Measures to assess adherence to prescription opioid guidelines

1. Measures to assess adherence to prescription opioid guidelines in the United States Veterans Health Administration (VA) Jodie Trafton, Ph.D., Eleanor T. Lewis, Ph.D., Amanda M. Midboe, Ph.D., Meenah Paik, MPH, Alexander Buscaglia, Robert Kerns, Ph.D., Rollin Gallagher, MD, Will Becker, M.D., Jack Rosenberg, M.D., Francine Goodman, PharmD Substance Use Disorder QUERI, Center for Health Care Evaluation, Program Evaluation and Resource Center, Pain Research, Informatics, Medical Comorbidities, and Education Center and VA/DOD Chronic Opioid Therapy Guideline Committee Introduction Method • Recommendations in the Guideline were extracted and clustered based on clinical and administrative relevance. • Team members with expertise in opioid therapy and experience in knowledge modeling defined metrics that use data elements available in VA administrative data files to assess use of recommended practices. • Metrics were coded in SAS using VA administrative data files then run on FY10 data, providing results at the facility level (n=140). • Variation in adherence to prescribing practices specified in the Guideline were assessed across VA facilities and practices. • BACKGROUND: • Opioid medications are commonly prescribed to treat pain but their use is controversial due to variable effectiveness and serious safety risks (e.g. overdose, misuse & addiction, functional impairment) • VA/DOD has developed and approved the 2010 Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain (“the Guideline”). This guideline provides recommendations intended to maximize the safety and effectiveness of this pain management option. • Local, regional, and national initiatives are in development or underway to improve the quality of chronic opioid therapy provided in VA. • Data is needed on (a) current quality gaps and (b) change in practices over time to guide quality improvement efforts and evaluate the impact of quality improvement initiatives. • This project was developed based on planning and discussion between: • Patient Care Services Chiefs for Pain Management and Addiction, • Substance Use Disorder QUERI coordinators, • Office of Mental Health Services Program Evaluation Center directors, • Authors of the Office of Quality and Performance funded VA/DOD Chronic Opioid Therapy guideline • OBJECTIVES: • To develop VA administrative data-based metrics to assess adherence to VA/DOD guideline recommendations to maximize safety and effectiveness of opioid therapy for chronic pain. • To identify gaps in adherence to guideline recommendations for opioid prescribing in VA at the facility level and system-wide. • To provide a system for on-going evaluation of prescribing practices within VA for chronic opioid therapy. Results • In FY10, a total of 1,291,034 VA patients received at least one prescription for an opioid medication. • Patients were then categorized hierarchically into unique groups based on the type and duration of opioid prescriptions received: • Tier 1: 95,059 patients received a long-acting formulation • Tier 2: 399,024 patients received chronic prescriptions (greater than 90 days supply) for short-acting opioids • Tier 3: 535,522 patients received acute prescriptions (less than 90 days supply) of short-acting opioids • Tier 4: 261,429 patients received prescriptions for tramadol formulations • The table to the right provides facility level rates of adherence to select guideline recommendations by tier. Conclusions • Guideline recommended practices are inconsistently implemented in VA facilities. • A few practices are poorly implemented across VA facilities. • Example: avoiding co-prescription of sedative medications in combination with chronic opioid therapy. • Some practices are well-implemented at some but not other VA facilities. • Examples: use of urine drug screening to assess for substance misuse; regular pharmacy reconciliation for patients with opioid prescriptions; use of rehabilitative medicine and physical therapy, and ensuring that patients with active substance use disorders receive substance use treatment while on prescription opioids. • Some practices are well implemented across VA facilities. • Examples: use of non-opioid pharmacological treatments for pain, and use of psychotherapy in patients with pain. • These metrics will be used to guide national and local quality improvement initiatives, monitor changes in guideline adherence over time, and identify model care practices that might be transported to other facilities. This project is supported by RRP 10-106 “Assessment of Gaps in Chronic Opioid Therapy”, a grant awarded by the Department of Veterans’ Affairs Health Services Research and Development Program (HSR&D) and the Quality Enhancement Research Initiative (QUERI). The views expressed here are the authors’ and do not necessarily represent those of the Department of Veterans Affairs.