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    E2   allen buckley sproule - salon g E2 allen buckley sproule - salon g Presentation Transcript

    • Challenges of Evaluating the Impactof theCanadian Opioid GuidelineMichael Allen MD MScNorm Buckley BA (Psych), MD, FRCPCBeth Sproule RPh, BScPhm, PharmDCADTH SymposiumSt John’s NLMay 20131
    • Disclosures• Michael Alleno No conflicts of interest to disclose• Norm Buckleyo Director of the Michael G. DeGroote National Pain Centre,which has as its mission the identification, creation,collation and dissemination of guidelines for painmanagemento Speakers fees, research support from: Purdue, Pfizer,Hamilton Anesthesia Associates, HSFO, CIHR2
    • Disclosures• Beth Sprouleo No conflicts of interest to disclose• Guideline evaluation supported by:o Meeting grants from CIHRo Administrative support from Michael G. DeGrooteNational Pain Centre (endowment from Mr. Michael G.DeGroote)o Volunteers• No industry funding3
    • Introductions• Policy makers• Researchers• Industry• Guideline developers• Anyone else?• Clinicianso MDso Pharmacistso Pain professionalso Hypertension professionalso CHEP4
    • Why did you come?• Interested in guidelines• Interested in hypertension• Interested in chronic pain• Had to go somewhere• Tell you what you did wrong5
    • Objectives• Describe history and process of guideline development• Introduce you to the guideline• Tell you what ‘the College’ thinks• Solicit ‘next steps’ advice for evaluating impact6
    • Published by NOUGGPublished by the National Opioid Use Guideline Group (NOUGG) a collaboration of:Federation of Medical Regulatory Authorities of CanadaCollege of Physicians & Surgeons of British ColumbiaCollege of Physicians & Surgeons of AlbertaCollege of Physicians and Surgeons of SaskatchewanCollege of Physicians & Surgeons of ManitobaCollege of Physicians and Surgeons of OntarioCollège des médecins du QuébecCollege of Physicians and Surgeons of New BrunswickCollege of Physicians and Surgeons of Nova ScotiaCollege of Physicians and Surgeons of Prince Edward IslandCollege of Physicians and Surgeons of Newfoundland and LabradorGovernment of NunavutYukon Medical CouncilApril 30 2010 Version 4.57
    • Principles• Guideline must be evidence-based, clinicallyrelevant, achievable• Evidence necessary but not sufficient• Review and revise as information becomes available• Get guideline ‘into play’• Evaluate impact on practice, patient care8
    • No Existing National Guideline• No previous national guideline• CPSO 2000 - guidelines for chronic non-cancer pain,including use of opioids (Mailiss, Tunks co-chairs)(methods?)• Public interest in widespread use of opioids• Canada 3rd in the world per capita sales• New evidence - Furlan 20069
    • Need for Strategy• Recognized need for both a guideline and asystematic dissemination strategy• Partnership with academic institution for‘maintenance’ of guideline and coordination ofdissemination strategy• Creation of ‘National Faculty’ to advise, develop andsupport the dissemination and evaluation10
    • Congruent Strategy• Remarkably ambitious vision• Congruent with other organizations such as CanadianPain Society national strategy for improvement ofpain care and access to care• May address reluctance of primary care to prescribeopioids, also assist others in appropriate use11
    • Guideline Strength• Great deal of clinical information in the guidelinedocuments• Depth varies from simple statement to discussion ofthe evidence supporting• References appended• ‘College approved’12
    • Tools• Strategy to create the background document (Part A),guideline itself (Part B) plus ‘roadmap’• Tools for practice• Website - PDF, web document• Opioid Manager - charting tool to structureinteraction (Centre for Effective Practice, Furlan);6-month trial, feedback, revised13
    • Contributors• Contributors: Research group, NOUGG, NationalAdvisory Panel• Knowledge included Furlan (2006) meta-analysis plus3 additional searches:o Update of Furlan since 2006o Management of patients with problematic use of opioidso Effect of long term use14
    • National Opioid UseGuideline Group (NOUGG)Ms. Rhoda Reardon (Co-chair) Mr. Clarence Weppler (Co-chair)Dr. Angela Carol Ms Connie CôtéDr. Patricia DeMaio Dr. Lindy LeeDr. Fleur-Ange Lefebvre Dr. Don LingDr. Cameron Little Dr. Bill PopeDre. Carole Santerre Dr. Ed SchollenbergDr. Said Secerbegovic Dr. Karen ShawMr. Doug Spitzig Dr. Janet WrightDr. Robbert Vroom Dr. Robert YoungDr. Anna Ziomek15
    • Research GroupDr. Andrea Furlan Dr. Angela Mailis-GagnonMs. Emma Irvin Dr. Anita SrivastavaDr. Luis Chaparro Dr. Meldon Kahan16
