Prescribing	  Prac,ces	  	  Dr.	  Alex	  Cahana,	  MD,	  Dphil,	  DAAPM,	                         FIPP	    Advisor	  to	  ...
Disclosure	  Statement	  	  •  Alex	  Cahana	  has	  no	  financial	  rela,onships	     with	  proprietary	  en,,es	  that	...
HB	  2876:	  Just	  measure	         April	  2	  –	  4,	  2013	       Omni	  Orlando	  Resort	  	        at	  ChampionsGat...
Points	  of	  Discussion	  •  Explain	  the	  incen,ves	  for	  over-­‐prescrip,on	  •  How	  measurement	  and	  coordina...
My	  disclosures	  •  I	  am	  not	  opio-­‐phobic	  •  I	  am	  not	  opio-­‐philic	  •  I	  am	  not	  needle-­‐phobic	 ...
Your	  disclosures	  •    Denial	  •    Anger	  •    Bargaining	  •    Depression	  •    Acceptance	                      ...
GeneraHon	  Rx	                                                   5	                                                   4	 ...
DissaHsfying	  encounter	  •  PaHents1	      <20%	  sa,sfied	  with	  Pain	  Care	  received	  •  Students2	      <10%	  sa...
Overtreatment	  is	  the	  new	  undertreatment	  
Adverse	  selecHon:	  70.0%                                                              61.4%60.0%                       ...
The	  result	  from	  the	  US	  experiment	                  Clinical	  harm	                   Social	  harm	           ...
Revise	  our	  pracHce	  model	  •  System	  is	  fragmented	      •  Coordinated	  care	  (PCMH)	  •  Care	  is	  inconsi...
1.	  Coordinated	  care	  •  Integra,on	  of	  behavioral	  health	  care	     specialists	  into	  primary	  care	  prac,...
Coordinated	  care	  •  Significant	  improvements	  in	  pain	  intensity,	  disability,	     and	  pa,ent	  global	  impr...
Coordinated	  Care	           n=3500	  
=4>?",(%@(A*B"$2(&-$5(9%,C5-"(D34-;*#"$(EFGH(9DI(#!!"&%$"&$!"&#$"&!!" %$"                                                 ...
=4>?",(%@(A*B"$2(&-$5(9CD(EFGH(*.((                      =%(I,-"(:+,""J(%,(K*2$(:+,""(E(F(L"*,(#!"!!" &!" %!"             ...
!"#$%&()*+,%-./01.23456789+-:;!(*<+-(-=1<%>!!" &!" %!"                                                                    ...
2.	  CollaboraHve	  care:	  
THE	  NON-­‐COLLABORATIVE	  PAIN	  CONSULT	                                    Anesthesiology	                            ...
INTERACTIVE	  LEARNING	  ENVIRONMENT	                                  UW	  Pain	  Faculty	  Specialists	                 ...
Knowledge	  network	                 (&)*$+                   3..#)/$&"                !&,*,                   (&)*$+,#$  ...
ECHO/TelePain/ROAM	  •  Twice-­‐Three	  weekly	  mul,disciplinary	  pain	     consulta,on	  to	  WWAMI	  plus	  Oregon	   ...
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)	                               Rock...
Measurement	  based	  care	                               Dozen worst after 12 months                     !"#$%       &#"(...
Posner,	  2011,	  QA/QI	  
Outcomes	  by	  provider:	  Patient-Reported Disability by Provider
Outcomes	  by	  provider:	  Patient-Reported Depressive symptoms by Provider
Measurement	  based	  care	                                                                              % of Total       ...
Codify	  into	  policy	  •  System	  is	  fragmented	      •  Coordinated	  care	  (PCMH)	  •  Care	  is	  inconsistent	  ...
EducaHon	  is	  important	                          Rosenbla`,	  2011	  
But	  not	  enough	  
HB	  2876	  :	  	  •    Educa,on	  and	  Guidelines	  (AMDG)	  •    Access	  to	  specialty	  care	  (TelePain)	  •    Opi...
HB	  2876	  :	  	  
Pilot	  data:	  Deaths	  from	  opioids	  decreased	  by	  50%	  
TelePain	  Effect	  on	  Opioid	  Death	  Rates	  	                  (by	  rural	  Washington	  State	  county)	  25	  20	 ...
Reducing	  Non-­‐Emergent	  ED	          UHlizaHon	  
Patient             need Clinical             ClinicalResearch               Care
How	  do	  we	  stop	  this	  epidemic?	       Just	  measure	  
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.

