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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	
  
Prescribing practices final
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	
  
Prescribing practices final
Prescribing practices final
Prescribing practices final
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	
  
Prescribing practices final
Overtreatment	
  is	
  the	
  new	
  undertreatment	
  
Adverse	
  selecHon:	
  
70.0%
                                                              61.4%
60.0%
                                                  51.7%
50.0%                                                                     Odds	
  ra,os	
  
                                                                          adjusted	
  for	
  
                                    38.5%
40.0%                                                           2.6	
     pain	
  severity	
  
                                                                          and	
  pa,ent	
  
30.0%                 26.8%                        2.1	
                  characteris,cs	
  	
  

                                      1.4	
  
20.0%
                        1.0	
  
10.0%

 0.0%
                      1-19 mg      20-49 mg.    50-119 mg.   120+ mg.
Merrill	
  2012	
  
The	
  result	
  from	
  the	
  US	
  experiment	
  

                Clinical	
  harm	
  

                 Social	
  harm	
  

               Cultural	
  harm	
  	
  
Prescribing practices final
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)	
  
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	
  
Coordinated	
  Care	
  

         n=3500	
  
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       ()**+,-."   /01+,230"   /)4)20*"506"   78809:0;"   <).+=>)8"   @;,2)*3.)" 5,,43.A3**)"   B,+0*"
                                                           ?,3.)8"
2.	
  CollaboraHve	
  care:	
  
THE	
  NON-­‐COLLABORATIVE	
  PAIN	
  CONSULT	
  

                                  Anesthesiology	
  




                                                       Psychiatry,	
  Psychology	
  
                  Pa,ent	
  



                                                       Addic,on	
  Medicine	
  

Primary	
  Care	
  
  Clinician	
  

                                       Rehabilita,on	
  Medicine	
  



                                                                                       26	
  
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
Knowledge	
  network	
  
               (&)*$+'                   3..#)/$&"'
                !&,*,'                   (&)*$+,'#$'
             (-*,*$+*.'                   (-&%)%*'
              +/'0!12'
!"#$#%#&$'




!"#$#%#&$'
Prescribing practices final
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	
  
3.	
  Measurement	
  based	
  care:	
  
                                Grassley	
  (R-­‐IA)	
  




                             Rockefeller	
  (D-­‐WV)	
  
Prescribing practices final
Prescribing practices final
Measurement	
  based	
  care	
  
                             Dozen worst after 12 months


                     !"#$%       &#'"(#)#*+%   ,$-#.*+%   &./0.''#1$%   2/#1#3%4'.%


  5.))%.$6"6.3%       789%         7:;9%        7::9%       7;<9%         7;89%

=#$#>"))+%.$6"6.3%     %             %            %           %             %
                     ?@A9%         ?;;9%        ?B<9%       ?@A9%          ?B9%


  C1*%.$6"6.3%       ?@D9%         ?@D9%       C1%EF4%      C1%EF4%        7G9%
Posner,	
  2011,	
  QA/QI	
  
Prescribing practices final
Outcomes	
  by	
  provider:	
  
Patient-Reported Disability by Provider
Outcomes	
  by	
  provider:	
  
Patient-Reported Depressive symptoms by Provider
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%
Prescribing practices final
Codify	
  into	
  policy	
  

•  System	
  is	
  fragmented	
      •  Coordinated	
  care	
  (PCMH)	
  

•  Care	
  is	
  inconsistent	
      •  CollaboraHve	
  care	
  
                                        (TelePain/ECHO)	
  


•  Cost	
  is	
  unsustainable	
     •  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%	
  
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	
  
Reducing	
  Non-­‐Emergent	
  ED	
  
        UHlizaHon	
  
Prescribing practices final
Prescribing practices final
Patient
             need




 Clinical             Clinical
Research               Care
Prescribing practices final
How	
  do	
  we	
  stop	
  this	
  epidemic?	
  