    • Process• Research group drafted initial guideline with 49recommendations• Modified Delphi process (electronic) over 4 rounds;80% agreement required• Final web teleconference• 24 recommendations17
    • National Advisory Panel (NAP)Ms Lori AdlerDr. John F. AndersonMs Catherine BiggsDr. Aline BoulangerDr. Robert James BoydDr. Norman BuckleyDr. Peter ButtDr. Michel CauchonDr. John ClarkDr. John CollingwoodMs Lynn CooperDr. Ann CrabtreeDr. Etienne de MedicisDr. Ted FindlayDr. Ian ForsterDr. John FraserDr. Brian GoldmanDr. Allan GordonDr. Neil HagenDr. Lydia HatcherDr. Phillipa HawleyDr. Howard IntraterDr. Margaret JinDr. Roman Jovey18
    • National Advisory Panel (NAP)Dr. Milan KharaDr. Brian KnightDr. Jill KonkinMr. James KrempienDr. Roger LadouceurDr. Andre LalondeDr. Vernon LappiDr. Lindy LeeDr. Joël LoiselleDr. Mary LynchDr. David MacPhersonDr. David MarshDr. Gary MazowitaDr. Gordon McFaddenDr. Patricia K. Morley-ForsterDr. Murray OpdahlDr. R. Keith PhillipsDr. Saifee RashiqMr. Loren RegierDr. Toomas SauksDr. Roger ShickDr. Chris SpanswickDr. Paul TaenzerDr. Eldon TunksDr. Preston Zuliani19
    • Canadian Opioid Guideline 2010• Updating responsibility accepted by the Michael G.DeGroote National Pain Centre (NPC) at McMasterUniversity• Guideline housed on NPC website, accessible in PDFformat under Creative Commons License• NOUGG National Faculty established to supportdissemination, evaluation20
    • National Faculty MembershipMichael AllenCheryl ArratoonStephen BarronVictoria Borg DebonoNorm BuckleyDonna Kay BunaJason BusseAngela CarolLynn CooperDaniele DaigleAmol DeshpandeRuth DubinPhilip EmberleyIsobel FlemingMelinda FowlerAndrea FurlanIan GoldstineDiane GromalaLydia HatcherHoward IntraterMel KahanFran KirbyAnthony LevinsonNatalie LidsterPeter MacDougallBernard MarlowErin McGinnisAmy MontourKaren NgLoren ReigerPaul RobesonKim RodDan RosenbaumSaid SecerbegovicDino SmiljicDoug SpitzigBeth SprouleDoug StichJanice SumptonErica WeinbergWende Wood21
    • National Faculty Working Groups1. Eyes and Ears in the Field Network2. Practitioners Tool Kit3. KT to Physicians and Pharmacists4. Patient and Public Education5. Policy-Makers and Health-Payers6. Guideline Impact Evaluation22
    • Canadian Hypertension Education Program• Evolving over 35 years• Amalgam of several groups involved in HT• 2003 – Outcomes Research Task Forceo Academiao Nongovernmental organizationso Provincial governmentso Public Health Agency of Canadao Statistics CanadaCampbell et al Can J Cardiol2006:22:55623
    • 24Canadian HypertensionEducation Program(Knowledge Creation)Annual systematicreview and critical appraisalof studiesSynthesis intorecommendationsScientificManuscriptsandSummariesIdentify New Knowledge, SelectWhat is Still ImportantAdapt KnowledgeTo Local/Regional ContextAddress Barriers toKnowledge UseTailor Tools forInterprofessionalTeam MembersMonitor Knowledge UseEvaluateOutcomesBy Combining Nationaland ProvincialAdministrative DataKnowledge Gaps, BestPractice GoalsProfessionalEducationCommitteeOutcomesResearchCommitteeHypertension Canada’s Annual KT Cycle for developingmanagement recommendationsAdapted from Graham ID, Logan, J., Harrison MB, Straus, S., Tetroe, JM, Caswell, W. et al.(2006). Lost in knowledge translation: Time for a map? Journal of Continuing Educationin Health Professions, 26, 13-24. 24
    • Canadian Hypertension Education Program• Statistics Canadao Canadian Health Measures Survey• Annual survey of 5000 people• Takes physical measure e.g. measurement of BP• Medicine cabinet counto Mortality and hospitalization data for HT-relatedconditions – stroke, heart failure, MI25
    • Canadian Hypertension Education Program• Public Health Agency of Canadao Canadian Community Health Survey Prevalence of diagnosed hypertension Prevalence of drug-treated hypertension• IMS Health – prescribing data• Conducts needs assessments26
    • Canadian Hypertension Education Program• Works with Implementation and RecommendationTask Forces to ensure recommendations reachappropriate audiences in appropriate formats27
    • Our Initial Approach• Looked at CHEP process and reviewed informationavailable from their sources and others• Reviewed established Canadian surveys todetermine if able to identify relevant outcomeso Canadian Community Health Surveyo Canadian Health Measures Surveyo Survey on Living with Chronic Disease in Canadao Canadian Alcohol and Drug Use Monitoring Survey28
