Taking Action Against Opioids through Research and Best Practice

Transcription

1 Taking Action Against Opioids through Research and Best Practice Darshak Sanghavi MD, Chief Medical Officer, Optum Labs Molly Jeffery, PhD, Scientific Director of Emergency Care Research, Mayo Clinic March 9,

2 Conflict of Interest Darshak Sanghavi, MD Chief Medical Officer, OptumLabs Has no real or apparent conflicts of interest to report.

3 Conflict of Interest Molly Jeffery, PhD Scientific Director of Emergency Care Research Mayo Clinic Has no real or apparent conflicts of interest to report.

4 Agenda The Opioid crisis The Opioid Key Performance Indicator dashboard as an action framework Topics of Interest for this Audience what s most relevant + pressing? The role of quality measurement Developing the framework KPIs in 4 domains prevention, pain management, OUD treatment and maternal & child health Using administrative data to develop insights How opioid use has changed over time Where opioid use starts Risks in continuing to use opioids Impact of CDC guidelines on physicians prescribing behavior?

5 Our focus: the intersection of Opioid Crisis with the healthcare system UnitedHealth Group UnitedHealth Group = UnitedHeathcare + Optum UHG Opioid Taskforce enterprisewide commitment National claims database OptumLabs Data Warehouse (OLDW) includes de-identified longitudinal claims data for -- privately insured and Medicare Advantage enrollees (150M) All covered services across the continuum of care broader than a single provider organization s perspective Geographic variation Our focus today: the intersection of the opioid crisis with the healthcare system 5

6 The Opioid Key Performance Indicator Dashboard 6

7 THE PROBLEM The opioid epidemic is a complex, national crisis Opioid overdose is now the leading cause of accidental death in the U.S. 30,000 40, to ,000 60,000 64,000 died from drug overdoses in the U.S. in 2016 Peak car crash deaths (1972) Peak H.I.V. deaths (1995) Peak gun deaths (1993) Adapted from The Upshot, New York Times. Drug deaths in America are rising faster than ever June 5. it s also expensive $4.5B opioid use disorder (OUD) cost burden on UHG in $12,000+ cost of untreated OUD per UHC member per year and multi-faceted. 70+ different opioid initiatives across the enterprise. The epidemic touches every aspect of the health care system and impacts millions of people nationwide so does UHG. How can we align to be most effective? 7

8 Strong link versus weak link sports Strong Link Sport: Basketball Weak Link Sport: Soccer 8

9 But what about soccer can we explain this? 4-3 9

10 Quality measures A health care quality measure is a way to calculate whether and how often the health and health care system does what it should. 10

11 Measure development pathway 1 3 Average time from measure to conception to implementation years

12 OUR OPPORTUNITY Creating a tool to help fight the complex epidemic What if we could develop Key Performance Indicators that: Chronic pain management High risk populations + conditions Acute pain management Alternative pain treatments Benchmark where we are Set targets for driving action Measure results Influence public health in the many places we need to impact? Opioid prescribing CDC Guideline Compliance Opioid epidemic Incidence + prevalence indicators Opioids and maternal and infant health EBM treatment for OUD and OD Prescribing in children and adolescents 12

13 AN ACTIONABLE DASHBOARD Development of 29 key performance indicators Claims data-driven, comprehensive set of opioid metrics KPIs were developed in four domains that address the opioid epidemic: OptumLabs convened diverse experts to develop 29 claims-based measures that look at the many facets of the opioid crisis. Prevention Pain management KPIs enable UHC and Optum benchmarking, target setting, and performance evaluation. OptumLabs county-level data and visualizations reveal striking geographic variation in the U.S. KPIs support the Optum/UHG Opioid Taskforce to drive an enterprise-wide response the opioid crisis. Opioid use disorder (OUD) treatment Maternal and child health Metrics have been shared via Health Affairs in support of public health 2017 Optum, Inc. All Rights Reserved. 13

