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Opioid Task Force - CPE Opportunity
How to Assess Health-System Implementation of the CDC Recommendations for Prescribing Opioids

by Mark E. Greg, PharmD, RPh Director, Ambulatory Pharmacy Management, Northwestern Medicine Physician Network Oak Brook, IL

Introduction

In recent years, prescription opioid misuse and especially prescription opioid-related deaths have received significant media attention. Health systems are uniquely qualified to implement programs to improve opioid prescribing. A structured approach is essential for assessing pain management practices including opioid prescribing, with the expectation that these efforts will lead to more effective pain management with lower risks of opioid-related morbidity and mortality. Although this discussion will focus on opioid prescribing taking place in ambulatory settings, primarily physician practices, the overall process is applicable to any inpatient or ambulatory setting. For integrated delivery networks (IDNs), ongoing collaboration between system inpatient and ambulatory opioid initiatives is highly recommended.

The United States Department of Health and Human Services - Centers for Disease Control and Prevention (CDC) issued the “CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016” in March 2016 (https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm).¹ This was followed by “Quality Improvement and Care Coordination: Implementing the CDC Guidelines for Prescribing Opioids for Chronic Pain” in September 2018 (https://www.cdc.gov/drugoverdose/pdf/prescribing/CDC-DUIP-QualityImprovementAndCareCoordination-508.pdf).² The reader is encouraged to review and become familiar with these documents as an in-depth review of this material is beyond the scope of this article. Similarly, the impact of Healthcare Effectiveness Data and Information Set (HEDIS), Centers for Medicare & Medicaid Services (CMS), and payer opioid-related measures, as well as recent updates to State of Illinois laws and related regulations, are beyond the scope of this discussion.

“Implementing the CDC Guidelines for Prescribing Opioids for Chronic Pain” provides a detailed overview of how to assess and implement an appropriate opioid prescribing program. The document is broken down into an overview, three chapters, references, and six appendices. The publication encourages the use of an interdisciplinary team including pharmacists. The chapter titles are: 1) Evidence-based Opioid Prescribing, 2) Clinical Quality Improvement (QI) and Opioid Measures and Protocols, and 3) Practice-level Strategies for Care Coordination. This discussion will focus on Chapter 2.

Chapter 2, Page 10 of “Implementing the CDC Guidelines for Prescribing Opioids for Chronic Pain” includes Exhibit 1: Clinical QI Opioid Measures, a table containing 16 potential measures in alignment with CDC Prescribing Guideline Recommendation statements. In addition to potential improvement in quality, many payers measure and may financially incentivize health systems to meet or exceed certain opioid prescribing goals. The first five measures address starting an opioid in a new or opioid-naïve patient (termed New Opioid Prescription Measures) and the remaining eleven address long-term opioid therapy. By clicking on each measure listed in Exhibit 1, a link takes the reader to Appendix B in the document containing details on how to operationalize the measure using the electronic health record (EHR) and other data. Table 1 is an adaptation of Exhibit 1 in the Guideline which includes yes/no columns that may be helpful when conducting an opioid measure assessment of your organization.

Chapter 2, Page 11 identifies five steps for implementing an opioid QI effort in a healthcare system or practice.

Key Quality Improvement Steps

Step 1: Obtain Leadership Support and Identify a Champion

Obtain leadership support as a critical first step
It is likely appropriate opioid-related initiatives are currently taking place within your organization. If not, you may be the catalyst for that initiative. Leadership support may be obtained from various departments including administration, pharmacy, nursing, medical director, quality, physician practices, emergency department, immediate care, and others.

Regardless of your role, a first step may be to ask your manager or other key contacts within your organization where appropriate opioid prescribing falls as an organizational priority. Perhaps there is an active committee examining pain management or opioid prescribing. If not, you may be the person to promote this as a Pharmacy & Therapeutics, Quality Improvement, Utilization Management, Patient Safety, Emergency Medicine, Immediate Care Center initiative, or Ambulatory Primary Care Initiative. Leadership reacts to metrics including quality, cost-avoidance, and financial performance.

Identify a champion(s) to drive the change process
In general, an administrative champion or one or more physician champions are key individuals to engage. Granted, in many cases, pharmacists may be the drivers of quality improvement initiatives and are highly respected by physicians, yet physicians may be more likely to listen to and accept direction from fellow physicians. Securing physician champion support may be aided by informing them that they work will be shared among the team. That is the role of the multidisciplinary change or quality improvement team as discussed below.

