Adapting and evaluating a complex adaptable intervention to reducing opioid prescribing in primary care (Opioid SMART)

Description

Despite the best intentions of clinicians and policy-makers, the quality of care that patients receive can vary a lot. Audit and feedback aims to improve patient care by comparing how healthcare is delivered against set standards. It shows where there is variation and encourages NHS staff (doctors, nurses, managers) and organisations (hospitals, general practices) to make improvements.

I previously led an audit and feedback programme for GPs in West Yorkshire asking them to reduce opioid prescribing. Opioids are morphine-based medicines that can result in addiction and increased risks of falls and early death. They are often given as painkillers, but there is little evidence they help with chronic non-cancer pain. After one year, the feedback resulted in 15,000 fewer patients being given opioids, protecting them from potential harm, and a saving to the NHS of £900,000. Yet some practices were not able to reduce their prescribing, and some took much longer than others to improve.
‘Feedback facilitation’ involves bringing in a trained facilitator to help those practices struggling to improve care on their own. Previous research suggests facilitation works but it costs time and money, including for general practices. So, it is important to know whether and when such facilitation might help most. I plan to use a new type of study design to answer this question, a Sequential Multiple-Assignment Randomised Trial (SMART) design. SMART designs answer these questions by changing what support practices get based upon how well they are doing at different times. Work has been done on SMART designs in the US, but they have yet to be tried in the UK.

The aim of the project is to support general practices to reduce prescribing of potentially harmful opioid painkillers for chronic non-cancer pain using a SMART design. This will improve understanding of if and when feedback facilitation should be offered and its costs compared to its benefits.

There are four parts to this project:
First, I will work with my patient group and practice staff to update and develop an existing audit and feedback programme feedback facilitation for delivering and testing in primary care.
Second, I will test both interventions with six general practices to check that we can deliver them as intended and that they are acceptable.
Third, all 285 practices in West Yorkshire will receive the audit and feedback programme as part of a planned quality improvement project. The SMART design will offer some practices feedback facilitation if they are not able to reduce their prescribing after six or twelve months. I will calculate the additional costs and benefits to patients and the NHS.
Finally, I will gather different kinds of data to examine how the practices interacted with the feedback facilitation in the SMART design and why and how it worked (or not).

This project was co-designed by my existing patient and public group who want to support practices that struggle to improve quality of care. The group has nine diverse members, some with experience of chronic pain. They will be involved throughout, including designing the study and facilitation, interpreting data, trial management, and dissemination.

 

Impact

This project will help improve patient care by reducing potentially harmful opioid prescribing, so improving patient health and reducing deaths. It will also show if the SMART design is helpful for future research. I will work with my patient group to help policy makers roll out this programme across England and show how it can be adapted to other priorities, such as antibiotic prescribing.