14 Opioids and pain management: Expert advisory panel Co- Chairs Opioid Use Disorder and Prevention Thomas McLellan, PhD Chair of the Board, Treatment Research Institute (TRI) and Professor Emeritus of Psychology, University of Pennsylvania School of Medicine. Former Deputy Director of the White House Office of National Drug Control Policy under President Barack Obama Pain Management Mark Wallace, MD Professor of Clinical Anesthesiology, Chair Division of Pain Medicine, University of California, San Diego Medical Center. Member of the CDC Prescribing Opioids for Chronic Pain Workgroup that issued the 2016 guidelines Area of Expertise First Last Institution Substance Use Disorder Yngvild Olson, MD Board, American Society of Addiction Medicine (ASAM); clinician Integrative Medicine Bob Saper, MD Boston University School of Medicine and Public Health Policy and HEOR Kun Zhang, PhD Center for Disease Control and Prevention, Prescription Drug Overdose Health Systems Team HEOR, Nonmedical Determinants Ellen Meara, PhD Dartmouth College Psychiatry, Substance Abuse Joji Suzuki, MD Harvard Medical School; Brigham and Women s Hospital Pain Mgmt, Anesthesiology, Back Pain Paul Christo, MD Johns Hopkins University Pain Management/Anesthesiology and Psychiatry Michael Hooten, MD Mayo Clinic HEOR Molly Jeffery, PhD Mayo Clinic Policy Audra Stock, LPC, MAC Substance Abuse and Mental Health Services Administration (SAMHSA) Physical Therapy Julie Mae Fritz, PT, PhD University of Utah Health Services Gary Franklin, MD University of Washington Policy Don Schwarz, MD RWJF Neonatal/Perinatal Medicine Munish Gupta, MD Harvard Medical School; Beth Israel Deaconess Medical Center 2017 Optum, Inc. All Rights Reserved. 14

15 The Opioid Dashboard KPIs Domain areas Primary outcome measures Secondary process measures Prevention Pain Management New opioid fillers per 1000 enrollees Initial opioid prescription compliant with CDC recommendations New opioid fillers who avoid chronic use Prevalence of opioid overdose (OD) Chronic pain treatment with opioids is well managed Post-surgical pain is well managed Initial opioid prescription is prescribed while patient is not exposed to benzodiazepines Initial prescription is not for methadone Initial opioid prescription is for short acting formulation Initial opioid prescription is for <50MME/day Initial opioid prescription is for <=7 days supply No use of opioids for new low back pain patients No concurrent opioid and benzo use Appropriate contact before second opioid prescription Appropriate contact with provider among chronic opioid users No ER visit for breakthrough pain among chronic opioid users Evidence of non-opioid pharmacological treatment for pain Evidence of non-pharmacological therapy for pain OUD Treatment Maternal, Infant, & Child Health Evidence of medication-assisted treatment (MAT) among patients with OUD or OD Prevalence of opioid use disorder (OUD) Percentage of infants with NAS born to mothers on MAT Initial opioid prescription compliant with CDC recommendations for patients under 18y age Prevalence of OD in patients <18y age Evidence of MAT following OD No opioid prescription following MAT initiation Evidence of naloxone fill among patients with OUD or OD No opioid prescription following any OUD or OD Dx Rate per 1,000 births of infants born with neonatal abstinence syndrome (NAS) New opioid filler per 1000 enrollees under 18y age Prevalence of OUD in patients under 18y age 2017 Optum, Inc. All Rights Reserved. 15

16 Opioid KPI Dashboard: Outcome Measures (2016) Last data update 7/20/2017; Claims complete until 04/ Optum, Inc. All Rights Reserved.

17 Opioid Dashboard: Key performance metrics Domain areas Primary outcome measures 2016 Secondary process measures 2016 New opioid fillers per 1000 enrollees 122 Initial opioid prescription is prescribed while patient is not exposed to benzodiazepines* 91.1% Initial prescription is not for methadone* 100.0% Initial opioid prescription compliant with CDC 55.4% recommendations (composite) Initial opioid prescription is for short acting formulation* 99.6% Prevention Initial opioid prescription is for <50MME/day* 77.2% Initial opioid prescription is for <=7 days supply* 79.7% Pain Management Opioid Use Disorder (OUD) Treatment Maternal, Infant, & Child Health New opioid fillers who avoid chronic use 97.9% No use of opioids for new low back pain patients 87.1% Prevalence of opioid overdose (OD) per 100,000 enrollees 35.9 No concurrent opioid and benzodiazepine use 78.0% Appropriate contact before second opioid prescription 54.0% Chronic pain treatment with opioids is optimally managed (composite) Avoidance of breakthrough post-surgical pain leading to ED visit and new opioid prescription Evidence of medication-assisted treatment (MAT) among patients with OUD or OD 9.4% 95.3% Appropriate contact with provider among chronic opioid users** 95.1% No ED visit for breakthrough pain among chronic opioid users** 85.3% Evidence of non-opioid pharmacological treatment for pain among chronic opioid users** Evidence of non-pharmacological therapy for pain among chronic opioid users** % 23.8% 27.8% Evidence of MAT following OD 10.8% Prevalence of opioid use disorder per 1000 person years 7.97 No opioid prescription following MAT initiation 79.7% Percentage of infants with NAS born to mothers on MAT 20.6% Initial opioid prescription compliant with CDC recommendations for patients under 18y age (composite) Prevalence of OD per 100,000 person years in patients under 18y age 2017 Optum, Inc. All Rights Reserved. Evidence of naloxone fill among patients with OUD or OD 0.73% No opioid prescription following any OUD or OD Dx 41.0% Rate per 1,000 births of infants born with neonatal abstinence syndrome (NAS) % New opioid filler per 1000 enrollees under 18y age Prevalence of OUD per 1000 person years in patients under 18y age 0.21 *Composite measures for: Initial opioid prescription compliant with CDC recommendations **Composite measures for: Chronic pain treatment with opioids is optimally managed