Form a change team (if appropriate) or at least engage key staff
Representatives may include providers (e.g., physicians, advanced practice nurses, physician assistants, pharmacists), nursing, quality, administration, electronic health record support, and IT/analytics. Your providers will be able to share what their needs are based upon the challenges they encounter in daily practice. Meetings involving the physician champion(s) may require early morning or late afternoon times to accommodate clinic hours/patient care activities. Ongoing collaboration between system inpatient and ambulatory opioid initiatives is highly recommended.

Obtain needed resources and determine readiness
Key resources will include meeting time, a meeting location/virtual meeting, IT/analytics support, EHR support, and data. Key questions to ask your champions and key participants include, “Does the organization identify a problem with current pain management/opioid prescribing?” and “Is the organization willing to make changes in pain management practices?” Changing culture takes time.

Step 2: Assess Current Approaches to Opioids and Identify Areas for Improvement

Assess current policies and practices
Does the organization have any? If not, create your own. What do you need? How detailed do you want them to be? What do your providers need to make them successful? What have your peers in other health systems developed? The internet includes postings by many health systems that may serve as policy templates.

Complete the self-assessment questionnaire
An organizational self-assessment is included in Appendix C (pages 52-56) of the guidelines.

Collect data on your patient population and opioid therapy
Decide what data you wish to collect. What opioids are being prescribed? What is the morphine milligram equivalent (MME) count? Are opioids in combination with benzodiazepines being prescribed? Is naloxone being prescribed for at-risk patients? Your EHR may be able to capture prescription claims data. Some organizations may also receive prescription claims data or reports from payer partners. Review of data may require manual calculation of morphine milliequivalents per day as well as screening for other concomitant CNS-depressant medications.

Determine access to specialists and other resources
What resources are available? Mental health, pain specialist, substance use programs, and providers of Medication Assisted Therapy (MAT) are just a few important resources. If providers are uncertain how to connect patients requiring substance abuse treatments with available resources, a major “win” may be for the organization to prepare and provide printed lists of substance use providers or EHR links for referrals to MAT providers.

Identify areas for improvement
What are your greatest needs? Reporting data will accomplish the following: 1) provide baseline measure performance; 2) identify outliers (under- and over-prescribers); and 3) identify those prescribers and patients who may benefit from opioid prescribing assistance. Use the data to help guide your team.

Step 3: Select and Prioritize Guideline Recommendations

Pick a few key areas where you may have the greatest short-term impact, “wins.” Perhaps it will be reducing the number of patients receiving more than 90 MMEs per day or it will be increasing the number of at-risk patients receiving ≥ 50 MMEs/day who are also prescribed naloxone. Perhaps it will be increasing the number of patients receiving chronic (≥ 90 continuous days) opioid therapy that have a signed opioid treatment agreement (OTA) in place. Keep in mind that these guidelines are suggestions and any initiatives should be based upon the unique needs of your health system.

Determine which guideline recommendations to implement
Appendix B (pages 33-50) of the guidelines entitled, Operational Clinical Quality Improvement (QI) Opioid Measures provides short and long-term opioid measure operational definitions. Operational definitions include the criteria used to build reports. These will assist your data and analytics architects when creating your reports.

Prioritize what will be implemented
What will you be able to accomplish within your organization? What is the most pressing need? Be realistic given the resources available within your organization and expected time frame to see results.

Step 4: Define System Goals

Set measurable goals
These goals will vary based upon your baseline data and what may be realistically accomplished within your organization. Administrative and physician leadership prefer metrics.

Step 5: Develop a Plan, Implement, and Monitor Progress

Develop a plan for implementing selected guideline recommendations
Implement the changes
Monitor progress using QI measures and other data
Review metrics for assessment of opioid prescribing practices

Methods for Obtaining Data That Can Be Used When Analyzing Opioid Prescribing

Appendix B of the guidelines includes 16 operational definition templates. The criteria included in the operational definitions are listed in Table 2.

In most cases, the EHR will be the best source for this data. Many individuals and departments within health systems struggle with obtaining reports given the number of requests submitted to the EHR and IT/analytics teams. Obtaining the support from the health system population health team, quality team, executive administration, and chief medical officer for any opioid-related reports will be critical to raising the priority of your request and successfully obtaining your reports. The health system’s data architects will work with you to build your reports according to the operational definitions developed. Validating the data once the report is built will be required to be certain the data elements reported match the actual EHR results. This process may be labor-intensive depending upon the sample size and number of EHR records that need to be reviewed. It is critical to be certain that the report is accurately capturing the intended data required. Trust, but verify. The data needs to be accurate so that when reports are shared with various groups and prescribers, the information appropriately reflects what is taking place in clinical practice.

