Overview

Physicians created a set of opioid prescription guidelines, reference tools, and provider education opportunities for ambulatory settings across specialties based on analysis of provider prescription trends to decrease high-risk opioid prescription patterns.

Organization Name

NewYork-Presbyterian

Organization Type

• Academic Hospital

National/Policy Context

• Almost 1,500 people in New York City died of a drug overdose in 2017.
• At NewYork-Presbyterian Hospital, emergency department visits for opioid use disorder more than doubled between 2015 and 2017.
• Patients with acute and chronic pain who fill high-dose opioid prescriptions are at higher risk for opioid dependence than those that fill low-dose prescriptions.
• There was no single unifying set of guidelines for opioid prescription, as there are separate guidelines from the state of New York, specialty societies, and the Center for Disease Control.
• Several factors contributed to the ability of NewYork-Presbyterian Medical Groups to implement this intervention:
  • A unifying electronic medical record was implemented across all regions of the medical group, allowing for tracking of physicians’ prescription patterns.
  • In March 2016, electronic prescribing of opioids became mandatory for standardization of monitoring prescriptions, allowing for better prescription tracking.
• The surgeon general wrote a letter calling medical professionals to work to turn the tide on the opioid epidemic

Local/Organizational Context

• Physicians from different practices in NewYork-Presbyterian Medical Groups agreed to provide insight during the development of the opioid prescription best practices.

Patient Population Served and Payor Information

• New York-Presbyterian Medical Groups is a healthcare organization in the New York City metropolitan area, with locations in Hudson Valley, Westchester, Queens, and Brooklyn. It employs over 800 doctors and 300 other medical professionals.
• Medicare contributes to 31% of NewYork-Presbyterian’s revenue, while Medicaid contributes to 28% of the organization’s revenue.

Leadership

• Dr. Dalal was medical director for physician services at the time and was leading the effort to standardize opioid best practices.

Research + Planning

• A set of guidelines and materials were developed prior to implementation of this intervention. The guidelines were heavily influenced by 2016 CDC recommendations and those from other specialty societies. Dr. Dalal worked with primary care physician champions and determined what should be included in the guidelines. The guidelines underwent iterative revisions with input from members of the physician leadership.

Tools or Products Developed

• The innovators created standardized best practices for opioid prescriptions in the ambulatory setting by seeking the input of clinical leaders across the medical groups. The resulting guidelines included only a subset of important recommendations. It was decided that if the guidelines were to be adopted, they should be easy to remember, non-controversial, and high impact.
• The guidelines included:
  • In general, do not prescribe opioids as first-line treatment for chronic pain (excluding active cancer, palliative care, or end-of-life care). Before prescribing opioids, consider non-opioid therapies such as NSAIDs, tricyclics, SNRIs, topical agents, exercise, physical therapy, or cognitive behavioral therapy. If opioids are required, they should be combined with non-opioid therapy, as appropriate.
  • For Schedule II-IV controlled substances, the New York State Prescription Monitoring Program (PMP) website must be reviewed. Providers must review the patient’s prescription history for evidence of similar medications prescribed by other providers during the past 6 months.
    For the purposes of these guidelines, all opioid prescriptions will be evaluated as morphine milligram equivalents (MME) per day.
    The opioid strength of each medication unit (e.g. tablet, milliliter, patch) will be converted to the equivalent dosage in milligrams of morphine, which will be multiplied by the number of units dispensed and divided by the duration of the prescription (e.g., 30 days).
    Opioid prescription dosages will be classified as Level 1, 2, and 3 as follows:
    • Level 1: 0–49 morphine milligram equivalents/day
    • Level 2: 50–89 MME/day
    • Level 3: Over 90 MME/day
  • Patients receiving Level 2 and 3 opioid prescriptions should receive in-person follow-up every 3 months. Patients without an upcoming appointment should be scheduled.
  • Level 3 prescriptions should be avoided when possible. Consider pain management consultation for patients requiring Level 3 opioid prescriptions.
  • Patients on chronic opioid therapy (> 3 months) should be encouraged to review and sign a controlled substances agreement. The agreement details the responsibilities of the patient and prescriber with respect to controlled substances and is signed by both parties. The agreement establishes the need for a single prescriber of opioids for the patient, regular follow up, and limits on early refills. The patient also agrees not to sell or transfer the medications and to store the medication securely.
  • Concurrent prescription of opioids and benzodiazepines should be avoided whenever possible. Both drug classes are central nervous system depressants, and combined usage greatly increases the risk of respiratory collapse, hospitalization, and death. Clinical rationale for each controlled substance prescription must be documented clearly. Each prescription must be accurately linked to the appropriate diagnosis in the clinical note, patient case, or order group.
  • Clinical rationale for each controlled substance prescription must be documented clearly. Each prescription must be accurately linked to the appropriate diagnosis in the clinical note, patient case, or order group.

