Measurement Based Care: Enhancing quality of Pain …...IOC FOC IOC: 01 Aug 10 Slide 6 of 13 PI –...

Measurement Based Care:Enhancing quality of Pain Care

Disclosures

• I am not opio-phobic• I am not opio-philic• I am not needle-phobic• I am not needle-philic• I am not CAM-phobic• I am not CAM-philic• ‘I just wanna know how my patients are doin’• Because I don’t measure outcome I believe my practice

is not medically, financially or ethically sustainable

John J. Bonica

Passing of the Mantle

UWMCUWMC

InpatientInpatient

OutpatientOutpatient

HMCHMC

InpatientInpatient


SCHSCH

InpatientInpatient


VAPSHCSVAPSHCS

InpatientInpatient


SCCASCCA


Doctors pour drugs, of which they know little,

for diseases of which they know less,

into patients - of which they know nothing.

Voltaire (1694-1778)

Unintentional Prescription Opioid Overdose Deaths Washington 1995-2009

* Tramadol only deaths included in 2009, but not in prior years.

Source: Washington State Department of Health, Death Certificates

0

100

200

300

400

500

600

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Num

ber o

f dea

ths

Prescription Opioid + alcohol or illicit drug

Prescription Opioid +/- Other Prescriptions

24

*490

Trends for Specific Opiates Washington 1995-2009

Source: Washington State Department of Health, Death Certificates

0

50

100

150

200

250

300

35019

95

1997

1999

2001

2003

2005

2007

2009

Num

ber o

f dea

ths

Methadone

Oxycodone

Hydrocodone

Non-fatal Hospitalizations for Prescription Opiate Overdose, 1987-2009

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

0

100

200

300

400

500

600

700

1995

1997

1999

2001

2003

2005

2007

2009

# of

hos

pita

lizat

ions Rx Opioid Overdose Diagnosis

As Primary Diagnosis

Newborns with Drug WithdrawalWashington State, 1990-2009

0

1

2

3

4

5

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

Rate

per

1,0

00 li

ve b

irth

s

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

Treatment is not Always Mechanism Based

Health Care Costs of Chronic Pain in the US

Panic DisorderMultiple Sclerosis

HIV InfectionAnxiety

DementiaStroke

PregnancyDepression

CancerArthritis

GI DiseaseDiabetes

Respiratory DiseaseHypertension

Heart Disease

0 50 100 150 200Cost (billions)

Chronic Pain

Indirect Costs

Total Economic Burden =

$210 billion1

1National Research Council. Musculoskeletal Disorders and the Workplace. Washington, DC: National Academy Press; 2001

CMS $ 2009

Practice Variation

Variations in Prescribing

Variations in Outcomes

Outcome Measures Approach*

1.Pain 2.Physical functioning 3.Emotional functioning 4.Participant ratings of improvement and

satisfaction with treatment 5.Symptoms and adverse events 6.Participant disposition

*IMMPACT’s 6 core domainsTurk et al. Pain 2003;106:337-45

Home Page

CPAIN - Patient Profiles

CPAIN - Outcomes Tracking

Benefits from Previous Medications

0%10%20%30%40%50%60%70%80%90%

100% Tried Medication

Medication Helpful

*Whole bar is % of patients who tried treatment in the past, red is those that are currently using the treatment, blue is % of

patients using the treatment who have benefited from it

Patient Outcomes: Clinic vs. National Average

0123456789

10

Baseline 3 months 6 months

Pain Intensity

0123456789

10


Physical Function

0

3

6

9

12

15

18

21


Anxiety

02468

101214161820


Depression

ClinicNational Average

Patient Complexity: Clinic vs. National Average

I'm sure that there is a medical treatment and cure for my pain

I expect that my pain will get worse over time

When I do something that causes my pain to increase, it means that I am harming my body even more

Less Complex More Complex

Disabling Pain Beliefs

0%

25%

50%

StronglyDisagree

Disagree Neutral Agree StronglyAgree

0%

25%

50%

StronglyDisagree


0%

25%

50%

StronglyDisagree


ClinicNational Average

Invasive vs. Non-Invasive Interventions

Non-InvasiveInterventions34% (N = 375)

Invasive Interventions66% (N = 730)

p-value

Age (SD) 46 (14.5) 47 (14.1) 0.442

Gender (% Female) 64% (238) 63% (457) 0.778

Duration of Pain, months (SD) 77 (87.3) 102 (109.1) < 0.001a

Unable to work because of pain 31% (108) 45% (306) < 0.001b

a Effect Size based on Cohen’s d = 0.2b Odds Ratio (95% CI) = 1.8 (1.4, 2.4)