    • Unique Issues Identified• Multiple clinical outcomes as targetso improved pain-related outcomes (severity, function)o reduced harms (overdose, abuse, addiction)• Desired prescribing outcomes complexo Increase: more people receiving needed pain medication,or more inappropriate prescribing?o Decrease: reduced access to medication for treating pain,or reduced inappropriate prescribing?29
    • Unique Issues Identified• Diagnostic complexityo Pain – types, responsiveness to opioidso Misuse, abuse, physical dependence, addiction in patientsalso using/needing therapeutically• Additional implicationso Diversion, crimeo Lack of coverage for non-drug treatments30
    • Establishing Baseline Data• CIHR submissions for national multidisciplinarysurvey to establish baseline data• To build on previous work of opioid prescribingpractices and experienceso Surveys of family physicians (Allen 2011, Wenghofer 2011)o Survey of Ontario physiatrists (Furlan 2010)o Survey of Ontario pharmacists (Kahan 2011)• CIHR grant research questions: barriers toimplementing guidelines, awareness of guidelines,current prescribing practices• Not Funded (x2)31
    • Process to Identify Outcomes• Established a Definitions Outcome Groupo Identified and invited individuals from across Canadain the pain and addictions areas, includingresearchers and clinicians• Objective: to define outcomes most relevant toassess the impact of the guideline• Categorized outcomeso Practice, Clinical, Processo Pain, Addiction32
    • Definitions Outcome Group
    • Definitions Outcome Group
    • Definitions Outcome Group
    • Further Refinement• Linked outcomes identified to specific guidelinerecommendations• Drafted possible measurement indicators foroutcomes• Developed a process to prioritize outcomeso Survey of National Facultyo Rated outcomes and measures on scale of 1-536
    • National Faculty Survey37Results - scores out of 5:≤ 4.0 lower importance = 25% of outcomes≥ 4.1 - 4.4 high importance = 50% of outcomes≥ 4.5 very high importance = 25% of outcomesSample
    • Outcome Evaluation• Each outcome then rated based on the followingcriteria* by the working group:• Feasibleo data to measure outcome should be available fairlyeasily and cheaply• Credibleo should be valid and reliable• Comparableo can be used to compare across geographic areas andacross time• Understandableo should be easy to interpret with no ambiguity as towhether performance has improved or deteriorated38(*adapted from the Dept. of Health, Nova Scotia)
    • Further Prioritization• Each member of the working group ranked top 5outcomeso 16 outcomes were picked by at least one member• These 16 outcomes were sent to National Facultyand other experts for ranking on scale of 1 to 5o 78 sent, 45 responses = 57%39
    • Further Evaluation• Outcome list sent to the original NOUGG NationalAdvisory Panel and Research Group, and theImplementation National Faculty• Asked for feedback on which outcomes can be easilymeasured and how, and any potential collaborators• Feedbacko Don’t rely on self-reported informationo Potential collaborators: WCB, Prescription MonitoringPrograms, Centre for Effective Practice40
    • Outcomes41Rank Outcomes Score1 Effects of opioids on quality of life, pain, and function. 1462 Use of tools to screen patients for addiction risk. 1383 Monitoring patients for aberrant drug-related behaviours. 784 Opioid prescribing at greater than the watchful dose. 745 Mortality rates associated with prescription opioid overdose. 646 Prevalence and incidence of prescription opioid addiction. 627 Discontinuation or tapering of opioids because of adverse effects or ineffectiveness. 598 Monitoring patients using information from prescription monitoring programs. 429 Use of validated pain scales. 4410 Use of treatment agreements. 4311 Concomitant prescribing of benzodiazepines and opioids. 2912 Amounts of opioids prescribed per patient per unit time (e.g. per month or per year). 2913 Type and amounts of adjunctive medications prescribed for CNCP patients taking opioids. 2314 Health-care facilities availability of appropriate policies for providing guidance on opioid prescribing. 2515 Emergency room visits associated with prescription opioid overdose. 3016 Initiation of fentanyl in patients who have not been on 60 MEQ of strong opioid. 14Originally rated as of veryhigh importance
    • Questions for Discussion• Anybody with similar experiences?• Any other guidelines being evaluated foreffectiveness?• What could we have done better?• What should we do now?• Would anyone like to collaborate with us?42
    • Thank you for your participationhttp://nationalpaincentre.mcm43