Identifying Research Gaps in Clinical Practice Guidelines ...nationalacademies.org/hmd/~/media/Files/Activity Files/MentalHealth... · ©2017 MFMER | slide-1 Identifying Research

©2017 MFMER | slide-1

Identifying Research Gaps in Clinical Practice Guidelines for Prescribing Opioids for Acute Pain:The Mayo Clinic Perspective

Elizabeth B. Habermann, PhD MPHProfessor of Health Services ResearchRobert D. and Patricia E. Kern Scientific Director for Surgical Outcomes

July 9, 2019


No Disclosures


Optimizing Opioid Prescribing for Mayo Clinic Surgical Patients

History and Progress to Date


2015-2016


Ann Surg. 2017;266;564-573.


Methods

• Adults undergoing 25 common elective procedures (2013-2015):

• 7,651 adults

• 5,756 (75.2%) opioid naïve

ProceduresGENERAL SURGERY

1. Lap Cholecystectomy

2. Lap Initial Inguinal Hernia Repair

3. Initial Inguinal Hernia Repair

4. Ventral Hernia Repair

GENERAL SURGICAL ONCOLOGY

5. Simple Mastectomy

6. Breast Lumpectomy

7. Ileocecectomy

8. Laparoscopic LAR

9. VATS Wedge Resection

ORTHOPEDIC

10. Total Shoulder

11. Total Hip

12. Knee Arthroscopic Meniscectomy

13. Total Knee

14. Rotator Cuff Repair

SPINE

15. Lumbar Laminotomy

16. Lumbar Laminectomy

UROLOGY/GYNECOLOGY

17. Lap Hysterectomy

18. Vaginal Hysterectomy,

19. Lap Nephrectomy

20. Lap Prostatectomy

HEAD & NECK

21. Thyroid Lobectomy

22. Parathyroidectomy

23. Carotid Thromboendarterectomy

24. Parotid Gland Excision

25. Tonsillectomy


0

20

40

60

80

100

120

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orp

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ts (

OM

E) OME Prescribed in Opioid Naïve Patients

Ann Surg. 2017;266;564-573.


Results

• 80.9% of opioid naïve patients were prescribed > 200 OME

• Wide variation of post-operative opioid prescribing observed across and within surgical procedures

Therefore:

• Opportunities exist to standardize and optimize prescribing

Ann Surg. 2017;266;564-573.


2017


How should users of clinical practice guidelines be engaged in the dissemination, implementation, and clinical use of a guideline?

The Mayo Clinic Approach


Mayo Clinic Approach to Opioid Prescribing Guideline Development and Implementation

• Multidisciplinary teams were constructed per specialty

• Membership

• Surgeon Champion

• Health Services Researcher

• Data Analyst

• Pain Medicine Physician

• Nursing Administrator

• Pharmacist

• Health Systems Engineer




• Membership



• Data Analyst



• Pharmacist


Guideline

Development




• Membership



• Data Analyst



• Pharmacist


Guideline

Implementation


https://www.prosci.com/adkar/adkar-model



Guideline Development and Implementation

• Created framework for consistency and standardization

“prescribe the lowest amount ofthe lowest dose for the shortest duration”

with room for tailoring


Content courtesy of Danny Whipple



Guideline Development and Implementation

Guideline Development

• Kickoff meeting with each specialty

• Multiple stakeholders with different roles

• Review historical prescribing

• What are your goals?

• What is realistic?

• How can we meet needs of patient without introducing unnecessary risk?

Guideline Implementation

• Tailored to each specialty

• Involve all stakeholders

• Varies per surgical specialty and by hospital

• Who prescribes? (surgeon, resident, APP?)

• Who discharges the patient?

• Nursing often sets expectations for discharge

• Pharmacy involvement and reinforcement



Orthopedic Surgery

Implemented in Rochester in Summer 2017


Department of Orthopedic Surgery Prescribing Guidelines


Clin Orthop Relat Res.

2019 Jan;477(1):104-113.

Reduction and Standardization of Opioids Prescribed


Reduction and Standardization of Opioids Prescribed


2019 Jan;477(1):104-113.


Adherence to Guidelines


2019 Jan;477(1):104-113.


Meanwhile, in 2017…


Amount Optimal Amount

Prescribed to Prescribe

???


Survey of 2500 Recently Discharged Mayo Clinic Surgical Patients

• Goal:

• Determine how many opioids were used from what we know were prescribed

Ann Surg. 2018 Sep;268(3):457-468.


Surgery Discharge

21 350

28-Question Phone Survey

• Opioids Consumed

• Refills

• Pre-operative Users

• Patient Experience

Weekly Query

Mean 26.9±4.2

Methods


Opioid Utilization

61.5% Opioids Went Unused

77.3% of Patients had Leftover Opioids

55,199 pills remained unused at the time of survey!

(>1 million pills per/institution/year)

Ann Surg. 2018 Sep;268(3):457-468.