Demographic Characteristics

Non-InvasiveInterventions34% (N = 375)

Invasive Interventions66% (N = 730)

p-value

Pain Intensity (SD) 5.5 (2.2) 5.8 (2.1) 0.057

Type of PainNeuropathic onlySomatic onlyMixed

4% (15)27% (103)63% (238)

4% (29)25% (185)66% (481)

0.9820.4460.424

Positive for Emotional Distress on MHI-5

64% (174) 67% (337) 0.396

Pessimistic Outlook: Believes that pain will get worse

62% (227) 63% (449) 0.693

Believes that pain is the Number 1 problem in their life

79% (288) 86% (98) 0.004a

a Odds Ratio (95% CI) = 1.6 (1.2, 2.3)

Pain & Psychosocial Measures


80%

59%61%

48%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Intervention Helpful Adverse Effects

% o

f Pat

ient

s in

Coh

ort (

N =

110

5)

Non-Invasive

Invasive

p < 0.001, O.R. = 2.5 (1.9, 3.4)

p = 0.001, O.R. = 1.5 (1.2, 2.0)

Perception of TreatmentInvasive vs. Non-Invasive Interventions

64%

38%

64%

45%

0%

10%

20%

30%

40%

50%

60%

70%

Future Interest in Non-Invasive Interventions

Future Interest in InvasiveInterventions

% o

f Pat

ient

s in

Coh

ort (

N =

110

5)

Current Non-InvasiveInterventions

Current InvasiveInterventions

p = 0.995

p = 0.027, O.R. = 1.3 (1.0, 1.7)

Future Treatment Outlook


Opioid vs. Non-Opioid Medication

Non-Opioid Medication

22% (N = 229)

Opioid Medication

78% (N = 793)

p-value

Age (SD) 46 (15.1) 47 (14.1) 0.164

Gender (% Female) 62% (141) 64% (505) 0.560

Duration of Pain, months (SD) 83 (103.1) 99 (103.3) 0.048

Unable to work because of pain 36% (78) 43% (320) 0.049

Demographic Characteristics

Non-Opioid Medication

22% (N = 229)

Opioid Medication78% (N = 793)

p-value

Pain Intensity (SD) 5.5 (2.3) 5.8 (2.0) 0.030a

Type of PainNeuropathic onlySomatic onlyMixed

5% (12)35% (80)

55% (125)

3% (28)23% (185)69% (549)

0.240< 0.001b

< 0.001c

Positive for Emotional Distress on MHI-5

63% (109) 67% (369) 0.352

Pessimistic Outlook: Believes that pain will get worse

58% (130) 65% (505) 0.045

Believes that pain is the Number 1 problem in their life

83% (187) 85% (655) 0.583

a Cohen’s d = 0.1b Odds Ratio (95% CI) = 1.8 (1.3, 2.5)c Odds Ratio (95% CI) = 1.9 (1.4, 2.5)

Pain & Psychosocial Measures


82%

28%

80%

57%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Medication Helpful Future Interest in MedicationTherapy

% o

f Pat

ient

s in

Coh

ort

( N =

102

2)

Non-Opioid MedicationOpioid Medication

p = 0.496

p < 0.001, O.R. = 3.4 (2.4, 4.6)


Unable to Work Because of Pain Non-Opioid Medication OpioidMedication

Unable to Work & Prior Non-Invasive Treatments

25% 34%

Unable to Work & Prior Invasive Treatments

43% 47%

Disability:

Cost-effectiveness of treatment strategies for chronic pain

CPAIN Data Comparison

IMS Claims DB

PracticeMgmt. CPAIN

Pharmacologic therapy ✔ ✔ ✔

Non-pharmacologic therapy ✔ ✔

Treatment effectiveness ✔ ✔

Treatment safety ✔ ✔

Misuse, abuse, diversion ✔ ✔

Patient characteristics ✔ ✔

Prescriber characteristics ✔ ✔

In summary: Concept

Collect patient reported outcomes (e.g., pain assessment, QoL, mood, function, opioid risk screening)

Link measurement instruments - patients – research data – clinical tools – clinicians

Easily retrievable and incorporated into real time reports

Data repository that is relatively easy to access (for research)

Codify Standard of care

• Education/guidelines• Access to specialty care• Prescription monitoring program• Statewide outcome tracking tool

Proficiency training

• LOES: 4+ hours in multidisciplinary pain center• Didactic: 2 hours

– Includes review of AMDG guideline for care model• At home CME: 3+ hours

– COPE (for opioid prescribing training)– AMA (overview)

• Continuing CMEs: – Project ECHO

• Evaluation• Reimbursed by payer?

