It stands to reason that fully understanding when and why providers under- or overprescribe opiate medications might assist in standardizing prescribing practices and also help bring the opioid epidemic to heel. However, most healthcare systems lack the tools to easily collect this information meaningfully.
Investigators at the University of California, Irvine (UCI) Medical Center have decided to address this issue head-on. They created a sophisticated electronic prescription accountability program that provides a full, fair picture of provider prescribing compared to traditional tracking methods. The approach facilitates peer-to-peer comparisons of prescribing practices and gives department leaders a helpful tool they can use to drive quality improvement.
The impetus for the program came from the recognition that many patients with addiction problems were coming through the ED. Health system leaders did not firmly grasp how much the institution might be contributing to the problem, explains Shalini Shah, MD, chief of the division of pain medicine and director of pain services at UCI Medical Center.
“How do we as an organization at UCI take accountability for the quality and outcomes of pain delivery to our patients?” Shah asks, recounting the kind of discussion in which clinical leaders were engaging before the program was developed. “We felt as an organization that we ought to take accountability in some ways for the opiates that are leaving our institution and going out into our community.”
An institutional pain committee was formed to discuss a solution. The panel was comprised of nurses, pharmacists, physicians, and the institution’s chief medical and nursing officers. After considerable debate, the group decided on a way forward. “The best way to change physician behavior is to actually show [providers] how they compare to their peers,” Shah explains. “Let’s create a dashboard that allows each physician to be compared to [his or her] peers.”
Fortunately, one committee member was a statistical analyst with a clinical background in pharmacy who noted that she could collect the appropriate data from the health system’s electronic medical record easily. After data collection, control for appropriate variables. That is how the dashboard and the electronic accountability program began to take shape, beginning in January 2019, Shah reports.
Control for Variables
Initially, the dashboard focused on reporting data for three specific groups within the healthcare system: emergency physicians, hospitalists, and primary care physicians. “We send these data to departmental chairs, and the data are anonymized,” explains Shah, noting that no specific physician names are attached.
However, say the department chair of emergency medicine sees there are one or two outliers regarding opioid use among all emergency physicians. If so, that department chair can request identifying information on these outliers. That way, these physicians can receive education or other resources intended to improve their opioid prescribing. Any intervention in this regard is up to the discretion of the specific department chair, Shah observes.
“We made it very clear to the institution and the physicians that this [accountability tool] is not meant to be punitive; it is not meant to poke holes at ... how they are practicing,” Shah stresses.
Rather, it is intended to inform the leaders of the three physician groups about how their providers are using opioids, on average, and to highlight opportunities for improvement with respect to any outlying physicians.
Even the institutional pain committee is blinded from any identifying information that is collected and reported, Shah notes. “We didn’t want people to gossip, leak information, or change their perception of each individual physician just based on opiate prescribing,” she explains. “The only person who has access to the de-identified information is our quality analyst, who does not do clinical care,” Shah says.
A key differentiating aspect of this approach is the fact that it controls for multiple variables. This creates a more accurate picture of a clinician’s prescribing compared to automatic dispensing machines, electronic prescribing databases, or even purchasing information, Shah observes.
“In the ED, sometimes you may be overburdened and see 30 patients in a day, but it doesn’t mean that your prescribing is higher [per patient] than a provider who saw five patients. We control for all of those variables,” she says. “You don’t really know as an institution where you are relative to your peers. This is why this type of accountability is a little bit different than what is out there right now.”
Bring Providers Aboard
Since the accountability program was implemented, it has been used regularly as a practice improvement tool for the three physician groups. “We present the data to our institutional quality oversight committee, which is led by our chief medical officer, [who then] reviews the completely blinded information,” Shah explains. “Then, we present to the different departmental chairs.”
However, Shah observes it is too early to conclude what results the approach has delivered. “We never captured these data previously. We don’t have a benchmark for comparison purposes,” she says.
Further, she notes other variables could be playing a role in prescribing practices, too. For instance, Shah notes new laws pertaining to opiate prescribing in the state could be curbing inappropriate or excessive opiate prescribing.
“We can’t say conclusively that [this program] has caused a decrease, but if you look at our institutional data, we do find that providers are satisfied with this type of accountability, and the institution is satisfied as well,” she says.
Also, Shah notes the program affords physicians a new opportunity to receive education in this area. Indeed, Shah views provider acceptance of the program as a big win in and of itself. She credits the way it was rolled out and explained to the clinicians. For example, the institutional pain committee made the case that regarding their opiate prescribing, physicians already are under the observation of payers, pharmacies, the state medical board, and the Drug Enforcement Administration. Thus, the accountability program would offer a layer of institutional protection.
“Why don’t we as an institution protect ourselves as peers ... [take steps] to practice homogenously as a group and minimize the outliers?” Shah asks. “That is how we sold it to the physicians.”
Because of this messaging, most physicians were on board once they were reassured the program would not assess their prescribing simply based on the number of prescriptions written. They were assured the analyses would control for the number of shifts worked, patients seen, and other variables. “We try to make it as across-the-board fair as possible. In that respect, the physicians have been very happy,” Shah reports.
While the accountability program is proprietary to UCI, there is no reason why other health systems cannot move in a similar direction to develop their own approaches to opiate prescribing. Meanwhile, Shah notes there are plans for continued fine-tuning of the approach and further expansion of the program’s reach to include surgeons.
“How much are surgeons prescribing when patients come in for surgery? What about mild surgery vs. moderate surgery or severe surgery? Is there a difference there in prescribing? How many outliers are there?” Shah asks. “That is the next [place] where we want to take this.”