Quality assurance and quality improvement of chronic non-malignant pain management:

Indicators as a primary care quality tool

July 2015 RNZCGP 15 presentation

University of Otago Wellington.

July 2015 RNZCGP 15 presentation

Dr Roshan Perera and Dr

Helen Moriarty

Impact and importance of chronic non-malignant pain

Public health burden

Social justice impacts vs socioeconomic , employment, social

welfare

Personal health and mental health complications

Pressure on health and social welfare systems

July 2015 RNZCGP 15 presentation

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 RNZCGP 15 presentation

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 RNZCGP 15 presentation

From BPJ issue 62 page 22

Figure 1: Number of oxycodone and morphine prescriptions dispensed (excluding injected preparations).5

July 2015 RNZCGP 15 presentation

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 non-

malignant pain and prevention of problems associated with prescription opioid use,. Sydney 2009.

^http://www.lawcom.govt.nz/sites/default/files/publications/2011/05/part_1_report_-

_controlling_and_regulating_drugs.pdf

July 2015 RNZCGP 15 presentation

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 RNZCGP 15 presentation

July 2015 RNZCGP 15 presentation

Overview of Indicator Development

Chronic Pain and ImPaCT projects

The Indicator “Suites”

Piloting and

Future plans

July 2015 RNZCGP 15 presentation

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 RNZCGP 15 presentation

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):314-27.

‘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 RNZCGP 15 presentation

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 RNZCGP 15 presentation

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 RNZCGP 15 presentation

Indicator topics

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 RNZCGP 15 presentation

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 1st presentation

3) Additional urine test within 3 months of 1st presentation

Denominator: Patients with chronic pain and a drug or alcohol past history.

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 RNZCGP 15 presentation

July 2015 RNZCGP 15 presentation

July 2015 RNZCGP 15 presentation

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 RNZCGP 15 presentation

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 RNZCGP 15 presentation