Data-Driven Approach Successfully Engages Orthopedic Surgeons in Decreasing Opioid Use

美国正面临阿片类药物泛滥的局面，为氢可酮开出的阿片类药物处方数量超过了所有其他国家。骨科医生是第三大阿片类药物处方者，与其他国家的处方模式相比，非阿片类药物替代药物用于疼痛治疗的使用不足。

社区卫生网络(CHNw)敏锐地意识到阿片类药物处方模式对潜在阿片类药物滥用的影响，并将减少阿片类药物处方作为工作重点;然而，它缺乏可用于了解术后阿片类药物用量的有意义的数据。在没有进一步信息的情况下，提供方不愿意改变他们的处方模式。

To address this challenge, CHNw created an orthopedics guidance team and leveraged data within its analytics platform to gain insight into prescribing habits over time, including the most frequently prescribed medication and the volume of pills prescribed by individual providers. This data drove peer-to-peer conversations among providers and discussions with patients related to reducing opioid use.

POTENTIAL FOR OPIOID MISUSE RAISES CONCERNS

Since 1999, the U.S. has experienced a steady increase in deaths from drug overdose with an average of 130 Americans dying every day from an opioid overdose. In 2017 alone, there were over 70,000 overdose deaths, 68 percent involving an opioid.¹

In Indiana, providers wrote approximately 5.8 million opioid prescriptions during 2015. The following year, there were 794 opioid-related overdose deaths in the state—a rate of 12.6 deaths per 100,000 persons compared to the national rate of 13.3 deaths per 100,000 persons.²The U.S. outpaces all other nations in opioid prescribing for hydrocodone. Orthopedic surgeons are the third-highest prescribers of opioid prescriptions and use fewer non-opioid alternatives than other countries.³

The quantity of opioid pills prescribed after surgery is a predictor for the quantity consumed by the patient. Also, only about 27 percent of opioids prescribed postoperatively are consumed by the patient, leaving unused opioids in the community, increasing the risk of opioid misuse and addiction.⁴

Community Health Network (CHNw) is a non-profit healthcare organization serving central Indiana, ranking among the nation’s most integrated healthcare systems. Based in Indianapolis, it strives to improve health and well-being in the communities that it serves, providing convenient access to exceptional healthcare services, where and when patients need them—in hospitals, health pavilions, and doctor’s offices, as well as workplaces, schools, and homes. CHNw needed to fully understand the opioid prescribing patterns of its providers to properly serve its community.

LACK OF DATA HINDERS UNDERSTANDING OF PRESCRIBING PATTERNS

在参加一次国际宣教活动时，CHNw骨科服务热线的负责人注意到，他在其他国家治疗的患者术后服用阿片类药物的数量要少得多，他们经常使用非甾体抗炎药来控制术后疼痛，并完全放弃使用阿片类药物。回到美国后，他深入研究了自己的个人处方模式，并对一年内阿片类药物的处方量感到惊讶。

CHNw的服务热线负责人和其他骨科医生敏锐地意识到阿片类药物处方模式对潜在的阿片类药物滥用的影响。尽管他们意识到潜在的负面影响，但他们并没有获得关于他们处方模式的有意义的数据，以及与他们的同龄人相比，这些处方实践是如何进行的。此外，提供者主要依赖于他们在最初培训期间学到的做法，往往不知道州和联邦新的阿片类药物处方要求。

在没有数据证明需要改变的情况下，医疗服务提供者对改变长期以来的处方模式犹豫不决。他们担心收到额外的补充请求，发现在诊所访问期间需要讨论阿片类药物的疼痛管理替代方案，以及对患者体验的潜在负面影响，特别是因为患者体验评分以前与提供者的可变费率补偿计划相关联。

The orthopedic service line wanted to address the opioid epidemic, but providers lacked the ability to monitor their prescribing habits effectively, and could not analyze appropriate or inappropriate trends. To make lasting practice changes, CHNw needed better data.

DATA-DRIVEN APPROACH FACILITATES EFFORT FOR DECREASING OPIOID PRESCRIPTIONS

CHNw holds a vision for quality, aiming to deliver an exceptional experience to every life it touches. The organization has a robustimprovement approach在整个网络中使用的重点是根据结果、经验、成本和护理的适当性来提高由其个体患者定义的质量。

Establishing an orthopedic guidance team

To achieve its vision of quality, CHNw has invested in permanent improvement teams. One such team is the orthopedic guidance team, responsible for facilitating progress within the orthopedic service line. This team identified opioid prescription reductions as a top priority, initially focusing its improvement efforts on reducing the number of opioids prescribed at discharge following orthopedic surgical procedures.

