Alex Cahana

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Coordinating Multiple Stakeholders
National Rx Drug Abuse Summit 4-11-12

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Alex Cahana

  1. 1. Coordinating Multiple Stakeholders April 10-12, 2012 Walt Disney World Swan Resort
  2. 2. Learning Objectives:1. Describe the relationship between prescriptiondrug morbidity and mortality and the under-treatment of pain.2. Identify measurement-based care as standardof care in pain medicine and describe how tomeasure pain, mood and function in everyclinical encounter.3. Evaluate how new state and federal policychanges will likely allow more prudent and saferuse of opioids for chronic, non-cancer pain.
  3. 3. Disclosure Statement•  All presenters for this session, Dr. Alex Cahana and Dr. Gary M. Franklin, have disclosed no relevant, real or apparent personal or professional financial relationships.
  4. 4. UW Pain Care Delivery Program acahana@uw.edu
  5. 5. John  J.  Bonica  
  6. 6. UW  Division  of  Pain  Medicine  &  Affiliates   APCA BCNH MHCS UAA IIPM ANMC InpatientInpatient Inpatient Inpatient Inpatient Inpatient (Seattle) Outpatient Outpatient Outpatient Outpatient OutpatientOutpatient Outpatient Outpatient (Seattle & Outpatient Outpatient AL)
  7. 7. My disclosures•  I  am  not  opio-­‐phobic  •  I  am  not  opio-­‐philic  •  I  am  not  needle-­‐phobic  •  I  am  not  needle-­‐philic  •  I  am  agnos3c  to  chi  gong  and  tai  chi  •  ‘I  just  wanna  know  how  my  pa3ents  are  doin’  •  Because  if  I  don’t  measure  outcome  I  believe  my  prac3ce  is  not   medically,  financially  or  ethically  sustainable  •  Standard  of  Care  needs  to  be  codified  
  8. 8. Today:  •  Situa3on  •  Model  of  Care  •  Value  •  Future  
  9. 9. Overtreatment  is  the  new  under-­‐treatment  
  10. 10. 132 to 1775690 to 1,442
  11. 11. Opioid  AddicEon  Treatment  
  12. 12. Serious Morbidity ICD-9 CM:"Diagnosis Codes: Respiratory insufficiency or failure: 518.5, 518.81,518.82, 518.5, 786.09; Aspiration pneumonia507.0; Anoxic encephalopathy: 348.1; Cardiac Arrest: 427.5; Rhabdomyolysis: 728.88, 728.89"Procedure Codes:Endotracheal administration: 96.04; Mechanical ventilation: 96.70-96.72; CPR: 93.93, 99.60Data Sources: Comprehensive Hospital Abstract Reporting System (CHARS)Oregon, State Inpatient Database (SID), Healthcare Cost and Utilization Project (HCUP), Agency for HealthcareResearch and Quality.
  13. 13. Opioid  Related  Deaths  2001- 265 2009- 644
  14. 14. Opioid Overdose Risk (fatal & non-fatal) by Average Opioid  overdose/death  raEo  Daily Dose of Medically Prescribed Opioids 10 9-fold increase 9 ** in risk relative to low-dose 8 patients 7 1.79 % 6 5 4 ** 3 0.68 % ** Significant 2 increment in risk p<0.05 1 0.04 % 0.26 % 0.16 % 0 Non-user 1-19 mg. 20-49 mg. 50-99 mg. 100+ mg. Dunn et al., Annals Int Med, 2010
  15. 15. Fracture  Hazard  RaEo  2.5 2-fold increase ** in risk relative 2 to non-users 10.0 %1.5 7.0 % 1 5.7 % 3.8 % ** Significant increment in risk0.5 p<0.05 0 Non-user 1-19 mg. 20-49 mg. 50+ mg. Saunders et al., JGIM, 2010
  16. 16. Adverse  selecEon:  70.0% 61.4%60.0% 51.7%50.0% 38.5%40.0%30.0% 26.8% Odds ratios adjusted for 1.0 1.4 2.1 2.6 pain severity20.0% and patient characteristics10.0%0.0% 1-19 mg 20-49 mg. 50-119 mg. 120+ mg. Merrill et al., under review
  17. 17. Newborns  with  Drug  Withdrawal  (GeneraEon  Rx)     Washington  State,  1990-­‐2009   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 Reporting System
  18. 18. WA  State  Healthy  Youth  Survey  Frequency  of  Use  to  Get  High  Past  30  days  Grade  10   Sabel J, Banta-Green C. CSTE 2009