18 We see wide variability across the U.S. New opioid fillers per 1000 enrollees, by county, 2016 (blue = better performance) Bin 2017 Optum, Inc. All Rights Reserved. 18

19 KPIs show wide variation, suggesting opportunities for significant improvement New Opioid fills per 1,000 enrollees at the county level, Optum, Inc. All Rights Reserved. 19

20 County Level Variation: % of 1 st Fills Noncompliant with CDC Guidelines, at the County Level Percent of new opioid fills not compliant with CDC guidelines, Optum, Inc. All Rights Reserved. 20

21 Measuring compliance with the CDC prescribing guidelines (2016) OUTCOME MEASURE PROCESS MEASURES 99.6% Initial opioid prescription is for short acting formulation 55.4% Initial opioid prescription compliant with CDC recommendations 77.2% Initial opioid prescription is for <50MME/day 79.7% Initial opioid prescription is for <=7 days supply 78.0% No concurrent opioid and benzodiazepine use 100% Initial prescription is not for methadone 2017 Optum, Inc. All Rights Reserved. 21

22 North Carolina: Initial opioid Rx is compliant with CDC recommendations, by county, 2016 (blue = better performance) 2017 Optum, Inc. All Rights Reserved. 22

23 North Carolina: Initial opioid Rx is for < 50 MME/day, by county, 2016 (blue = better performance) 2017 Optum, Inc. All Rights Reserved. 23

24 North Carolina: Initial opioid Rx is for < 7 days supply, by county, 2016 (blue = better performance) 24

25 Additional prescribing indicators (2016) OUTCOME MEASURES PROCESS MEASURES 122 New opioid fillers per 1,000 enrollees 87.1% No use of opioids for new low back pain patients 97.9% New opioid fillers who avoid chronic use 78.0% No concurrent opioid and benzodiazepine use 35.9 Prevalence of opioid overdose (OD) per 100,000 person-years 54.0% Appropriate contact with provider before second opioid prescription 2017 Optum, Inc. All Rights Reserved. 25

26 Measuring compliance with the CDC prescribing guidelines (2016) OUTCOME MEASURE PROCESS MEASURES 95.1% Appropriate contact with provider among chronic opioid users 9.4% Chronic pain treatment with opioids is optimally managed 45.9%* Evidence of non-opioid pharmacological treatment for pain among chronic opioid users 23.8%* Evidence of non-pharmacological therapy for pain among chronic opioid users 85.3% No ED visit for breakthrough pain among chronic opioid users *Subject to the limitations of claims data 2017 Optum, Inc. All Rights Reserved. 26

27 Aiming to measure post-surgical pain management (2016) OUTCOME MEASURES PROCESS MEASURES 95.3% Avoidance of breakthrough post-surgical pain leading to ED visit and new opioid prescription We are currently working on a research project led by UCSF in Post-surgical prescribing that may reveal significant opportunity here 2017 Optum, Inc. All Rights Reserved. 27

28 Looking at access to treatment and prevalence of OUD OUTCOME MEASURES PROCESS MEASURES 27.8% Evidence of medicationassisted treatment (MAT) among patients with OUD or OD 10.8% Evidence of MAT following Overdose 8 Prevalence of OUD per 1,000 person years* 41.0% No opioid prescription following any OUD or OD diagnosis *subject to the limitations of claims data 0.7% Evidence of naloxone fill among patients with OUD or OD 2017 Optum, Inc. All Rights Reserved. 28

29 MAT among patients with OUD, by county, 2016 (blue = better performance) Bin 2017 Optum, Inc. All Rights Reserved. 29

30 Maternal & Child Health Measures: Neonatal Abstinence Syndrome (NAS): Seeking better outcomes for mothers and babies* OUTCOME MEASURE PROCESS MEASURES 20.6% 1.2 Cases per 1,000 live births of infants born with NAS Percentage of infants with NAS born to mothers on MAT** **MAT = buprenorphine, methadone and naltrexone *Commercially insured members only (does not include Medicaid) 2017 Optum, Inc. All Rights Reserved. 30

