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Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
Prescribing practices final
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Prescribing practices final

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Clinical Track, National Rx Drug Abuse Summit, April 2-4, 2013. Prescribing Practices presentation by Dr. Alex Cahana.

Clinical Track, National Rx Drug Abuse Summit, April 2-4, 2013. Prescribing Practices presentation by Dr. Alex Cahana.

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  • 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  
  • 7. 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  
  • 8. 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  
  • 9. Overtreatment  is  the  new  undertreatment  
  • 10. 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  
  • 11. The  result  from  the  US  experiment   Clinical  harm   Social  harm   Cultural  harm    
  • 12. 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)  
  • 13. 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    
  • 14. 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  
  • 15. Coordinated  Care   n=3500  
  • 16. =4>?",(%@(A*B"$2(&-$5(9%,C5-"(D34-;*#"$(EFGH(9DI(#!!"&%$"&$!"&#$"&!!" %$" ()*&&" +,-*&&" $!" -­‐12   #$" !" ( ( 5( #( "( "( 2( ( -* *0 $* " -## #- %& 4* %, (/ <% ; %- " *3 +$ ##$ %, *# 2(9 .- )* 122 !" , :5 %% ." " / 78 )" $ 6"
  • 17. =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"
  • 18. !"#$%&()*+,%-./01.23456789+-:;!(*<+-(-=1<%>!!" &!" %!" ?02C" D:*C" $!" -­‐12   #!" !" ()**+,-." /01+,230" /)4)20*"506" 78809:0;" <).+=>)8" @;,2)*3.)" 5,,43.A3**)" B,+0*" ?,3.)8"
  • 19. 2.  CollaboraHve  care:  
  • 20. THE  NON-­‐COLLABORATIVE  PAIN  CONSULT   Anesthesiology   Psychiatry,  Psychology   Pa,ent   Addic,on  Medicine  Primary  Care   Clinician   Rehabilita,on  Medicine   26  
  • 21. INTERACTIVE  LEARNING  ENVIRONMENT   UW  Pain  Faculty  Specialists   Rural  Clinic   Rural  Clinic   MD,  PA   MD,  ARNP,  RN     Fellows, Residents, Medical students, PA, Nursing, Pharmacy,Rural Clinic Social work studentsMD Rural Clinic ARNP, MSW, Rural Clinic Admin. MD, ARNP, RN Rural Clinic MD, ARNP, CDC Rural Clinic MD, ARNP, PA
  • 22. Knowledge  network   (&)*$+ 3..#)/$&" !&,*, (&)*$+,#$ (-*,*$+*. (-&%)%* +/0!12!"#$#%#&$!"#$#%#&$
  • 23. 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  
  • 24. TransacHon  Cost  Analysis  Source:  Jan  Whikngton,  PhD  from  a  pilot  study  funded  by  NSF  
  • 25. Cyber  Security  Analysis  Source:  Barbara  Endico`-­‐Popovsky,  DHS  
  • 26. 3.  Measurement  based  care:   Grassley  (R-­‐IA)   Rockefeller  (D-­‐WV)  
  • 27. 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%
  • 28. Posner,  2011,  QA/QI  
  • 29. Outcomes  by  provider:  Patient-Reported Disability by Provider
  • 30. Outcomes  by  provider:  Patient-Reported Depressive symptoms by Provider
  • 31. Measurement  based  care   % of Total Category SpecimensSpecimens 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 & reportedprescription 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) NOTdetected 1.1%Specimens with illicit substance(s) detected & unreported medicationdetected & reported medication(s) NOT detected 1.0%
  • 32. Codify  into  policy  •  System  is  fragmented   •  Coordinated  care  (PCMH)  •  Care  is  inconsistent   •  CollaboraHve  care   (TelePain/ECHO)  •  Cost  is  unsustainable   •  Measurement  based  care   (CPAIN/PainTracker)  
  • 33. EducaHon  is  important   Rosenbla`,  2011  
  • 34. But  not  enough  
  • 35. HB  2876  :    •  Educa,on  and  Guidelines  (AMDG)  •  Access  to  specialty  care  (TelePain)  •  Opioid  tracking  (PDMP  /  EDIE)  •  Measurement  (PASTOR  /  Pain  Tracker)  
  • 36. HB  2876  :    
  • 37. Pilot  data:  Deaths  from  opioids  decreased  by  50%  
  • 38. 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  
  • 39. Reducing  Non-­‐Emergent  ED   UHlizaHon  
  • 40. Patient need Clinical ClinicalResearch Care
  • 41. How  do  we  stop  this  epidemic?   Just  measure  

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