25 Years Later: Improving the Quality of Pain Management: is Education Enough? Jean Guveyan Lecture Disclosures

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1 25 Years Later: Improving the Quality of Pain Management: is Education Enough? Jean Guveyan Lecture 2015 Deb Gordon RN BC, DNP, ACNS BC FAAN Co Director Harborview Integrated Pain Care Program Anesthesiology & Pain Medicine University of Washington Disclosures Honorarium for Advisory Boards for Pacira Chronic Regimen SQ continuous infusion ER morphine SL morphine Methadone Oxycodone/Acetaminophen (Percocet ) Total MED = 3grams/d Preop Instructions to taper Postop IV PCA DC Total MED = 4gram/d 25 Years Ago 1

2 We ve come a long way baby(?) Who decided whether the patient was in pain? What was the most common opioid analgesic? Was their a ceiling dose? What was the usual route of administration? What was the usual frequency of delivery? IOM s Definition of Quality Health Care The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (1990)...the health outcomes that patients desire (1998) Structure + Process + Outcomes IOM Committee on Quality Trio of problems: overuse, underuse, misuse Patient centeredness The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one s person, circumstances, and relationships in health care. Berwick D, Health Affairs 2009;28(4):w555-w565 2

3 Safe Effective Patient centered Timely Efficient Equitable Desired Patient Care Outcomes Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions Key components are affective support, access to health information, decisional control, and professional competence Knowledge based Patient centered System minded IOM. Crossing the Quality Chasm: A New Health System for the 21 st Century. Washington DC, The National Academis Press, 2001 Quality Pain Management Appropriate assessment (routine screening, comprehensive initial assessment, and frequent reassessments) Interdisciplinary, collaborative care planning that includes patient input Appropriate treatment that is efficacious, cost conscious, culturally and developmentally appropriate and safe Access to specialty care as needed Gordon DB et al, American Pain Society Recommendations for Improving the Quality of Acute and Cancer Pain Management. Archives of Internal Medicine 2005;165: Pain s Triple Aim 1. Improve the patient experience Collaborative inter professional care team 2. Improve health care outcomes Measurement based stepped model Track function, mood, risk, outcomes every encounter 3. Control costs Reduce unnecessary health care utilization (i.e. low yield imaging, Rxs, procedures, surgery, ED use) Dickenson KC, et al. Medical Care 2010 Dobscha SK,. et al. JAMA 2009 Tauben DJ. IASP Clinical Update 2012 Von Korff M, Moore JC. Annals Int Medicine

4 Complexity of Quality Multidimensional Dependent on perspective Ambiguous and abstract Poor outcomes can occur despite best health care, and patients may do well despite poor quality Relationships between structures, processes, and outcomes are unknown Donabedian A. Milbank Quarterly 2005;83(4): Quality Science Methodology, tools, measures, and standards Skills that assist in identifying failures in processes and systems that lead to breakdowns and errors Knowledge of: Systems Variation Psychology How to Gain Knowledge Reason J. Human error: models and management. BMJ. 2000;320: Robert Wood Johnson Foundation. (2009) Glossary of Health Care Quality Terms. Quality Improvement A data driven systematic approach to improving care locally. A process by which individuals work together to improve systems and processes with the intention to improve outcomes. Publications of results are often limited to lessons learned instead of generalizable results In some situations, results may be more generalizable than RCTs Baily MA, Bottrell M, Lynn J, Jennings B. The Ethics of Using QI Methods to Improve Health Care Quality and Safety: A Hastings Center Special Report. Garrison,NY:The Hastings Center;