  19. 19. 84-%)45$9 ;)<-(*$6%2 =&&-5-4(" @,2 J0-%$&0 L$HI"M @,2 L$HI"M K;/ @,2 : P$*"-$"Q %& @,2.* S..%+% !"#$%&"(%) UR1&-2"=10-"$$$$$$$$$$$$$$$$$$$@-3
  20. 20. More  opioids,  more  addicEon,  more  deaths  
  21. 21. • People die from Rx 100 Overdoses Every Day in the US • Rx Pain Killer 14,800 Deaths in 2008Source: CDC Vital Signs: overdoses of prescription opioid pain relievers -1999-2008
  22. 22. For Every One Death : 10 Treatment 32 Emergency admissions for dept visits abuse 1 Death130 People who 825 Non- Misuse/abuse medical usersSource: CDC Vital Signs: overdoses of prescription opioid pain relievers -1999-2008
  23. 23. Cultural Transformation
  24. 24. Today:  •  Situa3on  •  Model  of  Care  •  Value  •  Future  
  25. 25. Revise  our  pracEce  model  •  System is •  Coordinated care fragmented (PCMH) Patient activation•  Care is inconsistent •  Collaborative care (Telepain/ECHO)•  Cost is unsustainable •  Measurement based care (CPAIN / PainTracker)
  26. 26. Coordinated,  CollaboraEve  Pain  Management   The PatientMeasurement-Based Care Prescription Monitoring Tools Primary Care Providers Nurse Care Coordinator Pain s UDT Tracker EDIE CPAIN PMP DNIC Pain Specialists Structured 2ndOpinion TelePain Interdisciplinary RX Reviews Consultation & CME Pain Management Increasing Level of Care Lower Costs
  27. 27. 1. Care CoordinationWorkflowCPR = Center for Pain ReliefNCC = Nurse Care CoordinatorPCP = Primary Care Provider
  28. 28. 2.  ECHO/TelePain/ROAM  
  29. 29. “MulEplier  Effect”   (&)*$+ 3..#)/$&" !&,*, (&)*$+,#$ (-*,*$+*. (-&%)%* +/0!12!"#$#%#&$!"#$#%#&$
  30. 30.  3.  PaEent  reported  outcome
  31. 31. Today:  •  Situa3on  •  Model  of  Care  •  Value  •  Future  
  32. 32. 1.  Coordinated  Care   n=3500
  33. 33. 1.  Coordinated  care:  Pilot  data Pain Disability Anxiety Depression Opioid useWell engaged -6% -45% -44% -50% -56% Minimally engaged +28% +55% +10% +28% +1%Not engaged +29% +29% No f/u No f/u -3%
  34. 34. 2.  ECHO/TelePain/ROAM  •  40-­‐50  dial-­‐ins  each  session  •  1500  providers    •  76  loca3ons  •  2240  CME  hours  •  Regional  ‘Pain  champions’  (meta-­‐ECHO)  
  35. 35. 2.  ECHO/TelePain/ROAM   N = 94 N = 95 6 Mean  =  4.7 Mean = 4.5 N = 94 SD = 0.6 Mean = 4.3 SD = 0.7 SD = 0.7 5 4 Mean Rating 3 2 1 0 Learning best practice Developing clinical Comfortable teaching care expertise others what Ive learnedParticipants Rated Level of Agreement on a 5-point Scale: 1 = Not At All, 5 = To a Large Degree
  36. 36. 2.  ECHO/TelePain/ROAM   N = 85 N = 84 N = 84 N = 85 N = 86 Mean = 4.6 Mean = 4.4 6 Mean = 4.3 Mean = 4.4 Mean = 4.5 SD = 0.7 SD =0.7 SD = 0.7 SD = 4.5 SD = 0.6 5 4 Mean Rating 3 2 1 0 Reduced Reduced Providers Decreased Through early patient travel for emergency appropriate use visits by and effective specialty care room visits of testing patients to patient and testing specialists interventionsProviders Rated Agreement on a 5-point Scale: 1 = Strongly Disagree, 5 = Strongly Agree
  37. 37. 2.  ECHO/TelePain/ROAM   2007-­‐2009  25   41%  *  20   2008-­‐20010   54%  *    63%  *  15   29%   34%  10   43%  *   5   0   State     Clallam     Grant   Jefferson   Kitsap   Okanogan  
  38. 38. 3.  PaEent  Reported  Outcome  
  39. 39. 3.  PaEent  Reported  Outcome  
  40. 40. 3.  PaEent  Reported  Outcome  Estimated Savings per Claim over Duration of ER Group (N = 373) ID Group (N = 373) DR Group (N = 373)DisabilityTotal Cost of Illness per Claim (2010 US $) $66,525 $121,829 $233,600 Average Savings - $55,304 $167,075 % Saved - 45% 72% Theodore, in press
  41. 41. Today:  •  Situa3on  •  Model  of  Care  •  Value  •  Future  
