Clinical Research Oriented Workshop (CROW) Meeting: Sept 27, 2012

Present: Abby Crocker, Kairn Kelley, Ben Littenberg, Charlie MacLean, Connie van Eeghen

Fly-By Guest: Rich Pinckney

1.                  Start Up:  Does marketing really affect prescribing?

2.                  Presentation: Charlie - analyze narcotic prescribing in VT through various data sources and various ways to summarize and present data that are useful to clinicians. This generalizes to other medication categories as well and overlaps with Amanda's Medication Management Project. 

a.       Referencing his report to the Unified Pain Management System Advisory Council on Sept 5, Charlie gave the background on the current interest in the medication management of pain.  For example, methadone is long acting and has caused many deaths due to inappropriate management (whether due to dosing or diversion), as found in WA where it was on the state approved formulary.  WA has gone so far as to requiring a consult for non-cancer, chronic pain prior to prescription. 

b.      In response, there have been multiple educational efforts: state-wide conferences, QI projects, law enforcement, medical practice board, linkage to psychiatry, and a FAHC organized effort.  Goals: no harm, pain balanced with function, better for staff, no diversion.  These result in concrete recommendations: 28 prescribing cycles, chart management, use of agreement, minimum dosage for acute pain, etc.  The FAHC effort started January 2012.  Issues:

                                                  i.      Who owns these patients: primary care or specialty.  This is tricky: it depends on the patient’s issues, such as Crohn’s Disease, chronic headache with patch and shunt. 

                                                ii.      Guidelines for opiates: assessments, comprehensive treatment, monitoring, tapering, discontinuing, evaluation of aberrant behavior (pseudo-addiction)

1.      Rich: “to approach the patient issue with curiosity, rather than judgment”

                                              iii.      Standardization: treatment agreements, use of VPMS

                                              iv.      FAHC produces a large population report by PCP that includes all patients that have received a medication order for opiates (and maybe stimulants) through PRISM

                                                v.      FAHC can also produce a summary population report (which Charlie put together) that compares an individual provider with all FAHC PCPs (IM, FM, Residents, PA, NP, but not PED) that includes a count (or median) of unique patients on opiates, multiple Rx, multiple prescribers, proportion with red flag, 7 day increment Rx, and methadone patients.  Red flags:

1.      Multiple prescribers

2.      Multiple, short prescriptions

3.      Multiple formulations

4.      Trend in terms of morphine equivalents

5.      Any use of methadone

                                              vi.      Charlie also mocked up a detail population report with the above indicators and a summary report of FAHC PCPs in order of volume of opiate patients.

                                            vii.      Available through PRISM: urine screening, last vision, pain score

1.      New: Last VPMS search (date)

2.      Agreement present

3.      Standard functional measure (difficult)

4.      Pill counts

5.      Risk assessment scores (SOAPP, COMM, ORT, …)

c.       Harry Chen created the above referenced Council to find good uses for VPMS in light of the recommendations about opiate management.  New ideas:

                                                  i.      Opiate medical home or extension service, for example New Mexico Extension for Community Health Care Outcomes (ECHO) with shared case conferences and distributed services into the communities.  Mark Pasanen and Brian Erikson are exploring this.

                                                ii.      QI projects

                                              iii.      Population reporting for chronic disease: epidemiology, benchmarking, peer comparisons, insights into causes of variation, data for closing the loop in a QI cycle, and identification of targets for action. 

1.      Flags: ED visits

2.      What we care about: pain control, function, misuse, prevention of misuse, prescribing process

3.      Measures: past history of abuse, prescription patterns, risk stratification, monitoring, agreements, pill counts, urine testing

                                              iv.      Data sources:

1.      EMR: practice controls the system but does not see fills and non-practice providers

2.      VHCURES: claims paid regardless of location (might be able to see denied claims too) but does not include cash and is patient de-identified; pending Medicare

3.      VPMS: all fills in VT including cash; missing border states

d.      What’s next:

                                                  i.      Active medication list: PPIs, bisphosphonates, SSRI; Narcane, eGFR adjustments, Vitamin K (for overdose of Coumadin)

                                                ii.      BP and other physiologic data

                                              iii.      Lab data

e.       Tableau Public: software for graphic representations – see Top Drug Prescribers

                                                  i.      Runs off of any DB, including Excel

3.                  Next Workshop Meeting(s): Thursday, 2:00 p.m. – 3:30 p.m., at Given Courtyard Level 4. 

a.       Oct 4: Ben on exploring NHANES

b.      Oct 11: Rodger and Connie: R03

c.       Oct 18: Christina Cruz, 3^rd year FM resident with questionnaire for mild serotonin

d.      Oct 25: Abby

e.       Future agenda to consider:

                                                  i.      Kairn – review of draft article on IRR  

                                                ii.      Ben: budgeting exercise for grant applications; NHANES – lower female mortality for women taking birth control medications

                                              iii.      Rodger: Mixed methods article; article on Behavior’s Influence on Medical Conditions (unpublished); drug company funding.  Also: discuss design for PCBH clinical and cost research.  Also: Prezi demo. 

                                              iv.      Amanda: presentation and interpretation of data in articles

Recorder: Connie van Eeghen