The orthopedic guidance team established a goal of an 18 percent relative reduction in the average number of opioids per prescription. Understanding the importance of actionable, timely data to engage providers in change, the team also created a goal to implement robust analytic capabilities, including visualization of performance that could be used to inform providers of their individual prescribing patterns and habits.

Incorporating analytics to gain insight into prescribing practices

To extract and integrate data from many source systems, CHNw relies on the Health Catalyst^®Data Operating System (DOS™) platform. Leveraging data within the analytics platform, CHNw developed an Opioid Analytics Application to gain insight into prescribing habits over time, including the most frequently prescribed medication and the volume of pills prescribed by individual providers (see Figure 1).

For the first time, CHNw has near real-time orthopedic opioid data. The analytics application supports users in drilling down to individual provider, patient, surgical procedure, and type of opioid prescribed. Data analysts are able to make comparisons of opioid prescriptions over time to understand differences in prescribing patterns.

分析应用程序支持用户深入到单个提供者、患者、手术程序和处方阿片类药物类型。数据分析师能够对阿片类药物处方进行长期比较，以了解处方模式的差异。

Data spurs conversations with providers and patients

Using the data gained from the analytics application, the service line leader began discussions with each provider in the practices, sharing each individual’s opioid prescribing data, and sharing how their prescribing practices compared to that of their peers. The service line leader also shared examples of the small tests of change he had made in his own prescribing practices, and was able to demonstrate that there was not a negative impact on the patient experience, conversations with patients did not take an exorbitant amount of time, and had not increased the number of patient calls after discharge.

These personalized peer-to-peer discussions explored how the provider compared to their peers, national trends in opioid prescribing, and offered an opportunity to talk about concerns. CHNw also made education available to providers to help them better understand the state and federal limits on the number and frequency of opioid medications that can be dispensed at one time.

Changing prescribing practices required that providers engage their patients in a dialogue regarding the risks of opioids, the need to increase the use of non-opioid pain management strategies, and the importance of reducing the number of opioids prescribed. To support providers in having these discussions, CHNw shared best practices, including scripting, that providers can use to guide their conversations with patients and families.

Clinic support staff were provided education and empowered to begin conversations with patients and families during pre-surgery clinic visits for expectation setting about postoperative pain, strategies to manage pain other than by opioid prescriptions, and the importance of limiting excessive opioid pills in the community.

公众对阿片类药物处方风险的认识提高了患者和家属对这一话题的兴趣，并增加了他们使用非阿片类药物疼痛管理治疗方案的意愿。除了一对一的同伴教育，CHNw还在每季度的服务热线会议上公开分享阿片类药物处方数据。透明的数据共享允许供应商继续评估他们与同行的表现。

RESULTS

Using this data-driven approach to engage providers in changing opioid prescribing patterns, CHNw has realized substantial progress in decreasing opioid prescriptions, including:

• 35 percent relative reduction in the total number of opioid pills prescribed, outpacing the 18 percent goal.
• 20.4 percent relative reduction in the average number of opioid pills per prescription.
• 18.8 percent relative reduction in the number of opioid prescriptions.
• 这些减少导致社区中可获得的阿片类药物减少了239,230片，减少了阿片类药物滥用的可能性。
• Maintained patient satisfaction with pain control.

“Along with holding data and analytics to demonstrate the issue, having a shared group goal and increasing conversations has empowered physicians to reduce opioid prescriptions.”

– Stephen Sexson, MD
Orthopedic Surgeon
Network Product Line Leader

WHAT’S NEXT

在骨科服务的成功基础上，CHNw计划为每一种外科手术建立标准的处方指引。此外，改进团队正在与麻醉小组合作，在骨科手术住院阶段减少阿片类药物的使用策略，并计划扩大团队的工作范围，采用更多的服务线路，以确保患者获得充分的疼痛缓解，同时也将阿片类药物滥用的风险降至最低。

REFERENCES

1. Centers for Disease Control and Prevention. (2018).Opioid overdose – Understanding the epidemic.
2. National Institute on Drug Abuse. (2018).Indiana opioid summary – Opioid-related overdose deaths.
3. Morris, b.j. & Mir, h.r.(2015)。The opioid epidemic: Impact on orthopaedic surgery.Journal of the American Academy of Orthopaedic Surgeons, 23(5), 267-271.
4. 罗德里格斯,a(2018)。Patterns of prescribed opioid use after surgery linked to prescription size, study says.The American Journal of Managed Care.