Methodsdesign preliminary studies in preparation for

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Methods/Design Preliminary studies In preparation for the grant submission, we analyzed preliminary data from the set of family medicine clinics that form the recruitment base for this pilot study. Sub- stantial differences in opioid prescribing practices were evident. Clinics, and providers within clinics, varied sub- stantially in the percentage of patients with three or more opioid prescriptions in the past year and average MEDD per patient. Compared with other patients, those with three or more opioid prescriptions more frequently reported smoking and drinking, were diagnosed more often with depression, and had substantially more clinic visits. Those in the highest MEDD group (4th quartile) had the least favourable profile. Of note, close to 50% of those in the 4th MEDD quartile reported regular alcohol consumption, which is discouraged in treatment agree- ments. These preliminary results align with evidence on the dose response relation between MEDD and poor outcomes, [40] and further suggest that implementing universal precautions for opioid prescribing can reduce harms. Specific Aim 1 consists of guideline translation and training of the systems consultants. Guideline translation has been conducted by the research team in consultation with the advisory panel. We followed a structured group decision-making approach called the integrative group process [41], a systematic technique for facilitating meet- ings of experts that incorporates the nominal group technique [28], the Delphi process [42], social judgment analysis [43], and cognitive mapping [44]. We began by conducting a structured Delphi process [28], in which we asked each member of the advisory panel to rate each recommendation in the opioid prescribing clinical guideline on its measurability, potential to reduce opioid abuse, and ease of implementation. We conducted follow- up telephone interviews with each panel member to understand the ratings they assigned. We compiled the re- sults of the Delphi process to prioritize the panelists rec- ommendations into a preliminary checklist. Checklists can be effective in improving healthcare processes and patient safety [45] by serving at least two purposes: (1) jogging the clinician s memory and (2) "making the minimum explicit" [46]. But a checklist Quanbeck et al. Health Research Policy and Systems (2016) 14:8 Page 4 of 10
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per se is a weak intervention [47] because it does not ad- dress barriers specific to the setting in which it is to be used. A checklist can be effective as part of an interven- tion that creates social connections among clinicians [26, 47], but not when it functions as the whole inter- vention. For this reason, our implementation strategy will include not just a checklist, but implementation tools and support. We convened the advisory panel for a one-day, in- person meeting on November 18, 2014. During the meeting, the authors presented the initial checklist and asked panel members to provide feedback and revisions.
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