Lean A3 Improves Opioid Prescribing in Rheumatology


A Quality Improvement (QI) method called Lean A3 helped improve and sustain opioid prescribing within an ambulatory rheumatology clinic, say researchers writing in ACR Open Rheumatology last month.

Lean A3 Improves Opioid Prescribing in Rheumatology

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A Quality Improvement (QI) method called Lean A3 helped improve and sustain opioid prescribing within an ambulatory rheumatology clinic, say researchers writing in ACR Open Rheumatology last month.

As opioids are a major cause of mortality, states are increasingly mandating use of prescription drug monitoring programs, setting quantity and duration limits for opioids and making naloxone more available. While there are limited data regarding opioid prescribing in rheumatology clinics, it has been reported that 30 percent of patients with rheumatoid arthritis received an opioid prescription and increased opioid use over time.

“When opioids are being considered as part of any treatment plan, careful assessment of risks and benefits, patient education and consent, and appropriate monitoring are recommended,” wrote the authors, led by Constance van Eeghen Dr.PH. of the University of Vermont in Burlington.

Lean QI, which uses a structured approach to analyze workflow, is implicated to produce sustained, effective change in health care organizations. While ambulatory clinics have used QI methods to improve the opioid prescribing process, they have not described an implementation process or follow‐up information on whether the model was successful. A QI method called Lean A3 is based on a template of steps to guide a medical team through a workflow analysis that leads to problem identification, root cause analysis, and agreement on redesigned clinic workflows.

“Although Lean A3 has been successfully used in other ambulatory care clinics, we believe this is the first report describing successful use of Lean A3 to improve chronic opioid prescribing in an ambulatory rheumatology clinic,” the authors wrote.

The goal of this retrospective study was to increase the consistency of opioid prescribing with recommended elements, while secondary goals were improving satisfaction among providers and staff.

Pre‐postintervention analysis of rheumatology records included patients prescribed opioids at least once during the study period. Lean A3 was used to develop a Controlled Substance Visit Protocol to standardize eight recommended elements of the opioid prescribing workflow.


Patient education, including treatment agreements and consent forms (39 percent completion for both pre-implementation) increased to 78 percent and 80 percent, respectively (P < 0.001 for both). Risk assessment, as measured by the Current Opioid Misuse Measure, increased from 0.5 percent to 76 percent (P < 0.001). Best practices in prescribing, including prescribing in multiples of seven to avoid weekend refill requests, increased from 1 percent to 79 percent (P < 0.001). Monitoring parameters, including standardized functional assessment, increased from zero to 86 percent, prescription drug monitoring program queries, increased from 49 percent to 84 percent, and urine testing, increased from 1 percent to 32 percent (P < 0.001 for all). However, visits scheduled at least quarterly for patients on chronic opioids did not change. Overall, the number of patients prescribed opioids (185 versus 160; P < 0.001) and annual prescription opioid morphine milligram equivalents (MMEs) (1,933,585 MME versus 1,386,368 MME; P < 0.001) decreased.

“In order to accomplish these changes without new resources, this protocol was implemented one provider at a time, gradually including all active patients treated with opioids. Additional providers were not added until the QI team felt the clinic workflow was stable,” the authors wrote.

There were several barriers to implementation and maintenance of the process, but they were mainly addressed over the nine‐month implementation period.

“We were unable to resolve the barriers related to the prescribing strategy of seeing patients at least every 84 days. Availability of provider appointments continues to be too limited to meet this recommendation,” the authors wrote.

REFERENCE:  Constance van Eeghen, Melinda Edwards, Bonita S. Libman, et al. “Order From Chaos: An Initiative to Improve Opioid Prescribing in Rheumatology Using Lean A3.” ACR Open Rheumatology. September 4, 2019. doi:10.1002/acr2.11078

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