     Just	
  measure	
  

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Prescribing practices final

  • 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  
  • 14. Overtreatment  is  the  new  undertreatment  
  • 15. Adverse  selecHon:   70.0% 61.4% 60.0% 51.7% 50.0% Odds  ra,os   adjusted  for   38.5% 40.0% 2.6   pain  severity   and  pa,ent   30.0% 26.8% 2.1   characteris,cs     1.4   20.0% 1.0   10.0% 0.0% 1-19 mg 20-49 mg. 50-119 mg. 120+ mg. Merrill  2012  
  • 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  
  • 22. =4>?",(%@(A*B"'$2(&-$5(9%,C5-'"(D34-;*#"'$(EFGH(9DI( #!!" &%$" &$!" &#$" &!!" %$" '()*&&" +,-*&&" $!" -­‐12   #$" !" '( ( 5( #( "( "( 2( ( -* *0 $* '" -## #-' %& 4* %, (/ <% '; %- " *3 +$ ##$ %, *# 2(9 .- )* 122 !" , :5 %% ." " / 78 )" '$ 6"
  • 23. =4>?",(%@(A*B"'$2(&-$5(9CD(EFGH(*'.(( =%(I,-'"(:+,""'J(%,(K*2$(:+,""'(E(F(L"*,( '#!" '!!" &!" %!" ()*+''" $!" ,-.+''" -­‐12   #!" !" '( ( 5( #( "( "( 2( ( -* *0 $* '" -## #-' %& 4* %, (/ <% '; %- " *3 +$ ##$ %, *# .- 2(9 )* 122 !" , :5 %% ." " / 78 )" '$ 6"
  • 24. !"#$%&'()'*+,%-./'01.2'345'6789'+-:';!('*<+-'(-'=1<%>' '!!" &!" %!" ?02C''" D:*C''" $!" -­‐12   #!" !" ()**+,-." /01+,230" /)4)20*"506" 78809:0;" <).+=>)8" @;,2)*3.)" 5,,43.A3**)" B,+0*" ?,3.)8"
  • 26. THE  NON-­‐COLLABORATIVE  PAIN  CONSULT   Anesthesiology   Psychiatry,  Psychology   Pa,ent   Addic,on  Medicine   Primary  Care   Clinician   Rehabilita,on  Medicine   26  
  • 27. INTERACTIVE  LEARNING  ENVIRONMENT   UW  Pain  Faculty  Specialists   Rural  Clinic   Rural  Clinic   MD,  PA   MD,  ARNP,  RN     Fellows, Residents, Medical students, PA, Nursing, Pharmacy, Rural Clinic Social work students MD Rural Clinic ARNP, MSW, Rural Clinic Admin. MD, ARNP, RN Rural Clinic MD, ARNP, CDC Rural Clinic MD, ARNP, PA
  • 28. Knowledge  network   (&)*$+' 3..#)/$&"' !&,*,' (&)*$+,'#$' (-*,*$+*.' (-&%)%*' +/'0!12' !"#$#%#&$' !"#$#%#&$'
  • 30. 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  
  • 31. TransacHon  Cost  Analysis   Source:  Jan  Whikngton,  PhD  from  a  pilot  study  funded  by  NSF  
  • 32. Cyber  Security  Analysis   Source:  Barbara  Endico`-­‐Popovsky,  DHS  
  • 33. 3.  Measurement  based  care:   Grassley  (R-­‐IA)   Rockefeller  (D-­‐WV)  
  • 36. Measurement  based  care   Dozen worst after 12 months !"#$% &#'"(#)#*+% ,$-#.*+% &./0.''#1$% 2/#1#3%4'.% 5.))%.$6"6.3% 789% 7:;9% 7::9% 7;<9% 7;89% =#$#>"))+%.$6"6.3% % % % % % ?@A9% ?;;9% ?B<9% ?@A9% ?B9% C1*%.$6"6.3% ?@D9% ?@D9% C1%EF4% C1%EF4% 7G9%
  • 39. Outcomes  by  provider:   Patient-Reported Disability by Provider
  • 40. Outcomes  by  provider:   Patient-Reported Depressive symptoms by Provider
  • 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)  
  • 44. EducaHon  is  important   Rosenbla`,  2011  
  • 46. HB  2876  :     •  Educa,on  and  Guidelines  (AMDG)   •  Access  to  specialty  care  (TelePain)   •  Opioid  tracking  (PDMP  /  EDIE)   •  Measurement  (PASTOR  /  Pain  Tracker)  
  • 47. HB  2876  :    
  • 48. Pilot  data:  Deaths  from  opioids  decreased  by  50%  
  • 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  
  • 53. Patient need Clinical Clinical Research Care
  • 55. How  do  we  stop  this  epidemic?   Just  measure