1. 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
2. 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.
3. HB
2876:
Just
measure
April
2
–
4,
2013
Omni
Orlando
Resort
at
ChampionsGate
4. 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
5. 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
6. Your
disclosures
• Denial
• Anger
• Bargaining
• Depression
• Acceptance
Kubler
Ross,
On
death
and
dying,
1968
8. GeneraHon
Rx
5
4
Rate
per
1,000
live
births
3
2
1
0
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
Source:
Washington
State
Department
of
Health,
Comprehensive
Hospital
Abstract
Repor,ng
System
12. 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
16. The
result
from
the
US
experiment
Clinical
harm
Social
harm
Cultural
harm
18. Revise
our
pracHce
model
• System
is
fragmented
• Coordinated
care
(PCMH)
• Care
is
inconsistent
• CollaboraHve
care
(Telepain/ECHO)
• Cost
is
unsustainable
• Measurement
based
care
(PASTOR
/
PainTracker)
19. 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
20. 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
26. THE
NON-‐COLLABORATIVE
PAIN
CONSULT
Anesthesiology
Psychiatry,
Psychology
Pa,ent
Addic,on
Medicine
Primary
Care
Clinician
Rehabilita,on
Medicine
26
27. INTERACTIVE
LEARNING
ENVIRONMENT
UW
Pain
Faculty
Specialists
Rural
Clinic
Rural
Clinic
MD,
PA
MD,
ARNP,
RN
Fellows, Residents,
Medical students, PA,
Nursing, Pharmacy,
Rural Clinic Social work students
MD
Rural Clinic
ARNP, MSW,
Rural Clinic
Admin.
MD, ARNP, RN
Rural Clinic
MD, ARNP, CDC
Rural Clinic
MD, ARNP, PA
41. Measurement
based
care
% of Total
Category 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%
43. Codify
into
policy
• System
is
fragmented
• Coordinated
care
(PCMH)
• Care
is
inconsistent
• CollaboraHve
care
(TelePain/ECHO)
• Cost
is
unsustainable
• Measurement
based
care
(CPAIN/PainTracker)
49. TelePain
Effect
on
Opioid
Death
Rates
(by
rural
Washington
State
county)
25
20
41% * 54% * 2007-‐2009
63% * 2008-‐2010
15
29%
10
34%
43% *
5
0
State
Clallam
Grant
Jefferson
Kitsap
Okanogan
State
Clallam
Grant
Jefferson
Kitsap
Okanogan
Courtesy
of
Jennifer
Sable
WA
State
Dept.
of
Health,
2013