”Choosing Wisely” when your patient has chronic pain Project ECHO Presentation December 14, 2017

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”Choosing Wisely” when
your patient has chronic pain
Project ECHO
DR DAVID M KAPLAN MD MSC CCFP
PRIMARY CARE LEAD, HQO
DECEMBER 14, 2017

2. www.ChoosingWiselyCanada.org | @ChooseWiselyCA
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Presentation outline
• Describe the problem of unnecessary care in Canada
• Introduce Choosing Wisely Canada
• Explain the Suite of Health Quality Ontario
Partnered Supports for Primary Care Providers in
Ontario to assist with Chronic Pain
• Q&A

3. www.ChoosingWiselyCanada.org | @ChooseWiselyCA
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“MY HIP, LEG, SHOULDER AND BACK, ALL THE MUSCLES WOULD CONTRACT AND THEY WOULDN’T
RELEASE,” CHRISTINE SAID. “IT WAS LIKE GETTING A CHARLEY HORSE, BUT IT COULD BE CONSTANT
AND LAST FOR A COUPLE OF HOURS. I WAS FEELING THIS EVERY DAY.”
Christine’s story
• In the report, 9 Million
Prescriptions, Christine, a
registered nurse in Ottawa
who suffers from chronic
pain after a car collision
shares her experiences
with opioids – the benefits
and the harms.

4. www.ChoosingWiselyCanada.org | @ChooseWiselyCA
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Wedges of Waste
Berwick D. JAMA. 2012.

5. What doubled healthcare $ in Canada?
Approximately 30% of all
tests and treatments
medically unnecessary
and add little value

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Who has ever…
•Successfully stopped a treatment?
•Said no to a patient and had them leave
smiling ?
•Stopped themselves from ordering a
low-value test or treatment?

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New tests
are good
Better to do
something than
do nothing
Referring doctor
wants it
I don’t want
to get sued
I’ve always
done this
The patient
wants it
$$

8. Choosing Wisely Canada is a campaign to help
clinicians and patients engage in conversations about
unnecessary tests and treatments and make smart and
effective choices to ensure high-quality care.

9. • Societies develop lists
• Disseminate through multiple channelsClinicians
• Develop patient materials
• Disseminate broadly through multiple channelsPatients
• Coordinated approach toward media
• Multiple voices, a common messageMedia
• Work through health care stakeholder
organizations to implement and support adoptionStakeholders
Campaign Approach

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12. www.ChoosingWiselyCanada.org | @ChooseWiselyCA
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Opioid Wisely
• 5 new opioid related recs released in early 2018
• 4 currently existing
• At least 2 new patient assets in 2018

14. Health Quality Ontario
Partnered Support to the
Ontario Opioid Strategy

15. Issue
Overdoses and deaths
associated with Opioid use,
misuse and abuse have been
on the rise.
In 2015, over 700 people died
in Ontario from opioid-related
causes, a 194% increase since
2003.

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Strategy to Prevent Opioid Addiction & Overdose by
Enhancing Reporting System, Connecting Patients with High
Quality Care
Ontario is implementing a comprehensive opioid strategy to prevent
opioid addiction and overdose through:
On August 29, 2017 the Ontario government announced further
investments over three years to enhance this strategy.

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Ontario collaboration for Pain Management & Opioid Use
Partnered program to support managing pain and
practice improvement

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Set standards to
improve quality care
based on the best
evidence
Prescribing for Chronic Pain – Draft Standard
A quality standard currently in development
• Assessment
• Multimodal non-opioid therapies
• Safe prescribing of opioids
• Tapering and discontinuing
• Opioid Agonist therapy
• Prescription Monitoring Systems
• Patient and Health Professional Education

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Build capacity for quality
improvement across the system
Partnered Effort to Support Clinicians
with Opioid Prescribing and Pain Management
• A comprehensive, multi partner approach including CPD to support clinicians to
better support and manage pain with their patients.
• This program is intended to help all clinicians in Ontario to do the following:
• Reflect on and assess patients currently being prescribed an opioids and where appropriate,
consider tapering or other options for care
• More effectively help patients manage pain and opioid use disorder, reduce new starts
• Initial target audience is family physicians and primary care nurse practitioners.
• Sequencing of supports for other prescribers is currently being planned.

