a comprehensive primary care / systems engineering ... · coaching model the usual approach to...
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A comprehensive primary care / systems
engineering partnership model aimed at
mitigating the prescription opioid epidemic
Andrew Quanbeck, Ph.D.
Center for Health Enhancement Systems Studies / Department of
Industrial & Systems Engineering
University of Wisconsin-Madison
Funding: National Institute on Drug Abuse R34 DA036720-01ª1
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• National Institute on Drug Abuse
• UW Health Primary Care Clinics
• Advisory panel Jane Ballantyne, MD Paul Batalden, MD
Roger Chou, MD Perry Fine, MD
David Gustafson, PhD Jonas Lee, MD
Dennis McCarty, PhD Beth Potter, MD
John Frey, MD
• Project team: Bri Deyo, Aleksandra Zgierska, Bobbie
Johnson, Esra Alagoz, Nora Jacobson Jim Robinson,
Wen-Jan Tuan, Lynn Madden
Thank You!
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• No significant financial relationships
Disclosures
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• Background/motivation for study
• Aims
• Methods
• Anticipated outcomes & future work
Overview
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Aims of the Project
Goal is to improve patient safety by instituting a
set of universal precautions for opioid prescribing
in primary care
R34 grant mechanism is specifically for testing the
feasibility, acceptability, and preliminary
effectiveness of novel implementation strategies in
preparation for larger trials
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Implementation Strategy: Systems Consultation
Proven in a large randomized trial of addiction
treatment organizations (Gustafson et al., 2013) and
used by ~ 4000 organizations nationwide
Systems engineering tools:
Walkthrough exercises
Group decision making (nominal group technique)
Plan-Do-Study-Act change cycles
What adaptations are needed to translate the NIATx
approach to primary care?
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Source: “Personal Best”
Atul Gawande, writing in
the New Yorker
October 3, 2011
Peer coaching: The key to
cost-effective dissemination
(Gustafson et al., 2013)
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Coaching model
The usual approach to organizational change in
healthcare: surveillance, scolding, etc.
Our approach: self determination theory
Competence
Relatedness
Autonomous motivation
Perspective, empathy, and homophily
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First things first….
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Workgroup
Pain management specialists (3)
Primary care physicians (3)
Systems engineers (2)
Addiction and drug policy (1)
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Integrated Group Process (Gustafson et
al., 1993)
1. Choose participants
2. Develop a straw model through telephone interviews
3. Convene the group and revise the straw model
4. Design case scenarios
5. Enumerate the model
6. Identify sources of conflict
7. Average the smaller differences
8. Report the group’s judgment
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Patient archetypes
1. An existing patient of the clinic, not currently using opioids,
with a new chronic pain complaint, who might be a candidate
for opioid therapy
2. An existing patient of the clinic already on long-term
opioid therapy
3. An “inherited” patient (i.e., a patient that is new to the clinic
but is already on long-term opioid therapy)
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Mapping the recommendations onto an actionable,
checklist-based implementation guide
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• Create a detailed flowchart of Rx refill process and
monitor incoming requests
• Compare patient’s chart to checklist and set up
appointments with patients to take steps towards risk
minimization
• Set a clinic-wide expectation to limit dose to 100 MEDD
for current/future patients.
• Use skill, judgment, and advice in dealing with inherited
and/or high-dose patients.
General approach
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4 implementation clinics recruited (7 approached)
Initial site visits completed on May 24, 2016
6-month intervention period extends through end of
2016 (staggered)
Final site visit – October, 2016
Mixed-methods evaluation
Where we are now…
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Coming next…
• Parsing the systems consultation
implementation strategy into a set of
discrete components
• National study using SMART design to
promote systems-level improvement in
the most efficient manner possible
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For more information, see:
Quanbeck, A., Brown, R. T., Zgierska, A., Johnson, R.,
Robinson, J. M., & Jacobson, N. (2016). Systems
consultation: protocol for a novel implementation strategy
designed to promote evidence-based practice in primary
care. Health Research Policy and Systems, 14(1), 1.
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Preliminary Data
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
I-3 I-4 C-1 Mean C-2 C-3 I-1 C-4 I-2
% pts 3 months consecutive opioid use
Oct-Nov-Dec Jan-Feb-Mar Apr-May-Jun
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Background Data
-
20
40
60
80
100
120
140
160
180
I-3 C-2 I-4 C-1 C-3 Mean I-2 C-4 I-1
Average MEDD (mg)
Oct-Nov-Dec Jan-Feb-Mar Apr-May-Jun
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Background Data
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
I-3 C-1 C-2 C-3 Mean I-1 C-4 I-4 I-2
% MEDD > 100 (mg)
Oct-Nov-Dec Jan-Feb-Mar Apr-May-Jun
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Background Data
0%
10%
20%
30%
40%
50%
60%
70%
80%
C-1 I-4 C-2 I-3 Mean C-4 C-3 I-1 I-2
% UDT in Previous 12 Months
Oct-Nov-Dec Jan-Feb-Mar Apr-May-Jun
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Background Data
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
C-1 I-4 C-2 I-3 Mean C-3 C-4 I-2 I-1
% Treatment Agreement in Previous 12 Months
Oct-Nov-Dec Jan-Feb-Mar Apr-May-Jun
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Other outcomes
Benzo co-prescribing rates
Mental health screening rates
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Preliminary results
UDT screening
Completion of treatment agreements
Feasibility, acceptability
Comments from participants
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Discussion question
What would we need to do differently for this
model to work in trauma centers?
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Thanks!
Andrew Quanbeck, PhD
Please contact me for latest slide deck.