Quality assurance and quality improvement of chronic nonmalignant

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1 Quality assurance and quality improvement of chronic nonmalignant pain management: Indicators as a primary care quality tool July 2015

2 Dr Roshan Perera and Dr Helen Moriarty University of Otago Wellington. July 2015

3 Public health burden Impact and importance of chronic non-malignant pain Social justice impacts vs socioeconomic, employment, social welfare Personal health and mental health complications Pressure on health and social welfare systems July 2015

4 Health implications of chronic non-malignant pain Aging population with chronic conditions comorbidity Tail burden on ACC and other services Difficult nature of chronic pain patients Resistant to non-prescription approaches: Nothing else works Pain patients often embrace additional pain control, but not as keen to stop using them. July 2015

5 Importance of prescription drug misuse (1) National and international concern. Escalating use of prescription opioids for chronic non-malignant pain, world-wide. Public health burden - cost of Rx, accidental or non-accidental overdose, injuries under the influence, addiction, illicit use, diversion. Personal health burden iatrogenic dependence, comorbidity incl. mental health problems, opiate-induced hyperalgesia, opiate induced osteoporosis, opiate bowel syndrome, withdrawal syndromes, stand-over tactics. July 2015

6 From BPJ issue 62 page 22 Figure 1: Number of oxycodone and morphine prescriptions dispensed (excluding injected preparations). 5 July 2015

7 Importance of prescription drug misuse (2) Combined Australasian College strategy document (2009)* Law Commission review of Misuse of Drugs Act (2011)^ Amenable to quality and safety activities wr to - prescribing and dispensing; patient instruction and education; and patient monitoring. *Improvement of prescribing a significant patient safety issue. *The Royal Australasian College of Physicians. Prescription Opioid Policy: Improving management of chronic nonmalignant pain and prevention of problems associated with prescription opioid use,. Sydney ^ _controlling_and_regulating_drugs.pdf July 2015

8 Importance of using quality indicators To better know what we are doing To be reassured that it is correct practice To make efforts on improving practices To benchmark against others and learn from their good practices To commit to continuing quality improvement, not static or one-off July 2015

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14 Overview of Indicator Development Chronic Pain and ImPaCT projects The Indicator Suites Piloting and Future plans July 2015

15 The Chronic Pain Project Funded by HQSC Literature review Review of existing international indicators Analysis of existing indicators using SIAT (see below) Recommendation of indicators to HQSC Work now up on HQSC website July 2015

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20 Role of Sieve Indicator Appraisal Tool (SIAT) Tool for Indicator appraisal* Identifies all important aspects of Indicators Provides parameters for classifying Indicators Classification System aids appropriate Indicators selection for successful implementation in any health context. Results: Few existing indicators for opiate prescribing for CNMP were sufficiently developed for SIAT assessment *Perera R, Dowell T, Crampton P, Kearns R. Panning for gold: An evidence -based tool for assessment of performance indicators in primary health care. Health Policy. 2007;80(2):

21 Ground-up vs top down approach Points of difference Empirical data for indicator selection not always readily available Often top-down approaches, using expert consensus Research had explicit intention of identifying areas suitable for indicator development Relevance: addresses areas identified as important by stakeholders Engages field workers and end-users Stakeholder ownership and confidence Measure what matters July 2015

22 Strength-based approach: Builds on existing quality efforts Purposively constructed Take into account the feasibility of routine data collection and collation in community settings Fit for purpose Organised and linked functionally rather than theoretically Applicable for assessment of quality of care provision across a variety of settings July 2015

23 Indicator topics Topics derived from the identified clinical challenges Accuracy in documentation of pain syndrome Documentation of medication indications/ contraindications Risk profiling for medication misuse/other comorbidities Safe and effective pain management Monitoring medication use and abuse Appropriate numerators & denominators and clinical caveats July 2015

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25 Why indicator suites Indicators focus on discrete areas (pin-pricks of light) Clusters of related indicators provide a wider beam of illumination onto a particular aspect of care Enables comprehensive review of the aspect of care in question July 2015

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27 Example: Avoiding controlled drug misuse Addresses need for: Monitoring of compliance with opioids; possible diversion and potential abuse for high risk patients; Optimal management of high risk patients incl. risk documentation; risk f/up; and identification of worsening risk Appropriate use and interpretation of urine tests 3 Indicators: 1) Documented A&D risk assessment in the past 3 months 2) Documented baseline urine monitoring on 1 st presentation 3) Additional urine test within 3 months of 1 st presentation Denominator: Patients with chronic pain and a drug or alcohol past history.

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29 A greater truth? Consistent with the international literature Improved communication and capacity building Clear definition of roles/responsibilities/lines of reporting Tech skills and holistic care Ready access to specialist advice Consistent with the consensus indicators and outcome measures developed by other means Synergy in topic areas across the various approaches taken potentially suggests a greater truth evident July 2015

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32 So What? Comparison of care provision & benchmarking standards of care across service delivery settings, to: Compare current care to aspirational statements Identify gaps in quality/ safety/ equity of access Investigate extent and impact of variability in service provision Foster improvement initiatives and inform change Foster a quality culture: feasibility and benefits of routine use Pilot to gather data to enable target setting July 2015

33 Piloting the indicators Medical student summer project, implemented some example indicators Eg opiates and bowel management indicator Piloted in the palliative care setting (see our ImPaCT presentation) cf chronic pain setting. Key drivers to use are: staff involvement, quality of communication and documentation, shared sense of important and commitment to QA. July 2015

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