Alex Cahana

Coordinating Multiple Stakeholders

April 10-12, 2012 Walt Disney World Swan Resort

Learning Objectives: 1. Describe the relationship between prescription drug morbidity and mortality and the under-treatment of pain. 2. Identify measurement-based care as standard of care in pain medicine and describe how to measure pain, mood and function in every clinical encounter. 3. Evaluate how new state and federal policy changes will likely allow more prudent and safer use of opioids for chronic, non-cancer pain.

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.

UW Pain Care Delivery Program

[email protected]

John J. Bonica

Inpatient

Outpatient

Inpatient

Outpatient

Inpatient

Outpatient

Inpatient (Seattle)

Outpatient (Seattle &

AL)

Outpatient

Inpatient

Outpatient

Outpatient

MHCS

Inpatient

Outpatient

BCNH IIPM

Outpatient

APCA UAA

ANMC

Outpatient

UW Division of Pain Medicine & Affiliates

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

Today:

•  Situa3on •  Model of Care

•  Value •  Future

Overtreatment is the new under-‐treatment

132 to 1775

690 to 1,442

Opioid AddicEon Treatment

Serious Morbidity ICD-9 CM: "Diagnosis Codes: Respiratory insufficiency or failure: 518.5, 518.81,518.82, 518.5, 786.09; Aspiration pneumonia 507.0; 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, 99.60 Data Sources: Comprehensive Hospital Abstract Reporting System (CHARS) Oregon, State Inpatient Database (SID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality.

Opioid Related Deaths

2001- 265 2009- 644

Opioid Overdose Risk (fatal & non-fatal) by Average

Daily Dose of Medically Prescribed Opioids Opioid overdose/death raEo

0123456789

10

Non-user 1-19 mg. 20-49 mg. 50-99 mg. 100+ mg.

1.79 %

0.68 %

0.26 % 0.16 % 0.04 %

9-fold increase in risk relative to low-dose

patients

Dunn et al., Annals Int Med, 2010

**

**

** Significant increment in risk p<0.05

0

0.5

1

1.5

2

2.5

Non-user 1-19 mg. 20-49 mg. 50+ mg.

10.0 %

7.0 %

5.7 % 3.8 %

2-fold increase in risk relative to non-users

Saunders et al., JGIM, 2010

** Significant increment in risk p<0.05

**

Fracture Hazard RaEo

Merrill et al., under review

Adverse selecEon:

26.8%

38.5%

51.7%

61.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

1-19 mg 20-49 mg. 50-119 mg. 120+ mg.

1.0 1.4 2.1 2.6

Odds ratios adjusted for pain severity and patient characteristics

Newborns with Drug Withdrawal (GeneraEon Rx) Washington State, 1990-‐2009

0

1

2

3

4

5

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

Rate per 1,000 live births

Source: Washington State Department of Health, Comprehensive Hospital Abstract Reporting System

WA State Healthy Youth Survey Frequency of Use to Get High Past 30 days Grade 10

Sabel J, Banta-Green C. CSTE 2009

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More opioids, more addicEon, more deaths

• People die from Rx Overdoses Every Day in the US 100

• Rx Pain Killer Deaths in 2008

14,800

Source: CDC Vital Signs: overdoses of prescription opioid pain relievers - 1999-2008

For Every One Death :

10 Treatment admissions for

abuse

32 Emergency dept visits

130 People who Misuse/abuse

825 Non-medical users

1 Death

Source: CDC Vital Signs: overdoses of prescription opioid pain relievers - 1999-2008

Cultural Transformation

Today:



Revise our pracEce model

•  System is fragmented

•  Care is inconsistent

•  Cost is unsustainable

•  Coordinated care (PCMH) Patient activation

•  Collaborative care (Telepain/ECHO)

•  Measurement based care (CPAIN / PainTracker)

Primary Care

Providers

Nurse Care Coordinator

s

Pain Specialists

TelePain Consultation & CME

Structured Interdisciplinary

Pain Management

2nd Opinion RX Reviews

Pain Tracker CPAIN DNIC

UDT EDIE PMP

Increasing Level of Care

Measurement-Based Care Prescription Monitoring Tools The Patient

Lower Costs

Coordinated, CollaboraEve Pain Management

1. Care Coordination Workflow

CPR = Center for Pain Relief NCC = Nurse Care Coordinator PCP = Primary Care Provider

2. ECHO/TelePain/ROAM

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“MulEplier Effect”

