This educational study in a clinical journal by Kahan et al at the University of Toronto
examined “the effects of an intensive 2-day course on physicians' prescribing
of opioids” [1]. The most impressive feature of this study is its eight-year-plus
data-gathering period of opioid-prescribing levels among participating physicians,
most of whom were family physicians. Other interesting features are worth
mentioning, in both instructional design and study design.
The study design grouped participants
into self-referred physicians vs. physicians who were referred by medical
regulators, and added a control (nonparticipant) group. Undertaking a challenging
matching procedure, researchers matched nonparticipants according to specific
variables, including quarterly rates of opioid-prescribing, expressed as milligrams
of morphine equivalent. Subgroups of participant groups with very high
opioid-prescribing patterns were also identified; unfortunately, nonparticipants
to match these participants were difficult to find. Yet this targeted approach
to matching is appropriate and represents a significant investment of the
researchers’ time, allowing the comparative group findings shown below. Nonparticipants
were added to the study concurrently with their matched participants, per an
“index date” defined as “the date of course completion for participating
physicians. Control physicians were assigned the same index date as their
matched pair.” In one deviation from the primary outcome measure, matching was
done by number of opioid prescriptions rather than milligrams of morphine
equivalent. Another study design feature is the specific comparison of
opioid-prescribing rates for 2 years before vs. 2 years after the educational intervention,
again by group and subgroup vs. nonparticipants; participants who could not be
matched were analyzed separately from participants with matched pairs.
The instructional design of
the 2-day course incorporated several educational settings and modalities.
Planners used didactic presentations but added problem-based case discussions and
mock-interview learning interactions with standardized patients who offered
feedback. Pros and cons of changing prescribing patterns were discussed in a
session at the end of the course, featuring a faculty interview with a patient.
The course also provided a detailed syllabus with notes and references before
the course, as well as office materials. It should be noted that
benzodiazepine-prescribing was also addressed in course content. Finally, each
2-day course enrolled up to 12 participants, a limit that would confer an
individualized learning environment and some professional privacy in what might
be a sensitive concern among participating physicians.
The authors noted in the
introduction, “Medical education has been suggested as one strategy to improve
opioid prescribing among physicians” [2,3] and “Educational interventions
focused on opioid prescribing lead to positive improvement in physicians’ knowledge
and self-reported practices” [4]. Let's look at results by
reported subgroup.
Among physicians referred by medical
regulators, “the rate of opioid prescribing decreased dramatically in the year
before course participation compared with matched control physicians,” and “the
course had no added effect on the rate of physicians' opioid prescribing in the
subsequent 2 years.” It seems that these physicians might have changed their
behavior by arbitrarily reducing prescribing rates because of the regulatory investigation,
even without an educational intervention to inform their clinical decision-making.
In fact, the authors acknowledge this, noting, “We measured only the quantity
of opioids prescribed, not the quality of opioid prescribing.” The regulatory
concerns may have created a false baseline for the educational study that
measured only quantity of opioid prescribed rather than patient-selection or
other measure of competence.
Among the self-referred
physicians who were matched to nonparticipants, “there was no statistically
significant effect on the rate of opioid prescribing observed” from baseline to
2-year follow-up, although there had been a temporary decrease, particularly in
prescribing for patients aged 15 – 64 (here’s a nice graph with patient ages: http://www.cfp.ca/content/59/5/e231/F4.expansion.html).
On the other hand, “the rate of opioid prescribing decreased by 43.9% in the
year following course completion” among self-referred physicians with high
prescribing rates who could not be matched, suggesting that these physicians “might
have responded to what was taught in the course.”
1. Kahan M, Gomes T, Juurlink DN, et al. Effect of a course-based intervention and effect of medical regulation on physicians’ opioid prescribing. Can Fam Physician. 2013;59(5):e231-e239. http://www.cfp.ca/content/59/5/e231.full.pdf+html.
[Featured Article]
2. College of Physicians and Surgeons of Ontario. Avoiding Abuse, Achieving a Balance: Tackling the Opioid Public Health Crisis. Toronto, ON: College of Physicians and Surgeons of Ontario; 2010.
3. National Opioid Use Guideline Group. Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. Hamilton, ON: National Opioid Use Guideline Group; 2010.
4. Midmer D, Kahan M, Marlow B. Effects of a distance learning program on physicians’ opioid- and benzodiazepine-prescribing skills. J Contin Educ Health Prof. 2006;26(4):294-301.
Free full text PDF: http://www.cfp.ca/content/59/5/e231.full.pdf.
MeSH *Major* terms: Analgesics, Opioid/therapeutic use*; Drug Prescriptions/standards*; Education, Medical, Continuing*; Physician's Practice Patterns/standards*
