When Intermountain Healthcare leaders issued the challenge to cut the number of opioids we prescribe for acute pain by 40 percent, the Cardiovascular Clinical Program was quickly able to meet the goal and has been able to maintain the lower numbers ever since — all while still ensuring patients’ pain was properly managed. Here’s how they did it.
Linsey Krantz Hsieh, senior data manager of the Cardiovascular Clinical Program, says when her team began searching for ways to lower the number of opioids prescribed to patients who had just undergone cardiovascular surgery, they started by approaching cardiovascular surgeons. They learned that in most cases it wasn’t the surgeons who were prescribing opioids when patients were discharged but it was the advance practice providers (APPs), who work under their supervision.
Krantz Hsieh says the data her team analyzed showed fewer pills could be prescribed to patients following cardiovascular surgery without having a negative impact on our patients. They presented the data to the APPs and the goal was set to have 90 percent of all prescriptions be for 30 or fewer pills. In less than a week the APPs doubled the number of prescriptions at the 30 pills or below mark, Hsieh says.
“They were saying, ‘We’re not doing that already? We can do that,’” she says. “And they just did it and they’ve done it perfectly ever since.”
Ben Christensen, a physician assistant at Intermountain Medical Center, says because the recommendations were data-driven it helped APPs who were prescribing more than 30 pills at a time be more comfortable making adjustments. He says the APPs have been able to educate patients about how many pills they were getting and could always remind their patients that they would be back in a week to discuss their ongoing recovery needs.
Christensen says he always asks patients if they want opioids or narcotics for pain when they’re about to be discharged and says “you’d be pretty surprised how many patients don’t even want narcotic or opioid pain medication in the first place.”
Shelsea Oman, a nurse practitioner who works at McKay-Dee Hospital, says APPs were presented with data that showed that patients, in some cases, weren’t even taking their full prescriptions because they didn’t need them. She says the APPs were asked to prescribe less than 30 pills when discharging patients so they just did it. It was an easy change. She says they often prescribe fewer than 30 pills because they talk with patients and pay attention to how much pain medication they needed while recovering in the hospital.
Krantz Hsieh says it was quite rewarding to be able to share data that adds value to the work our clinicians are doing with patients.
“It was pretty remarkable,” she says. “I think it was a great example that shows if people have access to good data, they’ll act on it. They had a few questions, but we’d done a really good job of thoroughly reviewing our data so they were able to trust it. They knew it was the right thing for the patient and they could see they were already moving in that direction — they just needed a goal. They needed clear direction and then they were on board.”
Providers say the change hasn’t harmed care or a negative impact on patient satisfaction. Since the change Krantz Hsieh says her team has talked with the cardiovascular surgery teams about the number of patients who come back seeking refills on their opioid prescriptions and looked at patient satisfaction data to see if people are having trouble recovering with fewer opioid pills. They haven’t seen an increase in prescriptions being refilled or a drop in patient satisfaction scores, she says.
“Obviously we didn’t want people to be in pain unnecessarily,” she says. “We didn’t want to make things worse for the patient.”
Krantz Hsieh credits the team of people who worked with her to pull the data, the active leadership and support of the surgeons, and, of course, the fact the APPs were so quick to act on the information they received, with the dramatic progress that has been made.
David Min, MD, interim senior medical director of the Cardiovascular Clinical Program, says they utilized a patient-centered, data-driven methodology where clinicians and non-clinicians came together to brainstorm ideas and fresh approaches, in addition to developing ways to track to see whether their innovations were making a difference.
“The surgeons and APPs worked great together as members of our comprehensive heart team recognizing the clinical significance of this issue, working with others to quick developing strategies to combat it, and actively reviewing how their interventions worked and modifying them so that we could quickly address a growing crisis with our patients,” he says.
He says any patient initiative requires an “all-hands-on deck” approach to come up with innovative strategies and solutions.
The 62 percent increase in the number of prescriptions with less than or equal to 30 pills, reflects the change since mid-March 2018 until the end of the year at Utah Valley Hospital, Intermountain Medical Center, Dixie Regional Medical Center, and McKay-Dee Hospital where such cardiovascular surgeries are being performed, she says. This change prevented about 6,000 pills from going out into the community in 2018 alone and the providers have continued this pattern of prescribing throughout 2019.
Systemwide, Intermountain reduced the number of opioid tablets prescribed in 2018 by 30 percent, a remarkable number considering it represents a reduction of more than 3.8 million tablets. In fact, since 2017 Intermountain has reduced the number of opioid pills prescribed by 5,433,553. In addition to the changes the Cardiovascular Clinical Program implemented, Intermountain has explored alternative forms of pain control, healthcare provider and public education, and safe prescription takeback programs.
Intermountain continues to make progress on its opioid goals in 2019. As of July 10, Intermountain has seen an 18 percent reduction in the number of opioids prescribed for acute pain and a 16 percent decline in the number of opioids prescribed for chronic pain this year. In addition, Intermountain has seen a 51 percent decrease in patients with both a benzodiazepine and opioid co-prescribing, which increases the risk of overdose deaths.