Prescribing  Prac,ces    

Dr.  Alex  Cahana,  MD,  Dphil,  DAAPM,  FIPP  

Advisor  to  the  Vice  Chancelor  for  Venture  Academics,  and  Affiliate  Professor  of  Science,  Technology,  Educa,on,  and  Health  Studies  

Disclosure  Statement    

•  Alex  Cahana  has  no  financial  rela,onships  with  proprietary  en,,es  that  produce  health  care  goods  and  services  

•  Stuart  Gitlow  has  a  financial  rela,onship  with  a  proprietary  en,ty  that  produces  health  care  products  and  services.    This  financial  rela,onship  is:  Orexo  AB.  

HB  2876:  Just  measure  

April  2  –  4,  2013  Omni  Orlando  Resort    

at  ChampionsGate  

Points  of  Discussion  

•  Explain  the  incen,ves  for  over-­‐prescrip,on  

•  How  measurement  and  coordina,on  improves  outcome  

•  How  to  codify  this  model  into  policy    

My  disclosures  

•  I  am  not  opio-­‐phobic  

•  I  am  not  opio-­‐philic  •  I  am  not  needle-­‐phobic  

•  I  am  not  needle-­‐philic  •  I  am  agnos,c  to  chi  gong  and  tai  chi  

•  ‘I  just  wanna  know  how  my  pa,ents  are  doin’  

•  Because  if  I  don’t  measure  outcome  I  believe  my  prac,ce  is  not  medically,  financially  or  ethically  sustainable  

•  Standard  of  Care  needs  to  be  codified  

Your  disclosures  

•  Denial  •  Anger  •  Bargaining  •  Depression  •  Acceptance  

Kubler  Ross,  On  death  and  dying,  1968  

GeneraHon  Rx  

0  

1  

2  

3  

4  

5  

1990   1992   1994   1996   1998   2000   2002   2004   2006   2008  

Rate  per  1,000  live  births  

Source:  Washington  State  Department  of  Health,  Comprehensive  Hospital  Abstract  Repor,ng  System  

DissaHsfying  encounter  

•  PaHents1  <20%  sa,sfied  with  Pain  Care  received  

•  Students2  <10%  sa,sfied  with  Rural  Primary  Care  due  to  Pain  

•  Providers3  <15%  sa,sfied  with  delivering  Primary  Care  Pain  treatment  

1Upshur  2010  2Rosenbla`  2010  3Marcus  2009  

Overtreatment  is  the  new  undertreatment  

Merrill  2012  

Adverse  selecHon:  

26.8%

38.5%

51.7%

61.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

1-19 mg 20-49 mg. 50-119 mg. 120+ mg.

1.0  

1.4  

2.1  

2.6  

Odds  ra,os  adjusted  for  pain  severity  and  pa,ent  characteris,cs    

The  result  from  the  US  experiment  

Clinical  harm  

Social  harm  

Cultural  harm    

Revise  our  pracHce  model  

•  System  is  fragmented  

•  Care  is  inconsistent  

•  Cost  is  unsustainable  

•  Coordinated  care  (PCMH)  

•  CollaboraHve  care  (Telepain/ECHO)  

•  Measurement  based  care  (PASTOR  /  PainTracker)  

1.  Coordinated  care  

•  Integra,on  of  behavioral  health  care  specialists  into  primary  care  prac,ces  

•  Enhance  feedback  to  PCP  •  Care  management  by  nurses/MSWs  

•  Applica,on  of  care  algorithms  

Katon  1995  Unützer  2002    

Coordinated  care  

•  Significant  improvements  in  pain  intensity,  disability,  and  pa,ent  global  impression  

•  Reduced  pain  intensity  and  disability  and  depression  severity  among  pa,ents  with  depression  

•  Greater  use  adjunct  pain  medica,ons  •  Reduced  numbers  of  visits  overall  

Dobscha  2009  

n=3500  

Coordinated  Care  

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2.  CollaboraHve  care:  