Amount Opioids Prescribed vs ConsumedNaïve

Only

0 100 200 300 400 500 600 700

Carotid Endarterectomy

Parathyroidectomy

Arteriovenous Fistula Creation

MIS Partial Colectomy with Anastomosis

Carpel Tunnel Release

Breast Lumpectomy ± Sentinel Node

MIS Cholecystectomy

MIS Inguinal Hernia Repair

Ovarian Cancer Cytoreduction

Open Inguinal Hernia Repair

Simple Mastectomy ± Sentinel Node

MIS Hysterectomy

MIS Low Anterior Resection ± Diverting Ileostomy

MIS Prostatectomy

MIS Nephrectomy

Knee Arthroscopic Meniscectomy

Open Pancreaticoduodenectomy

MIS Lung Wedge Resection

Tonsillectomy

Rotator Cuff Surgery

Lumbar Laminotomy/Laminectomy

Open Lung Lobectomy

Lumbar Fusion

Total Hip

Total Knee

Median Amount Consumed (in OME) Median Amount Remaining (in OME)

a

Ann Surg. 2018 Sep;268(3):457-468.


20172018


Multidisciplinary teams of surgeons, pain medicine, residents,

nurses, pharmacists, and researchers…


Department of Surgery

Implemented in February 2018




Department of Surgery

Implemented in February 2018[Resident] Surgeon Champion: Cornelius Thiels, DO


Discharge Prescription Amounts in OME

Pre-Guidelines

Median: 150

IQR: 75 – 225

Post-Guidelines

Median: 60

IQR: 37.5 – 112.5

20 Tabs Oxy 8 Tabs Oxy

Range of 150 Range of 75

p<0.001

>50% Reduction

in Opioids Prescribed(hundreds of thousands of fewer unused pills in the community)

Unpublished QI Data

↓ Amount ↓ Variation


Post-Guideline Prescribing Levels

21%

38%

24%

17%

0%

5%

10%

15%

20%

25%

30%

35%

40%P

rop

ort

ion

of P

atien

ts

Low Dose Standard Dose High Dose Above Guidelines

Unpublished QI Data


Summary of Impact

• Following implementation of opioid prescribing guidelines in MCR Department of Surgery

• Opioids prescribed dropped by ~50%

• Variation in opioid prescribing also decreased

• Refill rates remained stable for 12 of 13 procedures

• Guideline compliance is respectable for 12 of 13 procedures

Unpublished QI Data


2019


Where are we now?

• Guidelines for postoperative opioid prescriptions have been implemented

• Orthopedic Surgery

• Department of Surgery

• Otorhinolaryngology

• Gynecologic Surgery

• Neurosurgery

• Ophthalmology

• Urology

• CV Surgery


Available within “Ask Mayo Expert”



Opioid Prescribing Reports and Dashboards Available



Opportunities for Long-Term Follow-Up

What databases are suited for long-term follow-up of outcomes in patients with acute pain who received opioids for that pain?



1. Longitudinal Administrative Claims

2. Mayo Clinic “Paneled Patients”

3. Rochester Epidemiology Project









each with its own generalizability concerns

Examples:

• Medicare Fee-for-service Data

• Military Health Data Repository

• Private Hospital or Insurer Longitudinal Data

• Premier

• Truven

• Optum


(BMJ 2019;365:l1849)Cohort:

We identified 524,318

patients meeting our

inclusion criteria, of whom

444,764 had at least 180

uncensored days of

follow-up.

Conclusion:

Tramadol use was

associated with a higher

risk of prolonged opioid

use in patients with an

acute episode of pain

compared with other short

acting opioids.


Longitudinal Administrative Claims Data

Can be studied with claims

• Health services and conditions:

• Outpatient visits

• ED visits

• Hospital admissions and LOS

• Diagnoses and procedures

• With pharmacy data:

• Opioids prescribed

• Refills

Cannot be studied with claims

• Patient-reported pain scores*

• HCAHPS or other measures of patient experience*

• Opioids consumed

• Non-prescription medications or pain management strategies

• Pharmacogenomic data*

*may be available if claims linked to EHR or other data sources






©2017 MFMER | slide-48https://rochesterproject.org/

https://rochesterproject.org/


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• Funded by the NIH for over 50 years

• A collaboration between health care providers in Minnesota and Wisconsin

• ~60% coverage of a 27-county region of MN and WI

• 700,000 records

Content courtesy of the Rochester Epidemiology Project team


Age 30 35 40 45 50 55 60

Medical visit dates: In region Out of region

Person

Residency timeline

In region

Implied in region

Out of region

Implied out of region

Unknown

Residency timelines

St. Sauver et al., Int J Epidemiol 2012; Rocca et al., Int J Epidemiol 2018



Uses of the census enumeration1966 1970 1975 1980 1985 1990 1995

2000 2005

Enumeration Enumeration

Controls

for case-control

studies

Referent

subjects

for cohort

studiesPrevalence

and incidenceTime, place, and person




Olmsted

Medical

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Mayo ClinicOther

providers

State and

national

death records

Demographi

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Diagnose

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Age 30 35 40 45 50 55 60

Linkage across care-providers




Type of data

Medical

diagnoses

and surgical

proceduresICD codes

Prescriptions of drugs RxNorm, NDF-RT codes

Life habits

Laboratory testsLOINC codes

Immunizations

Services and

proceduresICD and CPT codes

Demographic

data

Biological

specimens

on ≈10%








Thank You

[email protected]

@ebhabermann

mailto:[email protected]

Documents

Identifying Research Gaps in Clinical Practice Guidelines ...nationalacademies.org/hmd/~/media/Files/Activity Files/MentalHealth... · ©2017 MFMER | slide-1 Identifying Research