9/17/2018. Capstone Committee Chair Dr. Brenda Cassidy, DNP, RN, PCNP-PC Assistant Professor Health Promotion and Development

Transcription

1 Evaluating Emergency Department Opioid Prescribing Behaviors after Education about Mandated Use of the Pennsylvania Prescription Drug Monitoring Program Jennifer Martello, DNP, RN, FNP-BC University of Pittsburgh School of Nursing Capstone Committee Chair Dr. Brenda Cassidy, DNP, RN, PCNP-PC Assistant Professor Health Promotion and Development University of Pittsburgh School of Nursing Capstone Committee Member Dr. Ann Mitchell, PhD, RN, AHN-BC, FIAAN, FAAN Professor Health and Community Systems University of Pittsburgh School of Nursing 1

2 Background National Statistics Source: 1 Source: 2 2

3 Age-adjusted rates of drug overdose deaths by state, US 2016 Legend 6.9 to to to to to to 52.0 Source: 1 Pennsylvania Statistics, 2016 In 2016, 4,642 residents died from opioid overdose Thirteen Pennsylvanians per day PA overdose death rate is higher than national average (38 vs. 20 per 100,000 population) Source: 2 Lawrence County Statistics Source: 2 3

4 Patients (aged yrs.) in ED with CC pain, % Patients w/ CC Pain Total Patients Seen % Pennsylvania s New Opioid Laws Source: 3 CLINICAL MANDATE Source: 3 4

5 Prescription Drug Monitoring Programs [PDMPs] State-based electronic databases that contain information on controlled substance prescriptions dispensed by pharmacies and prescribers Goal: Help reduce misuse and diversion of controlled substances, including prescription opioids Source: 4 PDMP Who can access Prescribers Pharmacists Researchers Health insurers Medical licensing boards Law enforcement agencies What is monitored Controlled substance use by patients Prescribing practices of medical practitioners Population-level drug use trends Source: 4 UPMC Initiatives to Support the Mandate EpicCare Tools to Support Compliance with New PA Opioid Laws NetAccess Navigator added screenshot of the web link to the PA PDMP under the medication reconciliation tab Guidelines issued for improving pain management orders OAPP gathering data regarding prescriber comments/observations about PDMPs strengths, weaknesses, areas for improvement to share with state officials Centers of Excellence (COE) 5

6 Literature Review PDMP Effectiveness Identifying and reducing doctor shopping Impact on controlled substance availability and prescribing Association with improved health outcomes Reducing drug and medical costs related to inappropriate prescribing Monitoring compliance and abstinence Assisting in substance abuse treatment Assisting in drug misuse prevention and surveillance efforts Physicians express support for PDMPs Investigators find PDMPs an invaluable resource Source : 4 PDMP State Successes Source: 4 6

7 Review of the Literature Post-activity knowledge significantly improved (p<.001) 5 Knowledge of the PDMP and the main themes of the initiative significantly increased (p<.001) from pre- to post-test results 6 Common barriers to PDMP use included not knowing about the program, registration difficulties and data access difficulties 7 Outcome Provider Behavior *Low Study Design Descriptive /before-after Systematic Review Number of Studies Findings 7 Improved provider confidence or knowledge (Elhwairis and Reznich,2010) Limited adoption of select safe opioid prescribing practices (Cozier et al.,2010), (Srivastava et al.,2012; Ury et al.,2002; Young et al.,2012) Decrease in/lower risky opioid prescribing behavior (Gugelmann et al.,2013;hoffman et al.,2003) Time series 2 Little to no change in opioid prescribing practices (Kahan et al.,2013) Improved provider knowledge (Lofwall et al.,2011) Change in safe opioid prescribing behavior (Lofwall et al.,2011) RCT 1 Limited adoption of select safe opioid prescribing practices (Corson et al.,2011) Source: 8 Purpose Statement The purpose of this project was to evaluate opioid prescribing behaviors in an emergency department after an education program about the mandated use of the Pennsylvania Prescription Drug Monitoring Program. 7

8 Specific Aims Primary aim was to support the recent PA PDMP mandate by educating emergency department prescribers regarding the intended impact of the mandate on the opioid epidemic. Secondary aims were to evaluate staff knowledge and identify barriers to consistent use of the PA PDMP. Methods SETTING 30-Bed level 3 trauma Emergency Department within an academic facility This ED treats an average of 3,200 patients per month Approximately 25% of those patients present to ED with CC of PAIN 8

9 SAMPLE Enrollment All patients aged years old with CC Pain discharged from the ED Project Time Period 19 months Our Providers Procedures 9

