Controlled Evaluation of Group Health Integrated Group Practice - - PowerPoint PPT Presentation

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Controlled Evaluation of Group Health Integrated Group Practice - - PowerPoint PPT Presentation

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Controlled Evaluation of Group Health Integrated Group Practice Opioid Risk Reduction Initiatives (2006-2014) CARE Study Team Kaiser Permanente Washington Health Research Institute Care Study Team Sascha Dublin

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CARE Study Team

Kaiser Permanente Washington Health Research Institute

Controlled Evaluation of Group Health Integrated Group Practice Opioid Risk Reduction Initiatives (2006-2014)

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Care Study Team

Sascha Dublin Patient Advisory Committee Ryan Hansen Catherine Cartwright Evette Ludman Penney Cowan Michael Parchman David Duhrkoop Katie Saunders Mariann Farrell Karen Sherman Ada Giudice-Tompson Susan Shortreed Kathryn Guthrie Manu Thakral Catherine Lippincott Rod Walker Max Sokolnicki Megan Addis (Project Manager) Betts Tully Michael Von Korff (Principal Investigator)

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Presentation Goals

Review evaluation results of health plan opioid dose reduction and risk stratification/monitoring (RS/M) initiatives among chronic opioid therapy (COT) patients Consider implications of evaluation results for future efforts to reduce risks of prescription opioid overdose and addiction, and to enhance the effectiveness of chronic pain care

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Milligrams per 100 persons per year

Source: Kenan K, Mack K, Paulozzi L. Open Medicine 2012; 6:e41.

Starting in the late 1990’s, opioid prescribing for chronic pain by U.S. physicians increased dramatically

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This change in practice resulted in a four-fold increase in drug

  • verdose deaths involving prescription opioids

Drug Overdose Deaths, US, 1999-2013

Source: Centers for Disease Control and Prevention, NVSS, 2013

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Increased opioid prescribing contributed to an unprecedented rise in all-cause mortality among working age White Americans

U.S. Whites

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Increased mortality was caused by increased poisonings, driven largely by increases in prescription drug overdose deaths

Increased poisonings driven by prescription drug overdose

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Group Health Chronic Opioid Therapy (COT) Risk Reduction Initiatives

  • COT risk reduction initiatives were implemented in 26 Integrated

Group Practice clinics (Intervention setting) but not in contracted care clinics serving similar COT patients (Control setting).

  • Health plan opioid dose and risk reduction initiatives:

– Reduce high-dose opioid prescribing (2008 – 2010) – Implement risk stratification & monitoring (RS/M) initiatives (October 2010 – 2014)

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Group Health COT Risk Reduction Initiatives

Dose Reduction

  • Keep COT doses as low as possible (below state recommended 120mg

morphine equivalent dose (MED) threshold)

Risk Stratification/Monitoring (RS/M)

  • Single primary care prescriber for each COT patient
  • Collaborative care plan for all COT patients:
  • Prescription instructions and treatment agreement
  • Risk-stratified frequency of follow-up visits and urine drug screening
  • Standardized processes for refills, cross-coverage, consultations
  • Enhanced clinician and patient education

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Evaluation Design

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Group Health COT risk reduction initiatives Initiatives Dates

Intervention Clinics

GH Integrated Group Practice

Control Clinics

GH Contracted Care

Dose reduction initiative

2008-10 YES NO

Guideline-based Risk Stratification and Monitoring initiative

October 2010 and later YES NO

From 2006-14, we compared process and outcome trends among 31,142 COT patients from Intervention and Control clinics: A “natural experiment”. In 2014-15, we surveyed 1588 Intervention and Control COT patients, after the risk reduction initiatives had been sustained for many years.

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Evaluation Timeline

Intervention clinics Control clinics

Begins: 2014 Ends: 2015 Telephone Survey N=1588

COT Patient Survey Electronic health care data used to monitor trends N=31,142 Dose Reduction Phase 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Baseline

Risk Stratification/Monitoring Phase

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Results: Implementation Evaluation

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10 20 30 40 50 60 70 80 90 100 2006 2007 2008 2009 2010 2011 2012 2013 2014

Average daily dose (mg) received

Baseline Dose Reduction Phase Risk Stratification/Monitoring Phase

Trends in average daily morphine equivalent dose (MED) among COT patients in Intervention clinics were significantly lower than in Control clinics

Intervention Clinic COT patients

(N=22,673)

Control Clinic COT patients

(N=8,469)

