Clinical decision tool increased OUD treatment orders in primary care, didn't change mortality
Primary care patients who were treated under an electronic health record-integrated clinical decision support system were more likely to receive orders for naloxone or medications for opioid use disorder (OUD) than patients who received usual care.
Implementation of an electronic health record-integrated clinical decision support system (CDSS) improved rates of naloxone orders and opioid use disorder (OUD) treatment in primary care but did not affect days covered by a medication for OUD (MOUD) over 90 days after the primary care visit or overdose or death rates, a randomized trial found.
Between April 2021 and December 2023, 92 primary care clinics in three U.S. health systems were randomized to receive or not receive an electronic health record-integrated CDSS that provided personalized treatment recommendations to patients and clinicians. The study included 10,891 patients (54.3% female; mean age, 48 years) who had an OUD diagnosis in the last two years, an opioid overdose in the last six months, or a risk score indicating high risk of OUD or opioid overdose. Findings were published by JAMA Internal Medicine on July 14.
Researchers found no difference in OUD diagnoses within 30 days between groups. Participants in the intervention group had higher rates of orders for naloxone (1.4% vs. 0.7%; odds ratio [OR], 1.76 [95% CI, 1.14 to 2.72]) and MOUD or treatment referral (14.0% vs. 9.4%; OR, 1.48 [95% CI, 1.05 to 2.08]) within 30 days. The positive effects on MOUD orders or referrals were especially pronounced for patients who were American Indian or Alaska Native (OR, 2.47; 95% CI, 1.30 to 4.67) or Black (OR, 2.84; 95% CI, 1.39 to 5.80). However, there were no differences in the median number of days covered by MOUD over 90 days after the visit (84 vs. 83 days; rate ratio, 1.00 [95% CI, 0.93 to 1.08]) or in overdose or death rates during the intervention period.
It was notable how much lower the rate of naloxone prescriptions was compared with MOUD or referral orders (1.4% vs. 14.0%), the study authors said. They added that the findings may not be generalizable outside of integrated health care systems. Other limitations include that only orders for MOUD and referrals were measured, not prescription fills or completed referrals. The study did not include methadone, as prescriptions for methadone for OUD would have been written by external clinicians.
Overall, “these findings demonstrate an OUD CDSS can help increase access to OUD treatment in primary care,” the authors wrote.
An accompanying editorial called for further innovation in this area, such as making OUD treatment part of the expected scope of primary care clinicians' routine care. Potential strategies to increase retention in treatment include long-acting injectable buprenorphine, integration of behavioral counseling, and measurement-based care to monitor recovery and iteratively adapt treatment, the editorialists wrote.
“Implementation of [clinical decision support] alone has a relatively small effect but could be combined and synergize with nurse care management or a hub and spoke model, which have larger effects. Further innovation is needed to increase buprenorphine treatment in primary care and test new strategies for retaining patients on OUD treatment,” they concluded.