Dubois, et al Pain Medicine Position Paper., Pain Medicine 10 (6), 2009: 972-1000.

Pain Champion 1b

Tele-health in Washington

Jefferson Hospital

Forks Hospital

Olympic Medical Ctr

Harrison Hospital

Grays Harbor Hospital

UW Mark Reed Hospital

Morton Hospital

Mason Hospital

Willapa Harbor HospitalOcean Beach Hospital

OMCC

Skagit Valley Hospital

United General Hospital

Snoqualmie Valley Hospitall

Island Hospital

Oroville

RepublicOmak

Brewster

Grand Coulee

Chelan

Walla Walla

Wenatchee, CWH Quincy

St. Joseph Hospital

Longview RSN & Pediatric Clinic

Naselle Juvenile Facility

Yakima Valley Farmworkers Clinic

Ione

Colville

ChewelahNewportInchelium

Keller Deer Park

Spokane

Davenport

OdessaEphrata

Moses Lake Colfax

Dayton

PullmanPomeroy

Othello

Dayton

Connell

Sunnyside

Goldendale

Ellensburg

Whidbey Gen’eral Hospital

Makah Tribe

Quinault Tribe

Quileute Tribe

Shoalwater Bay TribeChehalis Tribe

Nisqually Tribe

Squaxin Island TribeSkokomish Tribe

UW Telehealth Sites

Other Telehealth Network Sites

UW Pain/ Project ECHO

• Twice weekly tele-videoconference statewide:– Pain (projected start 1/2011)– Addiction (started 11/2010)

• Expert UW multidisciplinary consultant group meets with 30+ pre-scheduled providers– Polycom or similar system– Nurse coordinator/Outcomes followed & measured– Case presentation– Knowledge-networks

Pain Tracker

Measurement based care

Integrates with CPAIN®

Emergency Department Information Exchange (EDIE) www.ediecareplan.com

Statewide ED Visit Network (EDIE)

14 hospitals pursuing EDIE implementation (yellow/green)

Registration Reveals Patient on Consistent Care Patient’s ED chart

flagged for doctor

Physician reviews ED care guidelines

Patient Discharged

medical screeningexam by ED physician

No controlledsubstances

ED case manager talks to patient prior to discharge

ED Visit Process

Usual Triage

The Process“Please

review Jane Doe”

24 hour referral line compiled and researched. Reviewed for appropriateness Program Coordinatorcalls PCP

Patient’s Primary Care Physician

PCPRecommendations

ED Care Guidelines CommitteeChaplin ED Nurse ED PhysiciansPsych Nurse Pharmacist Medical Director

ED Care Guidelines

ED Physician

11,146

4,959

0

2000

4000

6000

8000

10000

12000

ED Visits to All Hospitalssince Consistent Care Started (4 years)

6187 Reduced ED Visits

-56% ReductionBefore

After

n=264 patients

Measurement Based Care

Continue and work together

MHCS

Planning Timeline

Current Date

FOC: 01 Oct 12

FY 2010 FY 2011 FY 2012

3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q

IOC

FOC

IOC: 01 Aug 10

Slide 6 of 13

PI – Operationalize

• OPORD Published: NLT 30 Jul 10PII – Implementing

1

PIII – Assess

3

1

2 IOC, 1 Aug 10 “Quick Wins”

3 FOC, 01 Oct 12

Phase I begins, 01 May 101

Critical Points( CP)

Pain Management Campaign Plan

2

PIV – Revise Implementation

P V – Re-Assess

P VI – Sustain

Summary:

• System is fragmented

• Care is inconsistent

• Cost is unsustainable

The Model:1. Coordinated Care

– Use care managers– Pain tracker supports Medical Home

2. Collaborative Care– Standard of care & TelePain– Between patient, family & provider

3. Measurement-base Care– Tracking and providing aggregate reports (CPAIN)– Treatment based on data outcomes not output

4. Value based Care– Incentive alignment– Pay for things that have evidence that they work

78

PHASE IEstablish the Model

PHASE IIIntroduce the Model

PHASE IIIImplement the Model

Nationally

PHASE IVA

Develop & Sustain the Model

PHASE IVB

Integrate the Model into Long Term VA

Organizational Goals

Sustainable Pain Care

EffectiveCollaboration

PCP supported by Behavioral Health

Care Manager

Informed, Active Patient

Practice Support

MeasurementTelePain

Training

Codify Standard of Care:

• Education and Guidelines (AMDG)• Access to specialty care (TelePain)• Monitoring Program (PMP, EDIE)• Measurement-based care (CPAIN)

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

Measurement Based Care: Enhancing quality of Pain …...IOC FOC IOC: 01 Aug 10 Slide 6 of 13 PI –...

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