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The Integrated Program offerings include:
• Medical Mentoring for Addictions and Pain from Ontario College of Family Physicians
• Academic Detailing from the Centre for Effective Practice
• Continuing Professional Development (CPD) program of short online modules accessible to everyone developed with CPD Ontario
and leadership of Lynn Wilson, Mel Kahan (in development)
• eConsult, EMR Dashboard and the Peer Leader Program from OntarioMD
• Quality Improvement Decision Support Specialists (QIDSS) and analytic support for Family Health Teams from the Association of
Family Health Teams
• De-Implementation of High Risk Opioid Prescribing and Use Program from the Centre for Addictions and Mental Health (CAMH)
• Outreach to increase awareness of available supports and programs for patients, and investments to increase access to addiction
services through the Local Health Integration Networks (LHINs)
• Quality Standards, MyPractice Reports, Specialized Reports from Health Quality Ontario
• Digital Health Drug Repository made available through the Ministry of Health and Long-Term Care
• HQO’s MyPractice report was released in November, and a series of provincial and regional sessions are planned to support the
use of the data, increase awareness of the supports available to support direct patient care and practice improvement where
required.
Build capacity for quality
improvement across the system
Partnered Effort to Support Clinicians
with Opioid Prescribing and Pain Management

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Family physicians can confidentially see their individual opioid prescribing
patterns in comparison to others through their My Practice Report (formerly
Primary Care Practice Reports).
Key Measures include:
My Practice reports to include opioid section with measurement on:
• Opioid prevalence
• Opioid new starts
• Opioid- Benzodiazepines
• Opioid high dose
Who is it for?
Primary Care physicians can access their private reports through registering at
hqontario.ca/mypractice after September 5, 2017.
When?
The first report in this series was available to registered users late November
2017

22. Supporting Implementation
of Centralized Intake and
Assessment, and spread of
ISAEC to all 14 LHINsTitle
goes here.

23. MSK Centralized
Intake, Assessment,
and Management
All Ontarians have timely access to a high
quality, integrated continuum of MSK
Care.
• With guidance from Project Implementation Teams,
proven referral pathways will be integrated over time
o Hip and knee arthritis central intake and
assessment centres and the Inter-professional
Spine Assessment and Education Clinic (ISAEC) for
low back pain in fiscal year 2017/18
LHIN-led service delivery will reflect the context and
capacities of local systems
oPrimary care engagement and capacity
oSub-region service delivery and referral patterns
oNeed for virtual care and OTN support
Primary care providers will know what to
refer and where, to appropriately support
their patient’s care pathway. Shared care
models make them active participants in their
patient’s care across the continuum.
Specialists receive more appropriate referrals
which allow for more predictable practice and
improved wait list management.
Ontario’s health system will become more
sustainable, with improved access to
appropriate and high quality care.

24. A vision for
transforming MSK care
Establish centralized intake, assessment,
and management services to support
patients with hip and knee arthritis and
low back pain, meeting program-specific
inclusion criteria
Fidelity to a set of standard components
Set up to ensure successful adoption of
additional MSK clinical pathways and
future work in conservative care
Central
point of
contact for
referral
intake
Inter-
professional
assessment
Patient
Presents to
Primary Care
Provider (PCP)
Data Collection and Performance Monitoring
Local Community
Programs
Patient and PCP
use guidelines to
determine
appropriate next
steps
Surgical
Consultation
Shared Care Self-
Management
Plan
Patient and PCP
develop non-
surgical
management plan
Target: Assessment
within 4 weeks

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Presentation Summary
• We described the problem of unnecessary care in
Canada
• We were introduced to Choosing Wisely Canada and
the work we do
• Explained the Suite of Partnered Supports for
Primary Care Providers in Ontario to assist with
Chronic Pain
• Q&A

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