User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial

AbstractObjectiveTo determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder.DesignPragmatic cluster randomized controlled trial (EMBED).Setting18 emergency d...

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Published in:BMJ (Online) 2022-06, Vol.377, p.e069271
Main Authors: Melnick, Edward R, Nath, Bidisha, Dziura, James D, Casey, Martin F, Jeffery, Molly M, Paek, Hyung, Soares, William E, Hoppe, Jason A, Rajeevan, Haseena, Li, Fangyong, Skains, Rachel M, Walter, Lauren A, Patel, Mehul D, Chari, Srihari V, Platts-Mills, Timothy F, Hess, Erik P, D’Onofrio, Gail
Format: Article
Language:English
Subjects:
Addictions
Buprenorphine
Cognitive load
Coronaviruses
COVID-19
Drug abuse
Drug addiction
Drug withdrawal
Electronic health records
Electronic medical records
Emergency medical care
Genotype & phenotype
Health care
Intervention
Medical referrals
Narcotics
Opioids
Pandemics
Patients
Structured Query Language-SQL
Trends
Withdrawal
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Summary:AbstractObjectiveTo determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder.DesignPragmatic cluster randomized controlled trial (EMBED).Setting18 emergency department clusters across five healthcare systems in five states representing the north east, south east, and western regions of the US, ranging from community hospitals to tertiary care centers, using either the Epic or Cerner electronic health record platform.Participants599 attending emergency physicians caring for 5047 adult patients presenting with opioid use disorder.InterventionA user centered, physician facing clinical decision support system seamlessly integrated into user workflows in the electronic health record to support initiating buprenorphine in the emergency department by helping clinicians to diagnose opioid use disorder, assess the severity of withdrawal, motivate patients to accept treatment, and complete electronic health record tasks by automating clinical and after visit documentation, order entry, prescribing, and referral.Main outcome measuresRate of initiation of buprenorphine (administration or prescription of buprenorphine) in the emergency department among patients with opioid use disorder. Secondary implementation outcomes were measured with the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework.Results1 413 693 visits to the emergency department (775 873 in the intervention arm and 637 820 in the usual care arm) from November 2019 to May 2021 were assessed for eligibility, resulting in 5047 patients with opioid use disorder (2787 intervention arm, 2260 usual care arm) under the care of 599 attending physicians (340 intervention arm, 259 usual care arm) for analysis. Buprenorphine was initiated in 347 (12.5%) patients in the intervention arm and in 271 (12.0%) patients in the usual care arm (adjusted generalized estimating equations odds ratio 1.22, 95% confidence interval 0.61 to 2.43, P=0.58). Buprenorphine was initiated at least once by 151 (44.4%) physicians in the intervention arm and by 88 (34.0%) in the usual care arm (1.83, 1.16 to 2.89, P=0.01).ConclusionsUser centered clinical decision support did not increase patient level rates of initiating buprenorphine in the emergency department. Although streamlining and automating electronic health record workflows can potentially increase adoption o
ISSN:1756-1833
0959-8138
1756-1833
DOI:10.1136/bmj-2021-069271