TY - JOUR
T1 - Laboratory-generated urine toxicology interpretations
T2 - A mixed methods study
AU - Chua, Isaac S.
AU - Ransohoff, Jaime R.
AU - Ehrlich, Olga
AU - Katznelson, Ethan
AU - Virk, Zain M.
AU - Demetriou, Christiana A.
AU - Petrides, Athena K.
AU - Orav, Endel J.
AU - Schiff, Gordon D.
AU - Melanson, Stacy E.F.
N1 - Publisher Copyright:
© 2021, American Society of Interventional Pain Physicians. All rights reserved.
PY - 2021
Y1 - 2021
N2 - Background: Clinicians frequently order urine drug testing (UDT) for patients on chronic opioid therapy (COT), yet often have difficulty interpreting test results accurately. Objectives: To evaluate the implementation and effectiveness of a laboratory-generated urine toxicology interpretation service for clinicians prescribing COT. Study Design: Type II hybrid–convergent mixed methods design (implementation) and pre–post prospective cohort study with matched controls (effectiveness). Setting: Four ambulatory sites (2 primary care, 1 pain management, 1 palliative care) within 2 US academic medical institutions. Methods: Interpretative reports were generated by the clinical chemistry laboratory and were provided to UDT ordering providers via inbox message in the electronic health record (EHR). The Partners Institutional Review Board approved this study. Participants were primary care, pain management, and palliative care clinicians who ordered liquid chromatography-mass spectrometry UDT for COT patients in clinic. Intervention was a laboratory-generated interpretation service that provided an individualized interpretive report of UDT results based on the patient’s prescribed medications and toxicology metabolites for clinicians who received the intervention (n = 8) versus matched controls (n = 18). Implementation results included focus group and survey feedback on the interpretation service’s usability and its impact on workflow, clinical decision making, clinician-patient relationships, and interdisciplinary teamwork. Effectiveness outcomes included UDT interpretation concordance between the clinician and laboratory, documentation frequency of UDT results interpretation and communication of results to patients, and clinician prescribing behavior at follow-up. Results: Among the 8 intervention clinicians (median age 58 [IQR 16.5] years; 2 women [25%]) on a Likert scale from 1 (“strongly disagree”) to 5 (“strongly agree”), 7 clinicians reported at 6 months postintervention that the interpretation service was easy to use (mean 5 [standard deviation {SD}, 0]); improved results comprehension (mean 5 [SD, 0]); and helped them interpret results more accurately (mean 5 [SD, 0]), quickly (mean 4.67 [SD, 0.52]), and confidently (mean 4.83 [SD, 0.41]). Although there were no statistically significant differences in outcomes between cohorts, clinician-laboratory interpretation concordance trended toward improvement (intervention 22/32 [68.8%] to 29/33 [87.9%] vs. control 21/25 [84%] to 23/30 [76.7%], P = 0.07) among cases with documented interpretations. Limitations: This study has a low sample size and was conducted at 2 large academic medical institutions and may not be generalizable to community settings. Conclusions: Interpretations were well received by clinicians but did not significantly improve laboratory-clinician interpretation concordance, interpretation documentation frequency, or opioid-prescribing behavior.
AB - Background: Clinicians frequently order urine drug testing (UDT) for patients on chronic opioid therapy (COT), yet often have difficulty interpreting test results accurately. Objectives: To evaluate the implementation and effectiveness of a laboratory-generated urine toxicology interpretation service for clinicians prescribing COT. Study Design: Type II hybrid–convergent mixed methods design (implementation) and pre–post prospective cohort study with matched controls (effectiveness). Setting: Four ambulatory sites (2 primary care, 1 pain management, 1 palliative care) within 2 US academic medical institutions. Methods: Interpretative reports were generated by the clinical chemistry laboratory and were provided to UDT ordering providers via inbox message in the electronic health record (EHR). The Partners Institutional Review Board approved this study. Participants were primary care, pain management, and palliative care clinicians who ordered liquid chromatography-mass spectrometry UDT for COT patients in clinic. Intervention was a laboratory-generated interpretation service that provided an individualized interpretive report of UDT results based on the patient’s prescribed medications and toxicology metabolites for clinicians who received the intervention (n = 8) versus matched controls (n = 18). Implementation results included focus group and survey feedback on the interpretation service’s usability and its impact on workflow, clinical decision making, clinician-patient relationships, and interdisciplinary teamwork. Effectiveness outcomes included UDT interpretation concordance between the clinician and laboratory, documentation frequency of UDT results interpretation and communication of results to patients, and clinician prescribing behavior at follow-up. Results: Among the 8 intervention clinicians (median age 58 [IQR 16.5] years; 2 women [25%]) on a Likert scale from 1 (“strongly disagree”) to 5 (“strongly agree”), 7 clinicians reported at 6 months postintervention that the interpretation service was easy to use (mean 5 [standard deviation {SD}, 0]); improved results comprehension (mean 5 [SD, 0]); and helped them interpret results more accurately (mean 5 [SD, 0]), quickly (mean 4.67 [SD, 0.52]), and confidently (mean 4.83 [SD, 0.41]). Although there were no statistically significant differences in outcomes between cohorts, clinician-laboratory interpretation concordance trended toward improvement (intervention 22/32 [68.8%] to 29/33 [87.9%] vs. control 21/25 [84%] to 23/30 [76.7%], P = 0.07) among cases with documented interpretations. Limitations: This study has a low sample size and was conducted at 2 large academic medical institutions and may not be generalizable to community settings. Conclusions: Interpretations were well received by clinicians but did not significantly improve laboratory-clinician interpretation concordance, interpretation documentation frequency, or opioid-prescribing behavior.
KW - Chronic pain
KW - Clinical decision support
KW - Compliance monitoring
KW - Diagnostic error
KW - Liquid chromatography-tandem mass spectrometry
KW - Opioid
KW - Palliative care
KW - Primary care
KW - Substance use disorder
KW - Urine drug testing
UR - http://www.scopus.com/inward/record.url?scp=85103229358&partnerID=8YFLogxK
M3 - Article
C2 - 33740356
AN - SCOPUS:85103229358
SN - 1533-3159
VL - 24
SP - E191-E201
JO - Pain Physician
JF - Pain Physician
IS - 2
ER -