Use of chart review tool and peer feedback to influence physician prescribing of controlled substances
Penti, Brian Robert
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PURPOSE: Develop and evaluate a chart review tool (CRT) to improve the safety and effectiveness of prescribing controlled substances in a primary care setting. METHODS: A Controlled Substance Review Committee, consisting of volunteer primary care physicians and a clinical pharmacist, developed a CRT to assess compliance with a primary care clinic’s controlled substance prescribing policy and effectiveness of therapy. The CRT was based on existing clinic policies and American Pain Society/American Academy of Pain Medicine clinical guidelines for opioid prescribing. Every month, committee physicians used the CRT to review medical records of patients prescribed controlled substances chronically. The CRT tracked factors from the previous 6 months, including morphine equivalent dose (MED) prescribed, indication for treatment, documentation of treatment effectiveness, the Opioid Risk Tool score (ORT score), results from urine drug testing (UDT) and patient violations of the clinic’s controlled substance policy. These findings are used to provide the treating physician constructive, non-punitive feedback. We also assessed if the use of the CRT resulted in change in MED prescribed. RESULTS: Ninety-nine patient charts from 14 different physicians were reviewed over 1 year. Eighty-eight of these patients were receiving opioids for chronic pain, with an average dose in MED 72.6 mg/day (SD 89). Twenty-nine percent of charts had documentation that the controlled substance was improving the patient’s quality of life or decreasing their pain. Sixty percent of patients had at least one violation of the clinic’s controlled substance treatment agreement in the prior 6 months, and half of the violations were due to missed appointments with specialists to help manage pain. Patients were more likely to have a violation of controlled substance policy in the past 6 months if they were prescribed both a benzodiazepine (BZD) and an opioid (p=0.04), had a documented treatment agreement (p=0.002), or were high risk per ORT score (p=0.001). The mean dose of opioids, for the 88 patients who were prescribed opioids, decreased 2.6 mg/day MED from time of chart review until the end of study (mean duration 6.3 months), compared to a 6.9 mg/day MED increase that occurred from 12 months prior to chart review to the time of chart review (p=0.01). CONCLUSION: Development and implementation of a CRT in an urban primary care clinic provided helpful insight on prescribing practices, and has promise to improve quality of opioid prescribing. The most common violation of the clinic policy was missed appointments with specialists, and patients prescribed both BZD and an opioid or were high risk per ORT were most likely to have violations. Documentation of effectiveness of therapy was lacking.