  42. 42. Scalability  and  sustainability  •  State  (WA,  AK)  •  DoD/VA    •  Large  employers  (UW,  GE)  •  CMS/CMMI  
  43. 43. WA  State  legislaEon  (2876):    •  Mandates  Educa3on  and  Guidelines  •  Mandates  TeleHealth    •  Mandates  Opioid  tracking    •  Mandates  Measurement  at  each  encounter  
  44. 44. Most  emphasis  
  45. 45. NaEonal  legislaEon  •  Educa3on  -­‐  7  (CA,  FL,  ME,  NY,  UT,  WA,  WV)  •  TeleHealth  -­‐  5  (KS,  ME,  MN,  NM,  WA)  •  Monitoring  Program  -­‐  48  (NH,  MS  pending)  •  Outcome  tracking  -­‐  1  (WA)  
  46. 46. Mandatory  guidelines:  
  47. 47. 2009-­‐2010:  Deaths  from  opioids  decreased  by  50%  
  48. 48. State  ED  informaEon  exchange   No controlledRegistration Reveals Physician reviews substances Patient’s ED chart ED care guidelinesPatient on EDIE flagged for doctor medical screening Usual Triage exam by ED physician ED case manager talks to patient prior to discharge Patient Discharged
  49. 49. State  ED  informaEon  exchange   “Please  review   Jane  Doe”   24 hour referral line compiled and Reviewed for appropriateness Program Coordinator researched.ED Physician calls PCP PCP Recommendations ED Care Guidelines Committee ED Care Guidelines Chaplin ED Nurse ED Physicians Patient’s Primary Care Physician Psych Nurse Pharmacist Medical Director
  50. 50. EDIE:  Reducing  Non-­‐Emergent  ED  UElizaEon  
  51. 51. Revise  our  pracEce  model  •  System is •  Coordinated care fragmented (PCMH) Patient activation•  Care is inconsistent •  Collaborative care (TelePain/ECHO)•  Cost is unsustainable •  Measurement based care (CPAIN/ PainTracker)
  52. 52. EducaEon  is  important   Rosenblatt, 2011
  53. 53. !"#$%&%#()$*+$#,-.*/)(#$")*0,"*+$#,-,"$*/(%1$2*3"45678** Current Level of Knowledge1 Level of Interest in Learning 2 Mean (SD) Mean (SD)Assessment and management of genetic-biologic-psychological-social components 2.18 (1.0) 4.25 (0.85)commonly involved in development and maintenance of complex chronic paindisordersPathophysiology of chronic pain versus acute pain 2.34 (1.0) 4.25 (0.85)Use, interpretation, and application of measurement based tools when completing a 1.72 (0.9) 4.16 (0.88)comprehensive pain assessmentMultispecialty treatments and approaches for the care of chronic pain 2.12 (1.0) 4.37 (0.75)Types and roles of medications used for pain, including opioids and non-opioids. 2.29 (1.1) 4.56 (0.63)Types and role of non-medication treatment for chronic pain 2.23 (1.0) 4.52 (0.70)Common primary care clinical pain disorders 2.43 (1.0) 4.35 (0.85)Pain Medicine as a chronic illness specialty with knowledge and skills including 2.02 (1.1) 3.84 (1.06)diagnosis of complex complaints, complex medical and surgical illnesses, and bothconsultative and continuing multidisciplinary treatment.Learning more about pursuing a Residency in Pain Medicine - 2.85 (1.35)!*1 Scale = 1-Poor, 2-Fair, 3-Good, 4-Very Good, 5-Excellent2 Scale = 1-Not Interested, 2-Little Interest, 3-Neutral, 4-Somewhat Interested, 5-Very Interested
  54. 54. But  not  enough  
  55. 55. Take  Home  Message:  •  Coordinated,  collabora3ve,  measurement  based  model:  •  50%  decrease  in  deaths  from  opioids  •  65%  decrease  in  coun3es  par3cipa3ng  in  TelePain  •  56%  decrease  in  opioid  prescrip3on  rate  •  56%  decrease  in  opioid  related  ER  visits  •  50%  increase  in(see attached, for North American Spine Society 2012 Outstanding Paper Award)  global   health  ra3ng  1  year  aker  treatment  
  56. 56. It  aint  what  you   dont  know  that   gets  you  into   trouble.    Its  what  you  know   for  sure  that  just   aint  so.   Mark  Twain  

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