Quality assurance and quality improvement of chronic non- malignant pain management: Indicators as a primary care quality tool July 2015 RNZCGP 15 presentation
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
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
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