3. PaEent reported outcome

Today:



n=3500

1. Coordinated Care

1. Coordinated care: Pilot data

Pain Disability Anxiety Depression Opioid use

Well engaged -6% -45% -44% -50% -56%

Minimally engaged +28% +55% +10% +28% +1%

Not engaged +29% +29% No f/u No f/u -3%


•  40-‐50 dial-‐ins each session •  1500 providers •  76 loca3ons •  2240 CME hours

•  Regional ‘Pain champions’ (meta-‐ECHO)

N = 94 Mean = 4.7 SD = 0.6

N = 95 Mean = 4.5

SD = 0.7

N = 94 Mean = 4.3

SD = 0.7

0

1

2

3

4

5

6

Learning best practice care

Developing clinical expertise

Comfortable teaching others what I've learned

Mea

n R

atin

g

Participants Rated Level of Agreement on a 5-point Scale: 1 = Not At All, 5 = To a Large Degree


N = 85 Mean = 4.6

SD = 0.7

N = 84 Mean = 4.3

SD =0.7

N = 84 Mean = 4.4

SD = 0.7

N = 85 Mean = 4.4

SD = 4.5

N = 86 Mean = 4.5

SD = 0.6

0

1

2

3

4

5

6

Reduced patient travel for specialty care

and testing

Reduced emergency room visits

Provider's appropriate use

of testing

Decreased visits by

patients to specialists

Through early and effective

patient interventions

Mea

n R

atin

g

Providers Rated Agreement on a 5-point Scale: 1 = Strongly Disagree, 5 = Strongly Agree



0

5

10

15

20

25

State Clallam Grant Jefferson Kitsap Okanogan

2007-‐2009

2008-‐20010

34%

41% *

63% * 54% *

43% *

29%

3. PaEent Reported Outcome

3. PaEent Reported Outcome

Estimated Savings per Claim over Duration of Disability

ER Group (N = 373) ID Group (N = 373) DR Group (N = 373)

Total 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

Today:



Scalability and sustainability

•  State (WA, AK) •  DoD/VA •  Large employers (UW, GE)

•  CMS/CMMI

WA State legislaEon (2876):

•  Mandates Educa3on and Guidelines

•  Mandates TeleHealth

•  Mandates Opioid tracking

•  Mandates Measurement at each encounter

Most emphasis

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)

Mandatory guidelines:

2009-‐2010: Deaths from opioids decreased by 50%

Registration Reveals Patient on EDIE Patient’s ED chart

flagged for doctor

Physician reviews ED care guidelines

Patient Discharged

medical screening exam by ED physician

No controlled substances

ED case manager talks to patient prior to discharge

State ED informaEon exchange

Usual Triage

State ED informaEon exchange “Please review Jane Doe”

24 hour referral line compiled and researched.

Reviewed for appropriateness Program Coordinator calls PCP

Patient’s Primary Care Physician

PCP Recommendations

ED Care Guidelines Committee Chaplin ED Nurse ED Physicians Psych Nurse Pharmacist Medical Director

ED Care Guidelines

ED Physician

EDIE: Reducing Non-‐Emergent ED UElizaEon

Revise our pracEce model

•  System is fragmented

•  Care is inconsistent

•  Cost is unsustainable

•  Coordinated care (PCMH) Patient activation

•  Collaborative care (TelePain/ECHO)

•  Measurement based care (CPAIN/PainTracker)

EducaEon is important

Rosenblatt, 2011

!"#$%&%'#(')$*+$#,-'.*/)(#$")*0',"*+$#,-,"$*/(%1$2*3"45678** Current Level of Knowledge1

Mean (SD)

Level of Interest in Learning 2

Mean (SD)

Assessment and management of genetic-biologic-psychological-social components commonly involved in development and maintenance of complex chronic pain disorders

2.18 (1.0) 4.25 (0.85)

Pathophysiology 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 comprehensive pain assessment

1.72 (0.9) 4.16 (0.88)

Multispecialty 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 diagnosis of complex complaints, complex medical and surgical illnesses, and both consultative and continuing multidisciplinary treatment.

2.02 (1.1) 3.84 (1.06)

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-Excellent 2 Scale = 1-Not Interested, 2-Little Interest, 3-Neutral, 4-Somewhat Interested, 5-Very Interested

But not enough

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

It ain't what you don't know that gets you into trouble.

It's what you know for sure that just ain't so.

Mark Twain

Alex Cahana

Health & Medicine

Transcript of Alex Cahana