J. M. Coughlin1,2, M. Shallcross1, W. Schäfer1, R. Khorfan1, J. Stulberg1,3,4, K. Y. Bilimoria1,3,4, J. K. Johnson1,3 1Feinberg School Of Medicine – Northwestern University,Surgical Outcomes And Quality Improvement Center, Department Of Surgery And Center For Healthcare Studies,Chicago, IL, USA 2Rush University Medical Center,Department Of Surgery,Chicago, IL, USA 3Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 4Northwestern Memorial Hospital,Chicago, IL, USA
Introduction: The United States is amidst an opioid epidemic. To reduce our reliance on opioids for pain management, our institution developed the Minimizing Opioid Prescribing in Surgery (MOPiS) initiative at five different hospitals. MOPiS is a multi-component intervention including (1) preoperative expectation setting on appropriate pain management (2) screening patients for addictive behavior and substance abuse risk, (3) optimizing perioperative non-opioid pain management, and (4) minimizing opioid prescribing at discharge. We conducted a pre-intervention formative evaluation to identify barriers to implementation, as well as solutions to address them.
Methods: Prior to implementation of the MOPiS initiative, we conducted semi-structured interviews at each hospital (n=5) with 23 key stakeholders (surgeons, nurses, pharmacists and administrators). The four components of the intervention were explained and interviewees were asked about perceived barriers and solutions for implementation. Interviews were audio recorded and transcribed. Responses were analyzed to identify common themes using the Theoretical Domains Framework (TDF), an integrative framework that applies theoretical approaches to interventions aimed at behavior change.
Results: Common themes of potential implementation barriers were identified and classified under five TDF domains: knowledge, social/professional role and identity, environmental context and resources, belief about consequences, and behavioral regulation (Table 1). Clinician knowledge of appropriate opioid stewardship is often lacking, and patients do not consistently receive comprehensive pain management education (knowledge). Providers of all levels cited time as the greatest barrier (environmental and context resources) to providing patient education. Pharmacists are not routinely incorporated into the treatment team, although they consistently express an interest in educating and advising (social/professional role and identity). Patients have varying expectations of post-operative pain management and physicians fear patient dissatisfaction if these expectations are not met (belief about consequences). Physicians who over-prescribe are not being held accountable for their prescribing practices (behavioral regulation).
Conclusions: Implementation barriers have the potential to derail any improvement initiative, and successful implementation of an opioid reduction initiative will require specific strategies to overcome barriers. In our MOPiS initiative, utilizing a pre-intervention formative evaluation process enabled the design of strategies to facilitate implementation of the components of the initiative.