10 19 months 4 months 6 months 9 months Phase One July 25, October 26, 2016 PA PDMP Mandate Launch (August 25, 2016) Informal intervention to ensure all computers in workspace are set up with PA PDMP link on desktop. Informal discussion regarding opioid epidemic, mandate, prescribers perceptions of usefulness and barriers to use Informal demonstration to all ED providers regarding PA PDMP link, how to register, access website, login and perform patient search Brief instructional posted in workspace 4 Phase Two November 1, 2016 April 30, 2017 Tools Development Chart Audit Tool 9 Pre- and Post-Knowledge Test 1,4 Formal Education Program 1,4 Validity Testing Expert Review for content validity Piloting for face validity Implementation Pre-Knowledge Test Formal Learning Program Post- Knowledge Test 10

11 Method: Formal Education Goal: 100% Participation PowerPoint Presentation 1,3 Themes The opioid epidemic PA PDMP mandate Access to PDMP PDMP goals and intent Phase Three May 1, 2017 January 30, 2018 Data Collection- Four Time Periods Pre PDMP Post PDMP/ Informal Intervention Pre Education Program Post Education Program Data Analysis- IBM SPSS Statistics 25 Descriptive Statistics Paired t test Cross-tabulated Chi-square test Fisher s Exact Test Results 11

12 Comparison of pre- and post-knowledge survey mean total score Increase in Mean Total Score Pre-Formal Knowledge Program Post-Formal Knowledge Program Mean Total Score N = 11 p =.000 Question 9: Barriers to Consistent PDMP Use I have not registered yet 1 1 It is difficult (or I don t know how) to access the web page, log in, and/or do a patient search Pre 4 4 I see no benefit to the PA PDMP when prescribing pain medications in the ER 0 2 I don t have time to do it 6 5 Other: 2 0 I resent being mandated to input clerical data rather than have it available as a resource Forced password changes Total Post Prescribing patterns, by time period during program Total Patients Seen Total Rx Written Narcotic Rx Written Pre PDMP Post PDMP/ Informal Intervention Pre EducationProgram Post EducationProgram 12

13 Percentage change in opioid prescription rates between time periods 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 21.5% 21.7% 13.3% 16.1% p = % Pre PDMP Post PDMP/ Informal Intervention Pre Education Program Post Education Program Discussion Limitations Threat to Internal Validity UPMC Jameson ER experienced a change in EHR systems June 3, 2017 Measurement Outcomes Unable to obtain data on PDMP use and prescription details (quantity, dose) Difficulty accessing patient records in MedHost 13

14 Discussion An Education Program National opioid epidemic PA PDMP Mandate PA PDMP intended impact on opioid epidemic Use PDMP to access patient records Increased provider knowledge (p =.000) Decreased opioid prescriptions written (p =.002) Future Possibilities To Promote Sustainability ulearn Module Individualized based on practice setting (primary care, emergency, inpatient, etc.) To Promote Consistent Use of the PDMP Link patient s PDMP record to patient s EHR Variables of Interest Evaluate individual provider prescribing behaviors Identify trends, set benchmarks Identify patients at risk for opioid misuse Begin MAT (medication assisted treatment) in ER provide counseling/referral information for rehab services prescribe non-medical pain management therapies Evaluate barriers identified and impact on prescribing behaviors What s New Sustainability Annual Education Mandates Consistent Use of the PDMP Direct link within EHR Health Promotion and Disease Prevention Drug and Alcohol Liaison Pain Management Referral Non-pharmacological treatment plan 14

15 Reference List 1. Centers for Disease Control and Prevention. WONDER: Wide-ranging online data for epidemiologic research. [Internet]. Atlanta (GA): CDC; 2016 [cited 2016 Oct 16]. Available from 2. Drug Enforcement Agency Intelligence Report. Analysis of drug-related overdose deaths in Pennsylvania, [Internet]. Washington (DC): DEA; 2015 [cited 2016 Oct 9]. Available from 3. Pennsylvania Department of Health. Prescription Drug Monitoring Program. Accessed August 5, 2016 at 4. Prescription Drug Monitoring Program Center of Excellence at Brandeis University. Briefing on PDMP effectiveness.[internet]. Bureau of Justice Assistance (BJA); Sept 2014 [cited 2016 Dec 16]. Available from 5. Finnell JT, Twillman RK, Breslan SA, Shultz J, Miller L, 2017 Sep. The role of continuing medical education in increasing enrollment in prescription drug monitoring programs. Clin Ther. 39(9), Kellams JR, Maye JP Jul/Sep. The last state to grant nurse practitioners DEA licensure: An education improvement initiative on the Florida prescription drug monitoring program. J Addict Nurs. 28(3), Lin DH, Lucas E, Murimi IB, Jackson K, Baier M, Frattaroli S, Gielen AC, Moyo P, Simoni-Wastila L, Alexander GC Feb. Physician attitudes and experiences with Maryland s prescription drug monitoring program (PDMP). Addiction. 112(2), Haegerich TM, Paulozzi LJ, Manns BJ, Jones CM What we know, and don't know, about the impact of state policy and systems-level interventions on prescription drug overdose. Drug Alcohol Depend. 145, Spratling R, Powers E Jan/Feb. Development of a data abstraction form: Getting what you need from the electronic health record. J Pediatric Health Care. 31(1),