Budget Impact Analysis of the Balanced Opioid Initiative: A Cluster Randomized Trial Aimed at Deprescribing Opioids...

This study compared the budget impact of 4 deimplementation strategies designed to promote guideline-concordant opioid prescribing.

In this cluster randomized trial of 32 primary care clinics, deimplementation strategies targeted the system, clinic, and prescriber levels. All clinics received system-level educational meetings with audit/feedback reports. At month 3, one-half were randomized to add practice facilitation, a clinic-level strategy. At month 9, one-half were again randomized to add prescriber peer consulting, a prescriber-level strategy, resulting in 4 groups: system, system + clinic, system + prescriber, and system + clinic + prescriber. The primary outcome was change in mean morphine milligram equivalent dosage. Secondary outcomes included adherence to opioid risk mitigation metrics (urine drug testing, treatment agreements, pain/function screening, and mental health screening). We calculated the cost of delivering each implementation strategy and budget impacts associated with changes in health care utilization.

Implementation costs per clinic were as follows: $4,416 (system), $5,610 (system + clinic), $7,164 (system + prescriber), and $8,358 (system + clinic + prescriber). With health care utilization changes incorporated, the system strategy's per-clinic costs increased to $10,908, yielding the greatest budget impact, the system + clinic strategy had the least budget impact at $7,266, and the system + prescriber budget impact was $9,625. The budget impact for system + clinic + prescriber was $8,703.

Higher-intensity deimplementation strategies significantly decreased mean morphine milligram equivalent and increased pain/function screening while decreasing treatment agreements and urine drug screening. The lowest-cost strategy (system) led to more costly downstream health care utilization, resulting in the greatest budget impact. Adding clinic- and prescriber-level strategies might help health systems decrease reliance on opioids for chronic pain, with less budget impact than providing system-level strategies alone.