5 Quality Is a System Property? Financial implications Increased LOS and readmissions Cost of monitoring and treating adverse events Value of patient satisfaction Dynamic Complexity of Systems Changing over time Tightly coupled Governed by feedback Nonlinear History dependent Self organizing Adaptive Counterintuitive Policy resistant Characterized by tradeoffs G.P. Richardson, August NIH Systems Dynamics Modeling symposium The Chain of Effect in Improving Health Care Quality Patient and Community Experience Aims (safe, effective, patientcentered, timely, efficient, equitable Microsystem Process Simple rules/design concepts (knowledge-based, customized, cooperative Organizational Context Facilitator of processes Design concepts (HR, IT, finance, leadership) Environmental Context Facilitator of facilitators Design concepts (financing, regulation, accreditation, education) Source: Institute for Healthcare Improvement 5

6 Strategies to Change Practice Patterns Common methods Education Feedback Practice guidelines Doctor Participation Administrative Rules Financial Incentives/Penalties Academic Detailing Quality Improvement Newer methods Problem based education or portfolio learning Breakthrough projects Risk management methods Business process redesign Leadership enhancement Shared decisions with patients If clinicians would only be educated about pain management, practice would improve Education only rarely changes behavior. Changes in organizational process must often be made to support practice changes in the clinical environment. Understand background factors lack of visibility lack of accountability absence of practical tools traditional outcomes of QA not useful Examine the context and process Max, Annals of Internal Medicine 1990; 113:

7 American Pain Society 1995 QI Guidelines for the Treatment of Acute and Cancer Pain I. Recognize and treat pain II. Make information about analgesics readily available III. Promise patients attentive analgesic care IV. Define explicit policies for use of advanced analgesic technologies V. Examine the process and outcomes of pain management with the goal of continuous improvement Max M et al., JAMA, (23): APS 2005 Recommendations for Improving the Quality of Acute and Cancer Pain Management All care settings should formulate structured, multi level systems approaches (sensitive to the type of pain, population served and setting of care) that ensure: 1. Prompt recognition and treatment of pain 2. Involvement of patients and families in the pain management plan 3. Improved treatment patterns 4. Regular reassessment and adjustment of the pain management plan as needed, and 5. Measurement of processes and outcomes of pain management. Gordon DB, et al. Archives of Internal Medicine 2005:165 QI Challenges in Pain Failure to define quality Lack of funding for quality research Inadequate implementation of QI activities Lack of physician involvement and leadership Gordon DB & Dahl JL, Pain 2004;107:1-4. 7

8 Misconceptions About Pain Care Quality High quality pain management means access to more or stronger analgesics Development of triage pathways to and development of available expert consultation resources is a solution to improving patient satisfaction We know the most safe and effective care processes or pathways 1999 Joint Commission Standards First evidence based standards Increase visibility and make pain a priority 5 th vital sign Unintended consequences 2015 update Petition to score nonpharmacological 8

9 The Pendulum of Opioid Therapy s Pain is Undertreated Marketing of ER Opioids Risk of addiction low Opioids are low risk Opioids are safe JC standards 2008-present Pain is overtreated? Addiction is high Opioids high risk The Problem a lack of appreciation of the capabilities of different disciplines, entrenched interprofessional conflicts, and inexperience in collaborating collegially makes team practice difficult... professional silos allow few opportunities for meaningful interaction and joint problem solving IOM (2011) p47 9

10 The Three Faces of Quality Measurement Research: to advance science, establish relationships Improvement: internal measures to understand processes and target improvements Accountability: external measures used for comparisons to make decision about purchasing health care Different definitions and measurement approaches are necessary for different purposes Pain QI Measurement Limitations Lack of precise or operational definition of quality pain management, the indicators, and measures Timing Perceptions vs. reality Interference of caring Little known about other possible indicators: quality across transitions, interprofessional teamwork Need translational research to help bridge gaps A 10 Year Review of Patient Satisfaction with Pain Management APS POQ 8 large US hospital/15 studies (n = 3,034) In all, satisfaction was consistently high Small, but significant negative correlations between pain intensity and satisfaction (.17, p<.05 to.47, p<.001) Most often cited reason was whether doctors and nurses were perceived to care about patients pain No relationship between expected or wanted pain levels and satisfaction Gordon DB et al, Pain Management Nursing 2002;3(4):