Primary  Care  Clinician  

THE  NON-­‐COLLABORATIVE  PAIN  CONSULT  

26  

Anesthesiology  

Rehabilita,on  Medicine  

Psychiatry,  Psychology  

Addic,on  Medicine  

Pa,ent  

UW  Pain  Faculty  Specialists  

INTERACTIVE  LEARNING  ENVIRONMENT  

Rural  Clinic  MD,  PA  

Rural Clinic MD, ARNP, PA

Rural  Clinic  MD,  ARNP,  RN    

Rural Clinic MD, ARNP, RN

Rural Clinic MD, ARNP, CDC

Rural Clinic ARNP, MSW, Admin.

Rural Clinic MD

Fellows, Residents, Medical students, PA, Nursing, Pharmacy, Social work students

Knowledge  network  

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ECHO/TelePain/ROAM  

•  Twice-­‐Three  weekly  mul,disciplinary  pain  consulta,on  to  WWAMI  plus  Oregon  

•  Total  a`endance:  2500+  

•  Average  a`endees/session:  35  •  Unique  a`endees:  400+  •  Unique  loca,ons:  100+  

•  >3500  hours  of  Chronic  Pain  Training,  Educa,on  and  Consulta,on  

TransacHon  Cost  Analysis  

Source:  Jan  Whikngton,  PhD  from  a  pilot  study  funded  by  NSF  

Cyber  Security  Analysis  

Source:  Barbara  Endico`-­‐Popovsky,  DHS  

Grassley  (R-­‐IA)  

Rockefeller  (D-­‐WV)  

3.  Measurement  based  care:  

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Dozen worst after 12 months

Measurement  based  care  

Posner,  2011,  QA/QI  

Outcomes  by  provider:  

Patient-Reported Disability by Provider

Outcomes  by  provider:  Patient-Reported Depressive symptoms by Provider

Measurement  based  care  

Category % of Total Specimens

Specimens in full agreement with reported medications 39.7%

Specimens with unreported prescription medication(s) detected 34.0%

Specimens with reported prescription medication(s) NOT detected 10.6% Specimens with unreported prescription medications(s) detected & reported prescription medication(s) NOT detected 7.7%

Specimens with Illicit substance(s) detected 2.0%

Specimens with illicit substance(s) & unreported medication(s) detected 3.8%

Specimens with illicit substance(s) detected & reported medication(s) NOT detected 1.1% Specimens with illicit substance(s) detected & unreported medication detected & reported medication(s) NOT detected 1.0%

Codify  into  policy  

•  System  is  fragmented  

•  Care  is  inconsistent  

•  Cost  is  unsustainable  

•  Coordinated  care  (PCMH)  

•  CollaboraHve  care  (TelePain/ECHO)  

•  Measurement  based  care  (CPAIN/PainTracker)  

EducaHon  is  important  

Rosenbla`,  2011  

But  not  enough  

HB  2876  :    

•  Educa,on  and  Guidelines  (AMDG)  

•  Access  to  specialty  care  (TelePain)  •  Opioid  tracking  (PDMP  /  EDIE)  

•  Measurement  (PASTOR  /  Pain  Tracker)  

HB  2876  :    

Pilot  data:  Deaths  from  opioids  decreased  by  50%  

0  

5  

10  

15  

20  

25  

State     Clallam     Grant   Jefferson   Kitsap   Okanogan  

34%

41% * 63% *

54% *

43% *

29%

TelePain  Effect  on  Opioid  Death  Rates    (by  rural  Washington  State  county)  

Courtesy  of  Jennifer  Sable  WA  State  Dept.  of  Health,  2013  

2007-­‐2009  

2008-­‐2010  

State                    Clallam                    Grant                Jefferson                Kitsap              Okanogan  

Reducing  Non-­‐Emergent  ED  UHlizaHon  

Clinical Care

Clinical Research

Patient need

How  do  we  stop  this  epidemic?  

Just  measure