• A decision aid was created to help clinicians calculate the morphine milligram equivalents for commonly prescribed opioid medications.

Training

• The intervention was discussed at town halls, internal medicine monthly meetings, quality steering committee meetings, and in email blasts to providers with summary of recommendations and reference chart.

Tech Involved

• Dashboard
• SQL
• Athena
• Email

Team Members Involved

• Administrator
• Data Analyst
• Physicians

Workflow Steps

• The guidelines (described above) were distributed in PDF format and via emails. The reference charts were printed out and placed in outpatient work rooms.
• Based on electronic medical record prescription data, a document with individual providers’ prescribing patterns was generated. Physicians were able to see how they were performing relative to the average of their peers. Internal chart reviews were performed to determine if there was opportunity for further coaching or education.
  • Emails were initially sent monthly. Intervals were increased to quarterly for physicians with target opioid prescription patterns, and intervals were decreased to weekly for physicians not meeting target patterns.
• Those physicians with outlying and unchanging opioid prescription patterns were contacted by Dr. Dalal or a local physician leader. Necessary action was taken in order to ensure improvement in prescription patterns.

Budget Details

• Time spent by Dr. Dalal and physician champions in implementation
• Time spent by analytics resources to capture data and build a Tableau dashboard

Where We Are

• The intervention was implemented in 2017. It is currently ongoing.

Outcomes

• Between January and September 2017, there was a 24% decrease in total morphine equivalents prescribed per patient managed across all specialties. Overall, there were fewer concomitant opioid and benzodiazepine prescriptions.
• Between January and September 2017, the number of referrals for pain management consultation nearly doubled.

Future Outcomes

• Other process outcomes: screening for substance use disorder in the office, prescribing naloxone for those at increased risk for overdose.
• Long-term prevention metrics: prevention of substance used disorder, prevention of overdoses and deaths, prevention of diversion events.
• Expansion into other care domains: Emergency department, inpatient care.

Benefits

• There is now greater clarity across the physician organization regarding controlled substance prescriptions and management of chronic pain.
• The intervention brought awareness to prescribing habits and the importance of clear clinical documentation. The innovators established methods to systematically identify providers who need improvement, allowing for targeted intervention and change.
• This work provided an example of how to use EHR data to improve quality of care. It has set the groundwork for additional work around monitoring practice patterns (ex. heart failure medications, anti-coagulation meds for atrial fibrillation) to improve quality of care.

Unique Challenges

• Prioritizing certain guidelines that will have the greatest potential impact on outcomes.
• A few providers were slower to change their prescribing practices until prescribing data was reviewed with them.
• Providing the feedback to doctors who were outliers was difficult. It can be hard to question clinical judgment. Some physicians were resistant to the feedback and were uneasy changing their opioid prescription patterns. To ameliorate these issues, the project leadership emailed the physician and/or spoke with the physicians in person, sometimes with the local medical director. One physician divested of pain management patients due to unwillingness to change opioid prescription patterns.