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Prescribing practices final

  1. 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. 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. 3. HB  2876:  Just  measure   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  4. 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. 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. 6. Your  disclosures  •  Denial  •  Anger  •  Bargaining  •  Depression  •  Acceptance   Kubler  Ross,  On  death  and  dying,  1968  
  7. 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. 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. 9. Overtreatment  is  the  new  undertreatment  
  10. 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. 11. The  result  from  the  US  experiment   Clinical  harm   Social  harm   Cultural  harm    
  12. 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. 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. 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. 15. Coordinated  Care   n=3500  
  16. 16. =4>?",(%@(A*B"$2(&-$5(9%,C5-"(D34-;*#"$(EFGH(9DI(#!!"&%$"&$!"&#$"&!!" %$" ()*&&" +,-*&&" $!" -­‐12   #$" !" ( ( 5( #( "( "( 2( ( -* *0 $* " -## #- %& 4* %, (/ <% ; %- " *3 +$ ##$ %, *# 2(9 .- )* 122 !" , :5 %% ." " / 78 )" $ 6"
  17. 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. 18. !"#$%&()*+,%-./01.23456789+-:;!(*<+-(-=1<%>!!" &!" %!" ?02C" D:*C" $!" -­‐12   #!" !" ()**+,-." /01+,230" /)4)20*"506" 78809:0;" <).+=>)8" @;,2)*3.)" 5,,43.A3**)" B,+0*" ?,3.)8"
  19. 19. 2.  CollaboraHve  care:  
  20. 20. THE  NON-­‐COLLABORATIVE  PAIN  CONSULT   Anesthesiology   Psychiatry,  Psychology   Pa,ent   Addic,on  Medicine  Primary  Care   Clinician   Rehabilita,on  Medicine   26  
  21. 21. INTERACTIVE  LEARNING  ENVIRONMENT   UW  Pain  Faculty  Specialists   Rural  Clinic   Rural  Clinic   MD,  PA   MD,  ARNP,  RN     Fellows, Residents, Medical students, PA, Nursing, Pharmacy,Rural Clinic Social work studentsMD Rural Clinic ARNP, MSW, Rural Clinic Admin. MD, ARNP, RN Rural Clinic MD, ARNP, CDC Rural Clinic MD, ARNP, PA
  22. 22. Knowledge  network   (&)*$+ 3..#)/$&" !&,*, (&)*$+,#$ (-*,*$+*. (-&%)%* +/0!12!"#$#%#&$!"#$#%#&$
  23. 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. 24. TransacHon  Cost  Analysis  Source:  Jan  Whikngton,  PhD  from  a  pilot  study  funded  by  NSF  
  25. 25. Cyber  Security  Analysis  Source:  Barbara  Endico`-­‐Popovsky,  DHS  
  26. 26. 3.  Measurement  based  care:   Grassley  (R-­‐IA)   Rockefeller  (D-­‐WV)  
  27. 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. 28. Posner,  2011,  QA/QI  
  29. 29. Outcomes  by  provider:  Patient-Reported Disability by Provider
  30. 30. Outcomes  by  provider:  Patient-Reported Depressive symptoms by Provider
  31. 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. 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. 33. EducaHon  is  important   Rosenbla`,  2011  
  34. 34. But  not  enough  
  35. 35. HB  2876  :    •  Educa,on  and  Guidelines  (AMDG)  •  Access  to  specialty  care  (TelePain)  •  Opioid  tracking  (PDMP  /  EDIE)  •  Measurement  (PASTOR  /  Pain  Tracker)  
  36. 36. HB  2876  :    
  37. 37. Pilot  data:  Deaths  from  opioids  decreased  by  50%  
  38. 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. 39. Reducing  Non-­‐Emergent  ED   UHlizaHon  
  40. 40. Patient need Clinical ClinicalResearch Care
  41. 41. How  do  we  stop  this  epidemic?   Just  measure  

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