Optimal Prescribing Update and Support (OPUS)

1. Optimal Prescribing Update and Support (OPUS) Webinar July 19, 2012

2. Opus Enters the ‘marketplace of Ideas Opus enters the ‘marketplace of ideas’

3. Session Opening Dr. Ian Schokking, MD

4. Agenda • 7:00 Welcome and Introductions (30 minutes) Session Opening OPUS e4Pros Practice Support Program Provincial Academic Detailing • 7:30 EQIP Portraits (5 min) and Patient Lists (10 min) • 7:45 Statins and PPIs (90 min) • 9:15 Action Period Planning (15 min) • 9:30 Evaluation and Next Steps (30 min) • 10:00 Adjournment

5. Triple Aim of OPUS and Pre-approval • Divisions' Triple Aim • Outcomes • Experience • Costs • Pre-Approved Special Authority

6. Aims of this OPUS Session • Reflect on our prescribing in light of evidence • How to use OPUS Registries to pull charts of patients who might benefit from a change in prescribing • How to discuss medication changes with patients • Introduce Special Authority Pre-Approval pilot study • What do OPUS leaders need to facilitate sessions?

7. OPUS Steps Session Lead & Medical Office Asst prepare Action Period GP self-audit of charts Patient visit: handout or key message QLS: Session Lead, GPs, MOAs discuss portraits & actions Follow-up QLS: discuss process lessons & results 1 3 5 2 4 Engage community pharmacist in Best Possible Med. Hist. Some GPs sign Special Auth’ty Pre-Approval 3b 2b

8. Introductions • OPUS and– Dr. Keith White • e4PROS – Dr. Kendall Ho • Practice Support Program – Liza Kallstrom • Provincial Academic Detailing – Dr. Ruth Campbell

9. EQIP Portraits Dana Stanley

10. From UVic Coded MD ID Coded Envelope Coded MD ID Rx Portrait for MD GP address Anonymity: ‘Confidential Portraits’ Aggregate Drug Data on Anonymous GP’s practice GP Code GP Code EQIP PORTRAIT EQIP PORTRAIT

11. Past and Current EQIP Topics • First line antihypertensives • Statins • Proton pump inhibitors and H2RAs • Blood glucose test strips • Antibiotics for urinary tract infections • Antibiotics for upper respiratory tract infections • Oral medications for type 2 diabetes • Appropriate use of ACE-Is and ARBs New EQIP topics are accredited for 1.0 Mainpro-M1 credit

12. Review of Portraits • Your personal prescribing portrait was mailed to you. • If you brought yours, please do NOT show others. • The goal is self-audit and self-improvement • Today we will focus on 3 anonymous portraits from BC: • 1) a median portrait • 2) a ‘good’ portrait (more consistent with evidence) • 3) a ‘less good’ portrait (less consistent with evidence)

13. Patient Lists Dr. Shakeel Bhatti

14. Your ‘Patient List’ with OPUS Column 1 Subset of Hypertension Registry 2 ‘Hyperlidemia’ Registry 3 Cardiovascular Registry Subset 4 Cardiovascular / Anticoagulation 5 Osteoarthritis Registry Subset

15. Why Statins and PPIs? Dr. Keith White

16. Statins Dr. Ruth Campbell

17. Proton Pump Inhibitors (PPIs) Drs. Ian Schokking and Keith White

18. Mary Age 40 • After a negative endoscopy and H.Pylori test 2 years ago, this lady has taken rabeprazole 20 mg daily. • She has been symptom free for 6 months since losing some weight.

19. Frank Age 35 • Overweight, 3 months ago classic symptoms of GERD at walk-in. • 4 week sample of Tecta and a slip for some bloodwork. • Symptoms disappeared, so he did not bother with the bloodwork. • Return to walk-in and got a further month’s sample of Tecta. •  Ran out of Tecta and his symptoms back. Loves Mexican food.

20. Frederick, Twin brother of Frank • Same symptoms, so went to a W/I and asked for some Tecta. • Symptoms were unaffected by the Tecta. Went for the blood test, and was H.Pylori +ve. • Treated with an HP Pac, and his symptoms became worse. • Loves a big breakfast when he wakes up.  • After you explain about rebound, and chat with him about lifestyle modification, continued on Tecta once daily. • Appreciates PPI is adjunct to diet & exercise, not a replacement. • 3 months later he has lost 10 pounds and has elevated the end of his bed. What now? • After explain to Frederick that his pill is enteric coated and must be taken one hour before breakfast, symptoms recede and he can work on his diet etc. • 2 months later he is symptom free.

21. Mrs. Smith Age 47. • Had a GI Bleed due to an NSAID induced ulcer which bled. • Treated successfully and now comes to you to discuss her future management. • Has RA and really needs her NSAID.

22. Mr. Jones Age 55. • Has new onset dyspeptic symptoms. • Takes Toradol 10mg tid for back pain. • Recovering narcotic addict: takes the Toradol because it is non-narcotic and the literature from the Drug Rep states it is as effective as codeine.

23. Dorothy, age 74. • Had surgery for a perforated sigmoid colon, due to a diverticular abscess. • Became septic and spent some time in ICU. • Was given IV pantoprazole to prevent “Stress Ulcers”. • Had been on oral pantoprazole for a year before her illness, for dyspepsia. • Developed Ventilator Associated Pneumonia and C.Difficile. • Has been discharged on pantoprazole 20mg. Dail.