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

2006 2007 2008 2009 2010 2011 2012 2013 2014

GH-IGP GH-CC

Percent of COT patients with Urine Drug Test in Year

October 2010

Percent of COT patients with UDT in prior year

Intervention Clinic COT Patients

(N=8,469)

Control Clinic COT Patients

(N=22,673)

Baseline Dose Reduction Phase Risk Stratification/Monitoring Phase

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0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Trend in percent with COT care plans: Intervention clinic COT patients

Percent of Intervention Clinic COT patients (N=22,673) with care plans

2009 2010 2011 2012 2013 2014

October 2010

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Trends in number of COT patients in the GH-IGP and GH-CC

From 2006 to 2014, the percent of adults receiving COT increased from 1.9% to 2.7% in the GH-IGP and from 1.4% to 2.8% in GH-CC.

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Results: Patient Outcomes Evaluation

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0.00 0.05 0.10 0.15 0.20 0.25 0.30 2006 2007 2008 2009 2010 2011 2012 2013 2014 % of COT patients with overdose in the following quarter

Percent of COT patients with an opioid overdose (fatal or non-fatal) were significantly reduced during the GH-IGP dose reduction period (2008-10) but not during the risk stratification/monitoring period (2010-14).

The reduction in overdose rate within Intervention clinics during dose reduction phase was statistically significant (p=0.038) Intervention clinic COT patients (N=22,673) Control clinic COT patients (N=8,469) The reduction in overdose rate between Intervention and much smaller Control clinic population during dose reduction phase was non-significant There was no change in overdose rate within Intervention clinics during RS/M phase Baseline Dose Reduction Phase RS/M Phase

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Relative risk of opioid overdose by average daily morphine equivalent dose

Intervention clinic mean dose in…. 2014 2006

Dose reduction in Intervention clinics was not on a steep part of the dose-response curve for overdose risk

2014 2006 Control clinic mean dose in…

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Control COT patients (N=653) Intervention COT patients (N=935) Severe (7-10) Moderate (4-6) Mild (1-3)

PEG pain severity ratings (0-10)

Covariate adjusted mean difference (Intervention minus Control) = 0.17 (95% CI= -0.02, 0.35)

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5.2% 4.2% 18.7% 16.3%

  • 5%

5% 15% 25%

Control COT patients (N=653) Intervention COT patients (N=935) Moderate/Severe Mild

Adjusted relative risk comparing control to intervention: 1.08 (95% CI: 0.89, 1.32)

Mild to moderate prescription opioid use disorder was common among COT patients in the Intervention clinics after full implementation

  • f both risk reduction initiatives.

Percent with DSM5 prescription opioid use disorder

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Conclusions

  • Intervention clinics successfully lowered opioid doses and

implemented RS/M initiatives and sustained changes long-term

  • Dose reduction may have produced a modest reduction in
  • pioid overdose rates, but dose reduction was insufficient to

expect a large reduction in overdose rates

  • COT patients on lower doses in Intervention clinics had

similar pain ratings to Control COT patients on higher doses

  • Neither dose reduction nor RS/M initiatives lowered addiction

risks among COT patients.

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Potential next steps to reduce risks of opioid overdose and addiction while enhancing chronic pain care:

  • Increase access to safer and more effective therapies for chronic pain
  • Curtail inappropriate transitions from short-term to long-term opioid use
  • Reduce COT dose to low levels and taper patients off who are not benefiting
  • Ensure access to medication assisted therapy & naloxone for COT patients

unable to taper off opioids or to low dose

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Multi-faceted Implementation

  • Operational definition of COT (near daily use

for at least 90 days)

  • Responsibility for opioid management placed in

primary care

  • Lists of high-dose (≥ 120mg MED daily) COT

patients

  • Supervisory guidance for PCPs with long lists
  • f high-dose COT patients
  • Specialty consult advised caution
  • Voluntary CME

RS/M Phase: Oct 2010 – Sept 2014

  • Rapid Progress Improvement Workshop

defined changes for standard work

  • Strong and sustained leadership for changes
  • COT patient lists included risk stratification
  • Single PCP responsible for COT management
  • Standardized educational materials on-line
  • Clinic peer experts (gurus)
  • Prescribers notified of early refills
  • EHR practice tools/smart sets
  • Online training (87% participation)
  • In-clinic meetings to review progress
  • Targets for care plans set and monitored
  • Financial incentives for achieving targets
  • Patients notified of practice changes by letter

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Dose Reduction Phase: 2008 – Sept 2010