each default setting.

Results: A total of 104 health care professionals wrote 4320 prescriptions for opioids during the study period. Using linear regression, an increase of 0.19 tablets prescribed (95% CI, 0.15-0.22) was found for each tablet increase in default quantity. When evaluating each of the 15 pairwise comparisons of default quantities (eg, 5 vs 15 tablets), a lower default was associated with a lower number of pills prescribed in more than half (8 of the 15) of the pairwise comparisons; there was a higher quantity in 1 and no difference in 6 comparisons.

Conclusions and relevance: These findings suggest that default settings in the EMR may influence the quantity of opioids prescribed by health care professionals. This low-cost, easily implementable, EMR-based intervention could have far-reaching implications for opioid prescribing and could be used as a tool to help combat the opioid epidemic.

Trial registration: ClinicalTrials.gov identifier: NCT04155229.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Montoy reported receiving grants from University of California, San Francisco (UCSF), Clinical and Translational Science Institute during the conduct of the study. Dr Coralic reported receiving grants from UCSF during the conduct of the study; serving as a paid expert witness for Par Pharmaceutical in a patent litigation case; and serving as an expert witness for the defendant in a medicolegal case where the issue of opioid administration in the emergency department was discussed. Dr Raven reported receiving grants from CareStar Foundation and the California ED BRIDGE Program and nonfinancial support from Collective Medical outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. Study Flowchart

Treatment assignment for default quantities of prescription tablets is shown. All exclusions were due to missing dispense quantity data.

Figure 2.. Distribution of Dispense Quantities by Treatment Assignment

Each panel shows the results from 1 of 4 default settings.