Reducing opioid prescribing: a qualitative process evaluation of how general practices responded to enhanced feedback.

Problem

There is national and international concern over rising trends in opioid prescribing for chronic non-cancer pain. Given accumulating evidence of harm, reversing the current trend in opioid prescribing would benefit a substantial at-risk population. The Campaign to Reduce Opioid Prescribing (CROP) entailed sending 316 practices in West Yorkshire enhanced feedback (evidence-based, comparative and practice-individualised) on their overall opioid prescribing, and for high-risk patient groups. Reports were sent bimonthly for 12 months from April 2016.We evaluated how enhanced feedback to reduce opioid prescribing was perceived and acted upon.

Approach

Semi-structured interviews, guided by Normalisation Process Theory (NPT), with general practices explored the process and experience of the feedback on opioid prescribing. We purposively recruited participants according to baseline prescribing levels and degree of change following feedback. Recorded interviews were transcribed and data coded to NPT components and thematically analysed.

Findings

Interviews with 21 staff from 20 practices highlighted five issues:First, high achievers were practices which already had a clear structure for quality improvement. Identifying a project lead and regular practice meetings seemed important actions. CROP did encourage some less structured practices to change systems, e.g. use an action plan; include locums in regular meetings. Second, the non-prescriptive reports allowed practices to identify strategies to fit within their way of working, e.g. harnessing practice pharmacists; conducting their own searches; adding prompts to patient records; developing patient leaflets; agreeing a practice policy; ending repeat prescribing of opioids. Third, although some highlighted that implementation took time and effort (with risks of damage to patient relationships, appointment shortage and competing priorities), mitigating plans were mentioned, e.g. staggering reviews, agreeing a practice policy, or working on one high risk area only.Fourth, reducing opioid prescribing was recognised as a clinical priority and feedback motivated action. Impact came from graphical practice comparison, and change seen over the year. Patient benefit from reducing and stopping opioids was reported by those who achieved lower prescribing. Conflict between drivers of clinical excellence and patient satisfaction was raised as an issue on how a practice is judged. Finally, reports did not consistently make it through ‘gate-keeping’ processes within practices but the scale and frequency of feedback may have been sufficient to produce worthwhile population effects.

Consequences

CROP was a non-prescriptive, enhanced feedback intervention on an important prescribing issue which engaged practices in change and allowed adaption to their own ways of working. Changes in routine systems were embedded where there were structures already in place to discuss, agree, and implement change; but this intervention also encouraged varied actions in less structured practices.CROP illustrates a well-aligned collaboration between researchers and providers for a common quality improvement goal.