The primary care provider experience in an intervention to improve adherence to opioid prescribing guidelines
Cushman, Phoebe Anne
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BACKGROUND: Efforts to curb the opioid epidemic have generated multiple guidelines to increase the safety of opioid prescribing for chronic nonmalignant pain (CNMP). We performed a qualitative analysis of an intervention (TOPCARE, “Transforming Opioid Prescribing in Primary Care”) aimed at improving primary care physician (PCP) adherence to opioid prescribing guidelines. We explored 1) how TOPCARE influences PCPs’ knowledge, attitudes, and behavior regarding the opioid guidelines, 2) how PCPs’ clinical contexts influence implementation of TOPCARE, and 3) how characteristics of TOPCARE influence PCPs’ adherence to the opioid prescribing guidelines. METHODS: We conducted in-person, semi-structured interviews with 22 of 24 intervention PCPs from TOPCARE, a cluster RCT at 4 safety-net clinics. The multi-component TOPCARE intervention consists of a registry of patients who take opioids for CNMP, population management by nurse care managers (NCMs), education by academic detailers (ADs), and electronic decision support tools. We performed thematic analysis of transcribed interviews, double-coding every third interview. Our conceptual model merged two frameworks: Cabana et al.’s “Why don’t physicians follow clinical practice guidelines?” and Rycroft-Malone’s “Promoting Action on Research Implementation in Health Services” (PARiHS). RESULTS: Themes related to PCP knowledge that emerged from the interviews were increased knowledge of the content of the guidelines, increased strategies for application of the guidelines, and meaningful feedback. Attitude-related themes were PCPs’ personal stances toward the guidelines, increased outcome expectancy, reduced anxiety, and perceiving patients who take opioids for CNMP as challenging. Behavior-related themes were guideline-concordant prescribing becoming routine and increased transfer of tasks to NCMs. PCPs revealed clinic resources, clinic leadership, variability of practice style, and historico-political context to be important aspects of their clinical contexts that influenced their implementation of TOPCARE. The themes TOPCARE as NCM, integration of NCM into workflow, NCM as trusted member of the treatment team, supportive consultation, and population health approach all emerged as characteristics that PCPs found central to the effectiveness of the TOPCARE intervention in improving their adherence to opioid guidelines. CONCLUSION: An intervention to improve adherence to opioid guidelines increased PCPs’ knowledge and outcome expectancy. PCPs experienced tangible and emotional support to reduce variability and enable guideline-concordant care.