11 Patient Satisfaction Discussion Notoriously complex: based on patient expectations, beliefs, values, and sense of entitlement Almost always skewed to positive Because patient input into decision making critical, use questions about adequacy of information provided about pain and pain control options Predictive Validity Regression on Satisfaction in Revised APS POQ R Neither age nor gender predicted levels of satisfaction Significant predictors for satisfaction were: Higher pain relief (P<.001) Less time spent in severe pain (P=.03) Greater participation in pain treatment (P<.001) Lower severity for adverse effects (measured by the total sum of the 4 adverse effects to obtain a severity level) (P=.004) Gordon, DB et al, J Pain,2010;11(11), Pain Out: Correlates of Satisfaction 16,868 patients, wide range of procedures, age x = 55 yrs 42 clinical centers, 11 European countries + Israel, USA and Malaysia Median satisfaction 9 (interquartile 7 10) Higher satisfaction Greater % pain relief Higher allowance to participate in decisions No wish to have received more pain treatment Lower worst pain Less time spent in severe pain Less interference with sleep and emotions More drowsiness, less itch, less nausea Older age Higher chronic pain intensity prior to surgery Explained 35% variance Types of anesthesia and pain treatment techniques had no discernible impact Results consistent across centers and countries Schwenkglenks M et al, Pain,

12 The Cost of Satisfaction US CMS and NCQA require public reporting of satisfaction Prospective cohort ; N = 51,946 Satisfied patients had: Lower odds of ED visit Higher odds of inpatient admission Greater total expenditures Greater Rx drug expenditures 26% greater mortality risk [ahr] 1.26; 95% CI, , P =.02 Fenton JJ et al. Arch Intern Med 2012;172(5): The Other Cost of Patient Satisfaction JAMA 2012;307(13): Accountability: Performance Measures Primary purpose public reporting (external accountability) Rate based and reported as fractions or percentages of total number of eligible events Create market demand for systems with best performance scores (powerful drivers of healthcare choice) 12

13 US Medicare Hospital Compare Public Reporting Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys During this hospital stay, how often was your pain well controlled? During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? never, sometimes, usually, always Changing the Organizations that Deliver Care Redesign care based on best practices Use information technology to improve access to information and to support clinical decision making Improve workforce knowledge and skills Develop effective teams Coordinate care among services and settings Measure performance and outcomes The Big Challenge Transform health care to high reliability in patient safety with rates of adverse events and breakdowns in safety processes comparable to the best high reliability organizations in the world Dr. Mark Chassin, President, The Joint Commission 13

14 Systems Science to Improve Population Health Achieving optimal health for society lies in understanding of the factors identified by the behavioral, social, and public health sciences, not just the biological ones Tobacco, diabetes, mental illness, HIV/AIDs Advances in mathematical modeling, informatics, imaging, sensor technology, and communication tools have stimulated several converging trends in science Epigenomic regulation Population health behavior changes Improved scientific rigor in behavioral, social, and economic sciences Mabry PL et al, Am J Prev Med 2008;35(2S):S211 S224. Simulated Educational Interventions Deliberate exaggeration of 3 potential interventions 1. Prescriber 2. Medical User 3. Popularity Wakeland W et al, Health Education & Behavior 2013;40(IS) 74S-86S Today Preop Hypnosis to reduce catastrophizing Gabapentin 1200mg Acetaminophen 1gram Celecoxib 400mg Postop Ketamine IV lidocaine Ketorolac Gabapentin Acupuncture TENS DC Taper w/ monitoring 14

15 Conclusions Transformation in education, clinical care and reimbursement models are needed Need increased networks between public & private organizations, including health care providers, insurers, and people with pain and their advocates. Core patient reported outcomes Standardization is needed Measurement needs to be integrated into workflow and clinical feasible Appreciate reciprocal relationships: research, evidence based practice, and QI Quality is never an accident: It is always the result of high intention, sincere effort, intelligent direction, and skillful execution; It represents the wise choice of many alternatives Willa Foster 15