A Strategy to Reduce Opioid Drug Prescribing by Clinicians
Condition: Analgesics Opioid
Study type: Observational

Summary: 
      Under the auspices of the Oral Health Section of the NC Department of Health and Human
      Services clinician-investigators from the UNC Oral and Maxillofacial Surgery Department are
      conducting a survey to assess current analgesic prescribing practices in NC with a goal of
      eventually reaching consensus among clinicians for a wide range of procedures and conditions
      where pain control is important for successful patient outcomes. We hope that about 850
      dentists and 600 physicians will agree to take part in this research study. Participation in
      this Qualtrics survey e-mailed in mid-February 2019 will take about 15 minutes or less.
    

Detailed description: 
      METHODS

      Participants:

      Dentists, emergency room physicians and primary care physicians who are in active practice
      will be surveyed using the lists of active practitioners with Drug Enforcement
      Administration(DEA) licenses provided by the NC Department of Public Health.

      Inclusion criteria for dentists: Active dentist with DEA license including: endodontists,
      general practice dentists, oral and maxillofacial surgeons, and periodontists.

      Given the small numbers per specialty, all endodontists (n=128), periodontists(n=114), and
      oral and maxillofacial surgeons (n=178) will be surveyed. A stratified random sample (n =
      400) of general dentists (n=3905) will be selected from the list using region of the state as
      the stratification factor.

      Inclusion criteria for emergency room clinical staff: MD/DO/PA with a primary area of
      practice as emergency medicine or urgent care and area(s) of practice as emergency medicine,
      urgent care, family medicine, or adolescent & young adult medicine All DO (n = 191) will be
      surveyed. A stratified random sample (n= 400) of MD's (N = 1407) and PA's will be selected
      from the list using region of the state as the stratification factor.

      Qualtrics Survey:

      The survey will be divided into two general areas: 1) personal and practice demographics
      (sex, age, time in practice (years), practice size) and 2) clinical scenarios typical of
      patients seen by the respective practitioners who might be expected to experience acute pain.
      For each of the scenarios, practitioners will be asked the type(s) of medication that would
      be prescribed, the strength in mg, and the number of doses for each medication.

      The survey will be pre-tested by a sample of potential survey subjects who will be asked to
      provide open-ended comments regarding ease of completion, confusing items, and word changes.
      The survey methods of Salant and Dillman will be used as a guide.(8)

      A Qualtics linkage file will be created accessible only to the project investigators. The
      linkage file will only be used to identify non-respondents for follow-up. Surveys will be
      coded to maintain respondents' confidentiality. Linkage file will be in a pass word protected
      file separate from survey responses.

      Distribution:

      A mixed mode of distribution of the surveys will be used. Qualtrics software (Qualtrics,
      Provo, UT) will be used to create electronic versions of the survey to be sent to providers
      via email with an accompanying letter describing the purpose of the project and how
      confidentiality will be maintained. Teleform (Cardiff Software, Vista, CA) will be used as a
      paper alternative for providers who do not wish to respond to the electronic version. For
      these individuals a cover letter will be included describing the study along with a postage
      paid return envelope. Up to three attempts will be made at two-week intervals, depending on
      response versus non-response, to optimize subject participation.(8) The mode for the third
      round will be determined by the response rate from each of the first two rounds.

      Statistical Analysis:

      All survey responses will be de-identified to maintain provider confidentiality. The
      electronic and Teleform responses will be merged and analyzed using SAS (version 9.4, Cary,
      NC). Respondents will be excluded from data analysis if they do not complete the data for the
      prescribing practices.The primary outcome variable will be the clinicians prescribing opioid
      drugs for each survey scenario or not. Secondary analyses will explore possible explanatory
      variables for the primary outcome. Bivariate analysis will be done by status (degree and
      practice mode) to explore the effect of the explanatory variables (age; gender; time in
      practice; practice location; and practice size) on the preferred medication option for each
      clinical scenario. Comparisons among degree/specialty holders is not possible given that the
      scenarios presented are unique to the different groups. The use of Chi-square or Fisher's
      Exact test for the bivariate analysis will be determined based on the cell frequencies. Level
      of significance was set at 0.05.
    

Intervention name(s): Qualtrics survey questions
Intervention type(s): Other
Intervention description(s): Qualtrics Survey:
For each of the scenarios, practitioners will be asked whether opioids are prescribed or not, and the type(s) of other analgesic medications that would be prescribed, the strength in mg, and the number of doses for each medication
Observational model: Other
Time perspective: Prospective
Sampling method: Probability Sample
Study population: 
        General dentists, Endodontists, Periodontists, Oral and Maxillofacial Surgeons. Emergency
        Room Physicians
      
Keywords: opioids