title: Randomized Controlled Trial of Electronic Care Plan Alerts and Resource Utilization by High Frequency Emergency Department Users with Opioid Use Disorder.
abstract: BACKGROUND
  There is a paucity of literature supporting the use of electronic alerts for patients with high frequency emergency department (ED) use. We sought to measure changes in opioid prescribing and administration practices, total charges and other resource utilization using electronic alerts to notify providers of an opioid-use care plan for high frequency ED patients.
  
  
  METHODS
  This was a randomized, non-blinded, two-group parallel design study of patients who had 1) opioid use disorder and 2) high frequency ED use. Three affiliated hospitals with identical electronic health records participated. Patients were randomized into "Care Plan" versus "Usual Care groups". Between the years before and after randomization, we compared as primary outcomes the following: 1) opioids (morphine mg equivalents) prescribed to patients upon discharge and administered to ED and inpatients; 2) total medical charges, and the numbers of; 3) ED visits, 4) ED visits with advanced radiologic imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) studies, and 5) inpatient admissions.
  
  
  RESULTS
  A total of 40 patients were enrolled. For ED and inpatients in the "Usual Care" group, the proportion of morphine mg equivalents received in the post-period compared with the pre-period was 15.7%, while in the "Care Plan" group the proportion received in the post-period compared with the pre-period was 4.5% (ratio=0.29, 95% CI [0.07-1.12]; p=0.07). For discharged patients in the "Usual Care" group, the proportion of morphine mg equivalents prescribed in the post-period compared with the pre-period was 25.7% while in the "Care Plan" group, the proportion prescribed in the post-period compared to the pre-period was 2.9%. The "Care Plan" group showed an 89% greater proportional change over the periods compared with the "Usual Care" group (ratio=0.11, 95% CI [0.01-0.092]; p=0.04). Care plans did not change the total charges, or, the numbers of ED visits, ED visits with CT or MRI or inpatient admissions.
  
  
  CONCLUSIONS
  Electronic care plans were associated with an incremental decrease in opioids (in morphine mg equivalents) prescribed to patients with opioid use disorder and high frequency ED use.
authors.affiliation: Baystate Medical Center and Tufts University School of Medicine, Department of Emergency Medicine, Boston, Massachusetts.
authors.forename: Niels
authors.initials: N
authors.lastname: Rathlev
authors.affiliation: ARAMCO, Department of Emergency Medicine, Dharan, Saudi Arabia.
authors.forename: Reda
authors.initials: R
authors.lastname: Almomen
authors.affiliation: Baystate Medical Center, Department of Emergency Medicine, Springfield, Massachusetts.
authors.forename: Ashley
authors.initials: A
authors.lastname: Deutsch
authors.affiliation: Baystate Medical Center and Tufts University School of Medicine, Department of Emergency Medicine, Boston, Massachusetts.
authors.forename: Howard
authors.initials: H
authors.lastname: Smithline
authors.affiliation: Baystate Medical Center, Department of Emergency Medicine, Springfield, Massachusetts.
authors.forename: Haiping
authors.initials: H
authors.lastname: Li
authors.affiliation: Baystate Medical Center, Department of Academic Affairs Administration, Springfield, Massachusetts.
authors.forename: Paul
authors.initials: P
authors.lastname: Visintainer
mesh_terms: D000701:Analgesics, Opioid / Q000191:economics / Q000627:therapeutic use*; D057286:Electronic Health Records; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006760:Hospitalization; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009293:Opioid-Related Disorders / Q000188:drug therapy / Q000453:epidemiology*; D010351:Patient Discharge; D018579:Patient Selection; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D017010:Reminder Systems; D014481:United States / Q000453:epidemiology
chemical_list: D000701:Analgesics, Opioid
references.citation: J Biomed Inform. 2009 Apr;42(2):377-81
references.pmid: 18929686
references.citation: Ann Emerg Med. 2012 Jul;60(1):33-4
references.pmid: 22445101
references.citation: Ann Emerg Med. 1998 Nov;32(5):563-8
references.pmid: 9795318
references.citation: Emerg Med J. 2007 Jun;24(6):398-401
references.pmid: 17513534
references.citation: CMAJ. 2000 Apr 4;162(7):1017-20
references.pmid: 10763402
references.citation: J Emerg Med. 2012 Nov;43(5):883-8
references.pmid: 19944550
references.citation: Stat Med. 1992 Sep 30;11(13):1685-704
references.pmid: 1485053
references.citation: Acad Emerg Med. 2011 Jun;18(6):e52-63
references.pmid: 21676050
references.citation: Ann Emerg Med. 2011 Jul;58(1):53-5
references.pmid: 21689566
references.citation: Acad Emerg Med. 2011 Dec;18(12):1313-7
references.pmid: 22168196
references.citation: Pharmacoepidemiol Drug Saf. 2006 Sep;15(9):618-27
references.pmid: 16862602
references.citation: Am J Emerg Med. 1998 Nov;16(7):648-52
references.pmid: 9827738
references.citation: N Engl J Med. 2010 Nov 18;363(21):1981-5
references.pmid: 21083382
references.citation: Ann Emerg Med. 2006 Jul;48(1):1-8
references.pmid: 16781914
references.citation: West J Emerg Med. 2010 Sep;11(4):348-53
references.pmid: 21079707
references.citation: PLoS One. 2013;8(7):e69241
references.pmid: 23874923
references.citation: Ann Emerg Med. 2011 Jul;58(1):41-52.e42
references.pmid: 21689565
references.citation: Acad Emerg Med. 1997 Jun;4(6):574-80
references.pmid: 9189190
references.citation: Acad Emerg Med. 2000 Jun;7(6):637-46
references.pmid: 10905642
references.citation: Acad Emerg Med. 1996 Apr;3(4):312-7
references.pmid: 8881539
references.citation: J Hosp Med. 2015 Jul;10(7):419-24
references.pmid: 25854685
references.citation: Ann Emerg Med. 2006 Apr;47(4):328-36
references.pmid: 16546617