Case 1

You are a pharmacist in a health-system with an integrated delivery network (IDN). The IDN Medical Director invites you to be a member of the ambulatory pain management quality team. You attend the meetings as the pharmacy representative. One of the measures the team has chosen is the percentage of patients with a new opioid prescription for acute pain for a three-day supply or less. You suggest using the EHR prescribing data. The team agrees.

Case 1 Discussion

You work with the quality team to define the operational definition content for the measure and use the health system’s EHR as the source of your opioid prescribing data. You support the data architects and data analyst team building the reports according to the operational definitions developed. After the reports are created, you assist with validating the accuracy of the report data by reviewing patient profiles in the EHR.

How to prepare a quality improvement algorithm to assist with assessing opioid prescribing quality improvement

The following discussion is based on Step 5 of the above process as described on page 19.² After defining your goals and determining the area of focus, the next step will be to develop your plan. A standardized process is needed to guide the project and to measure progress (or lack thereof). This should include some type of Plan-Do-Study-Act (PDSA) cycle quality improvement tool (See Figure 1).³ One example is the DMAIC (Define, Measure, Analyze, Improve, Control) methodology.⁴DMAIC methodology is a core tool used to drive Six Sigma projects. Included below is a sample DMAIC process used for examining the impact of an ongoing prescriber awareness campaign on hydrocodone/acetaminophen (H/A) prescribing over time. Actual H/A prescription claims (fill) data from a specific payer population was chosen because the data was consistent, accurate, and available quarterly. The DMAIC process may be used and results shared within your quality team, prescribers, and other committees and key individuals to inform them of your progress.

Case 2

Your team’s reports are accurate and the data reveals H/A is the most frequently prescribed opioid in the ambulatory setting. The medical specialties in order of greatest H/A prescribing volume are: primary care, emergency medicine, immediate care, and orthopedics. The average days’ supply prescribed is 5. Data breakdown reveals: 10% ≤ 3 days’ supply prescribed, 70% ≤ 5 days’ supply prescribed, and 20% ≤ 7 days’ supply prescribed.

Case 2 Discussion

The quality team establishes the first year project goal to be 50% ≤ 3 days’ supply prescribed, 45% ≤ 5 days’ supply prescribed, and 5% ≤ 7 days’ supply prescribed. Your team’s plan includes an educational campaign to encourage prescribing a ≤ 3 days’ supply of H/A (assuming an opioid is required). You will also be working with the EHR team to change the default days’ supply for H/A from 5 days to 3 days in the prescribing software. Prescribers will still have the option of selecting a 5 days’ supply. The team decides to meet quarterly to review the data and discuss project feedback. You begin to meet with your prescribers to inform them of the project, share their baseline H/A prescribing, how they compare to their peers in the same medical specialty, and the first-year program goal. Your first quarter results are as follows: 25% ≤ 3 days’ supply prescribed, 55% ≤ 5 days’ supply prescribed, and 20% ≤ 7 days’ supply prescribed. Congratulations! You’re making progress toward your first-year goal. Now continue the PDSA process until you meet or exceed your goal.

Conclusions

Implementing an appropriate opioid prescribing initiative within your health system offers a tremendous opportunity for pharmacists to apply their expertise to improve the quality and safety of patient care. “Implementing the CDC Guidelines for Prescribing Opioids for Chronic Pain” provides a detailed overview to assist organizations with implementing an appropriate opioid prescribing program. Use of a structured approach with the Plan-Do-Study-Act (PDSA) cycle quality improvement process is highly recommended.

References

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1-49. doi: http://dx.doi.org/10.15585/mmwr.rr6501e1
Centers for Disease Control and Prevention. Quality Improvement and Care Coordination: Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain. 2018. National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, Atlanta, GA. Available at: https://www.cdc.gov/drugoverdose/pdf/prescribing/CDC-DUIP-QualityImprovementAndCareCoordination-508.pdf. Accessed June 6, 2020.
Plan-Do-Study-Act (PDSA) Worksheet. Institute for Healthcare Improvement. Cambridge, MA. http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx. Accessed June 6, 2020.
The Define, Measure, Analyze, Improve, Control (DMAIC) Process. American Society for Quality. https://asq.org/quality-resources/dmaic Accessed June 6, 2020.