31 Maternal & Child Health : Other Measures OUTCOME MEASURE Opioid prescribing in children and adolescents (<=18 years)* ADDITIONAL PROCESS MEASURES 36 New opioid filler per 1000 enrollees under 18y age 68.6% Initial opioid prescription compliant with CDC recommendations for patients under 18y age * Prevalence of OD per 100,000 person-years under 18y age Prevalence of OUD per 1000 person-years under 18y age *Commercially insured members only (does not include Medicaid) *Note: CDC Guidelines are recommendations for adults over 18 years. These were used as a gauge of pediatric prescribing issues Optum, Inc. All Rights Reserved. 31

32 Sharing the Opioid KPIs with the health care ecosystem 32

33 KPI translation potential for broad impact Exploring enterprise and national Opioid KPI and research opportunities ENTERPRISE PRODUCT INTEGRATION POTENTIAL POLICY AND NATIONAL INFLUENCE Optum Analytics Common Capabilities (ACC) for population management use Optum Performance Analytics products UnitedHealthcare Community & State (Medicaid) population Optum Behavioral Health benefit design influence OptumRx management (KPI alignment) Comprehensive Opioid Metrics Health Affairs Blog post FDA/CERSI grant (examine Long acting opioid prescribing using NLP) NCQA: learning collaborative for health plan quality improvement PQA: performance measures aligned with CDC recommendations Centers for Medicare and Medicaid: leveraging KPIs for quality monitoring and improvement NIDA and CDC: briefings and potential collaboration 2017 Optum, Inc. All Rights Reserved. 33

34 About the OptumLabs Data The OptumLabs Data Warehouse (OLDW) is a comprehensive, longitudinal, real-world data asset with de-identified lives across claims and clinical information. The Opioid KPI metrics were developed via retrospective analysis of over 125 million de-identified lives of claims data from the OLDW. This includes de-identified claims for privately insured and Medicare Advantage enrollees in a large, private, U.S. health plan. The database contains longitudinal health information on enrollees, representing a diverse mixture of ages, ethnicities and geographical regions across the United States. The health plan provides comprehensive full insurance coverage for physician, hospital, and prescription drug services. 34

35 Section Title Goes Here Multiple Lines Possible Third Line Here Using administrative data to gain new insights into the opioid epidemic 35

36 Questions we set out to answer With the amount of attention paid to the opioid epidemic, how has opioid use changed over time? Where does opioid use start? What s the risk of continuing to use opioids? Can we change physicians prescribing behavior? 36

37 Adjusted quarterly use prevalence 37

38 Concentration in chronic episodes 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 89% 62% 70% 3% 7% 14% Episodes MME Episodes MME Episodes MME Commercial Aged Medicare Disabled Medicare Acute Chronic

39 Source of first fill 39

40 Prescription more than 7 days Disabled Medicare Not ED ED 4% 43% Aged Medicare Not ED ED 5% 37% Commercial Not ED ED 3% 19% 0% 10% 20% 30% 40% 50%

41 Prescription more than 50 MME per day Disabled Medicare Not ED ED 14% 18% Aged Medicare Not ED ED 13% 18% Commercial Not ED ED 14% 23% 0% 5% 10% 15% 20% 25%

42 Long term use (10+ fills or 120+ days supply) Disabled Medicare Not ED ED 6% 15% Aged Medicare Not ED ED 3% 7% Commercial Not ED ED 1% 2% 0% 2% 4% 6% 8% 10% 12% 14% 16% 42

43 From data to practice improvement Opioid naïve adults (N=7,651) 25 common elective procedures (5 presented today)

44 Post-surgery prescribing Mayo Clinic 2013 to max %ile MME Lump Ing Hernia Lap LAR Hip Knee 25 %ile min 44

45 Follow-up survey: how many left? (Cornelius Thiels, MD, MBA) Lump Ing Hernia Lap LAR used remaining Hip Knee MME 45

46 New ortho prescribing guideline (excerpt) Level Max MME Example conditions Acute fracture Carpal tunnel Knee scope ACL recon Shoulder scope Minor spine Total Hip/knee/ shoulder Major spine Tabs hydrocodone (5mg) Tabs oxycodone (5mg) Tabs oxy 5 mg + tramadol 50 mg oxy 8 tram oxy 15 tram oxy 20 tram oxy 25 tram 40 46

47 Impact of new guideline (Wyles, Mabry, et al.) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Discharge prescriptions >400 MME No change in refill requests Pre 1 2 Pre 1 2 Knee Hip The complete manuscript of this study and its presentation at the American Surgical Association's 138th Annual Meeting, April 2018, in Phoenix, Arizona, is anticipated to be published in the Annals of Surgery pending editorial review. 47

48 Thank You Contact: 48