Eastern Kentucky is drowning in pills.
The Bluegrass State, especially its eastern half, has been hit hard by the national opioid abuse epidemic. In 2011, more than 15% of all 18- to 25-year-olds in the state were illegally using opioids, and hospital admissions and deaths from drug overdoses were spiking, with drug overdose death rates rivaling those for car crashes.
©thegoodphoto/Thinkstock.com
In 2012, attempting to address the crisis that was killing young and old alike and fracturing families, the Kentucky lawmakers passed legislation targeting opioid abuse. Among other measures, that year’s House Bill 1 took aim at "pill mills" by preventing nonphysicians from owning pain management clinics, and also significantly expanded the state's prescription drug monitoring program (PDMP), known as KASPER.
Because the regulations were written from a law enforcement – rather than a medical – perspective, the new law contained measures that proved difficult for prescribers to understand, let alone comply with. That meant a bad situation looked to be getting worse for doctors in Kentucky who wanted to make things better but weren’t always sure where to start.
So, Dr. Greg Hood, an internist in Lexington, Ky., decided to do something about it.
Already interested in health policy issues and active in his state’s chapter of the American College of Physicians, Dr. Hood worked with ACP leaders to formulate an education and implementation plan to help primary care practices shift toward rational opioid prescribing.
As an internist, he understood the realities of day-to-day medical practice in this hard-hit region, and he knew that effective change would need a multipronged approach.
Dr. Hood and his collaborators in the Kentucky ACP chapter, the national ACP, and the Johns Hopkins Bloomberg School of Public Health, Baltimore, put together a proposal, “Enhancing Effective, Safe Chronic Pain Management in PCMH-Recognized and ACO-Participating Primary Care Practices: A Kentucky ACP Chapter Quality Network Initiative.”
With partial funding from Pfizer and support from the ACP, the quality improvement (QI) project focused on achievable, practice-friendly steps.
The initiative involved eight primary care practices from two accountable care organizations (ACOs), a total of 41 providers participated, and each practice named a physician and a nonphysician “QI champion” to lead education and change efforts.
The whole health care team, from schedulers and medical assistants to nursing staff and prescribers, was involved, so all staff members would know why they were being asked to make changes.
The program had four primary objectives: to engage primary care teams, implement a QI program to enhance chronic pain management, evaluate the program’s impact, and, finally, further disseminate the program.
Before any practice improvement began, an ACP Quality Connect practice assessment tool gathered information about the state of chronic pain care in practices. At the outset, though about 60% of practices were screening for depression, nearly three-quarters of practices were not assessing and managing chronic pain effectively, and almost half were not consistently using opioid agreement forms and incorporating urine drug testing into practice.
Performance measures in the QI program included documented screening for clinical depression, documented pain assessments, and increased use of opioid agreements and urine drug testing – all evidence-based measures to ensure more appropriate opioid prescribing and reduce the risk of abuse or diversion.
Various practice improvement strategies were brought to the study sites and led by the QI champions. These included educational webinars about pain and mental health assessments, as well as opioid contracts and risk assessment. Nationally known QI experts participated in coaching calls with team members as implementation got underway. A patient brochure about opioids and controlled substance agreements was developed and brought into use.
After the holistic set of interventions was fully implemented, practices were again surveyed about how they were caring for their chronic pain patients.
What happened? As Dr. Hood suspected, things changed.
“Physicians and practices are capable of change if you design a project that gives offices what they need,” he said.
The average improvement from baseline for depression screening, for example, was 24%. Strikingly, one practice that never screened for depression before the QI initiative achieved a 92% screening rate post intervention. Urine drug testing and controlled substance agreement use jumped by 23%, with one practice going from 0% before intervention to 100% at follow-up.
Practices showed even more improvement – an average of 48% – in administering pain assessments, because six of the eight practices never administered pain assessments before the intervention. Improvements in this group ranged from 60% to 100%.
Lessons learned from the QI initiative, said Dr. Hood, included the importance of multilevel, ongoing engagement with all team members. Some financial support to help offset the time commitment came from Pfizer.