Higher ABIM exam score linked to reduced opioid prescriptions for back pain
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As the standard of care has shifted away from routine opioids for back pain, physicians with higher American Board of Internal Medicine exam scores have been less likely to prescribe opioids than those with lower scores, according to data.
“Opioid overdoses are spiking despite guideline changes that should have vastly reduced opioid prescriptions,” Bradley M. Gray, PhD, of the American Board of Internal Medicine (ABIM), in Philadelphia, told Healio Rheumatology. “This study shows that a major contributing factor to this is that a large group of physicians are not keeping current with recommended medical changes, including guideline changes and prescribing opioids for conditions — such as new onset low back pain — where opioids are very unlikely to be appropriate.”
“Yet physicians who kept current with medical knowledge, as measured by an ABIM exam, not only reduced opioid prescribing but increased prescribing of recommended alternatives,” he added.
To analyze the association of clinical knowledge with opioid prescriptions for back pain during 2009 to 2011, when opioid scripts in the United States peaked, compared with the period of 2015 to 2017, when guidelines began moving away from opioids as routine care, Gray and colleagues conducted a cross-sectional study using ABIM Maintenance of Certification examination scores as a measure of clinical knowledge. The study included 10,246 mid-career general internal medicine physicians in the United States who treated Medicare Part D beneficiaries from 2009 to 2017.
Main outcomes included any opioid prescription — as well as any doses greater than 50 daily morphine milligram equivalents or any durations longer than 7 days — filled within 7 days of outpatient visits for new low back pain. The researchers estimated the associations between opioid prescriptions and prior-year ABIM Maintenance of Certification examination score using serial cross-sectional logit regressions.
Regression covariates included yearly examination quartile — or “knowledge quartile” — interacted with 3-year group dummies, with 2009 to 2011 defined as “early,” 2012 to 2014 as “middle” and 2015 to 2017 as “late.” Other covariates included state and year dummies, physician, practice, patient characteristics and state opioid regulations.
According to the researchers, among the 55,387 lower back pain visits included in the study, the overall rate of opioid prescribing was 21.6% for any opioid prescription and 17.6% for those of high doses or long durations.
From 2009 to 2011, visits with physicians in the highest and lowest knowledge quartiles demonstrated similar adjusted opioid prescribing rates, with a 0.5 percentage point difference (95% CI, –1.9 to 3). However, by 2015 to 2017, physicians in the highest knowledge quartile prescribed opioids less frequently than those in the lowest knowledge quartile, with a 4.6 percentage point difference (95% CI, –7.5 to –1.8).
Visits in which high-dose or long-duration opioids were prescribed demonstrated no difference in the early period (percentage point difference = –0.1; 95% CI, –2.4 to 2.2), but showed a difference in the late period (4.8; 95% CI, –7.4 to –2.1) when comparing physicians in the highest and lowest knowledge quartiles.
“There was about a 20% reduction in opioid prescribing when comparing top to bottom quartile exam performance during the 2015 to 2017 period but not before,” Gray said. “Yet, even top-performing physicians prescribed opioids during 18% of visits for new onset back pain, a condition where opioids should rarely be prescribed.”
“As the ugly head of the opioid crisis re-emerges, this paper reminds us of the crucial role that primary care physicians play in terms of prescribing opioids, and how responsiveness to guideline changes is contingent on keeping current with medical knowledge as advocated by organizations, such as ABIM, through their MOC exam,” he added.
Gray also pointed to another study, recently published in BMJ Open by researchers from Harvard University, the Mayo Clinic and ABIM, which suggested that patients treated by physicians who score well on diagnostic-related questions on the ABIM MOC exam were at significantly lower risk for death, ED admission and hospitalization after a visit at risk for diagnostic error.
“Taken together, these studies tell us that a well-written standardized exam, like ABIM’s MOC exam, can tell you a lot about a physician,” Gray said.
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