24. Action Period Planning Dr. Keith White

25. Aims: your goal for Action Period Measures: How am I progressing? Change Ideas: What you plan to do/test Start Small and Grow

26. We want to provide the most appropriate drug at the right time for the most appropriate duration.

27. What does OPUS mean for you?

28. Action Period Expectations Photos courtesy of jscreationzs

29. Aims: What are we Trying to Accomplish? Answer the following questions: Which medications? Statins and PPIs What do you want to achieve? Review for appropriateness For whom? (everyone or just a subpopulation) All regular patients By When? (commit to a date) March 1st, 2012

30. Examples • To improve the prescribing of statins and PPI’s for Dr. McConville’s regular patients, such that all patients who are currently on a Statin or PPI are reviewed for appropriateness by March 1st 2012. To prescribe a Statin for all patients who meet indications but are not currently on a Statin and have not previously declined or not tolerated Statin use. • By March 31st, 2012, we aim to improve the duration of PPI treatment for Dr. Blair’s patients, such that all patients who are prescribed a PPI are reviewed within 4-8 weeks of commencing treatment for: • Continuation, • Change, or • Discontinuation

31. Practice Measures How will you know a change is an improvement? Examples: Count patients for whom statin is changed. Count number of PPIs tapered, stopped, switched. Count number of antihypertensives switched. Count number of patients who start anticoagulant.

32. Examples – Dr. McConville • % of patients currently on a Statin or PPI who have had their medication reviewed during an office visit. • % of patients who have had PPI or Statin reviewed for whom medication was discontinued. • % of patients who meet indications for statin who are prescribed a statin. Note: Excluding those who have declined previously or discontinued use.

33. Examples – Dr. Blair • % of patients who are listed as being on PPI treatment for over 4-8wks from EQIP portrait whose PPI is reviewed. • % of patients whose medication is reviewed that have: • No change • Attempted discontinuation • Recommended for gastroscopy

34. Where will you Record your Counts? • Make notes in margin of registry-patient list? • Make a bar chart? Check boxes on the bar chart? • Can you use your EMR? How will you output the results? • Counts on a tick sheet (e.g. back of patient handout pad)? (see examples) • How will you display and share your data? (preferably graphs)

35. Change Ideas: What changes can you make that will result in improvement?

37. Examples – Dr. McConville

38. Examples – Dr. Blair

39. What is your Action Plan? What is your Aim? • Which medications? • Time frame that is reasonable • A goal to shoot for What are your Measures? • Keep it to a manageable number • Leverage data you have available to you • How will you collect your data What are your next steps? • Who needs to be involved • Commit to a start date • Start Small

40. Example of an Action Period Test of Change What will you do with your statin patients? Review patient in OPUS Lists #2 or #3 and identify patients who could start or stop statins. Flag patient charts or call in patients you think would benefit from medication review. Discuss the benefit of statins with patients using patient handouts.

41. Example of an Action Period Test of Change What will you do with PPI patients? Review patient on OPUS List #5 and confirm patients on a PPI for longer than 8 weeks Flag patient charts or call in patients you think would benefit from medication review Discuss with patients the idea of tapering and eventually stopping their PPI therapy • Patient hand-out: Put Out the Fire (RxFacts, Harvard) • Alternate Rx pad: Step-down of medicines (NPS)

42. Action Period Report

43. Action Period Expectations • Try tests of change. • Track your progress. • EQIP resources available via phone. • Monthly support call. • Materials available at: http://www.gpscbc.ca/psp_opus

44. Examine your OPUS Patient Registries Before QLS • Your patient list is NOT to be viewed by others. • Did your list reflect your practice reasonably well? • Were you surprised by the number of patients listed? • Do you have any questions about the list?

45. Patient List with OPUS Column 1 Subset of Hypertension Registry 2 ‘Hyperlidemia’ Registry 3 Cardiovascular Registry Subset 4 Cardiovascular / Anticoagulation 5 Osteoarthritis Registry Subset

46. Table Discussions:What Patients do you Want Listed?Lists #2 and #3: ‘Hyperlipidemia’ Registry • Discuss 3 types of patients: • Women with no previous CVD events, taking statins. • Low-risk men with no CVD events, taking statins. • Men or women with CVD history not taking statins.

47. Table Discussions: What Patients do you Want Listed?List #5: ‘GERD/dyspepsia’ • Discuss 3 types of patients: • Long-term regular users of PPIs, without NSAIDs. • Long-term regular users of PPIs, with NSAIDs.* • Long-term episodic users of PPIs. * e.g. Osteoarthritis Registry, not Rheumatoid Arthritis

48. Patient Perspective • How will these practice changes you have just identified impact your patients? • Direct costs to patient • Patient preferences and barriers to changing medication • Relationship with you or other care givers • What else?

49. Communicating Changes to Patients • How will you contact the patient about changing the prescription? • Suggested wording to discuss the prescription change with the patient, including addressing their concerns and discussing how drug change will occur • What patient materials do you need to help make practice changes? • What barriers do you expect to encounter?

50. General Dr. Ian Schokking