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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

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Background

National Statistics

Source: 1

Source: 2

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Age-adjusted rates of drug overdose deaths by state, US 2016

6.9 to 11.0

11.1 to 13.5

13.6 to 16.0

16.1 to 18.5

18.6 to 21.0

21.1 to 52.0

Legend

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

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Patients (aged 18-85 yrs.) in ED with CC pain, 2016

972525%

3819275%

Patients w/ CC Pain

Total Patients Seen

Pennsylvania’s New Opioid Laws

Source: 3

CLINICAL MANDATE

Source: 3

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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 opioidsSource: 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)

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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

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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

Systematic ReviewOutcome Study

Design

Number

of Studies

Findings

Provider

Behavior

Descriptive

/before-after

7 Improved provider confidence or knowledge (Elhwairis and

Reznich,2010)

*Low 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.

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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

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SAMPLE• Enrollment

– All patients aged 18-85 years old with CC Pain

discharged from the ED

• Project Time Period

– 19 months

Our Providers

Procedures

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4 months 6 months 9 months

19 months

Phase OneJuly 25, 2016 - 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 TwoNovember 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

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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 ThreeMay 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

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Comparison of pre- and post-knowledge survey mean total score

65.45

90

0

10

20

30

40

50

60

70

80

90

100

Mean Total Score

Increase in Mean Total Score

Pre-Formal Knowledge Program

Post-Formal Knowledge Program

N = 11

p = .000

Question 9: Barriers to Consistent PDMP Use Pre Post

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

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 13 12

960

759

645 635

1335

890

972

887

287

193

129 143

0

200

400

600

800

1000

1200

1400

Pre PDMP Post PDMP/ Informal Intervention Pre EducationProgram Post EducationProgram

Prescribing patterns, by time period during program

Total Patients Seen

Total Rx Written

Narcotic Rx Written

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Percentage change in opioid prescription rates between time periods

21.5% 21.7%

13.3%16.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Pre PDMP Post PDMP/Informal

Intervention

Pre EducationProgram

Post EducationProgram

p = .002

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

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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

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Reference List1. 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 http://wonder.cdc.gov

2. Drug Enforcement Agency Intelligence Report. Analysis of drug-related overdose deaths in Pennsylvania, 2015. [Internet]. Washington (DC): DEA; 2015 [cited 2016 Oct 9]. Available from https://www.dea.gov/divisions/phi/2016/phi071216_attach.pdf

3. Pennsylvania Department of Health. Prescription Drug Monitoring Program. Accessed August 5, 2016 at www.doh.pa.gov/PDMP

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 www.pdmpexcellence.org

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), 1896-1902.

6. Kellams JR, Maye JP. 2017 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), 135-142.

7. .Lin DH, Lucas E, Murimi IB, Jackson K, Baier M, Frattaroli S, Gielen AC, Moyo P, Simoni-Wastila L, Alexander GC. 2017 Feb. Physician attitudes and experiences with Maryland’s prescription drug monitoring program (PDMP). Addiction. 112(2), 311-319.

8. Haegerich TM, Paulozzi LJ, Manns BJ, Jones CM. 2014. 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, 34-47.

9. Spratling R, Powers E. 2017 Jan/Feb. Development of a data abstraction form: Getting what you need from the electronic health record. J Pediatric Health Care. 31(1), 126-130.