E3: Prescribing and Peer Review

This is OnePath with Metrohealth, your toolkit for helping to combat the opioid epidemic as a member of the medical community with empathy, mindfulness, and a big-picture perspective. I’m Libbey Pelaia, educator within Metrohealth’s department of Opioid Safety. Thanks for joining us.

In our last episode, we talked about all the different ways that electronic health records and point-of-care dashboards are used to collect and contextualize physicians’ opioid prescribing data. All of these tools were created to promote safer prescribing habits and streamline the process of making informed choices as a care provider.

But… what else is done with this data to impact change? Is there a use for it beyond provider self-regulation, or its role as an organization-wide barometer of overall opioid safety?

Absolutely. The data collected by Metro’s opioid safety tools is used as a foundation for the department of opioid safety’s peer review program, and in this episode of OnePath, we will be taking a comprehensive look at this process, AND led by the perfect guide.

Dr. Joan Papp is the medical director of MetroHealth’s office of opioid safety. An emergency physician by training, Dr. Papp has been with Metro since 2000, and over those years has emerged as a national leader in opioid safety and safer prescribing best practices.

Peer review is an interpersonally and practically impactful tool for creating meaningful change in the practice of prescribers.

JP: Peer review is a concept of reviewing our peers in a number of arenas.The peer review that we're focused on in the office of opioid safety is controlled substance peer review. So, we abbreviate that in our office as CSPR, so we are the CSPR peer review committee.

Essentially, what this process is intended to do is to apply the standards for safe prescribing of these controlled substances throughout our system, by looking at those prescribing practices of our providers, giving those providers some feedback and recommendations for improvement. And, we try to do this in a confidential collegial environment with the goal of reducing adverse patient outcomes and reducing the total number of prescriptions for controlled substances that are leaving our system.

Before the peer review process was as established as it is now, the data collected by the opioid safety dashboard at MetroHealth was analyzed, and was able to provide some very important information.

We identified in our hospital system that about 50% of the opioid prescribing was coming from a fairly small number of providers.

When we decided that we needed to do a little closer look at those providers, we decided that it would probably be wise to focus on that group. And if we were able to change the behavior of those providers, we would make a big impact in opioid prescribing throughout the system. And then after focusing on those providers, we then look at each individual department and try to identify the outliers in each department, if there are one or two prescribers that rise to the top on all of the metrics, we will perform a review on those providers.

When described at a high-level, being selected for review by the office of opioid safety seems similar to something like being selected for an audit by the IRS. But in practice, when a provider is reviewed, lots of context is integrated into the analysis of their numbers.

The numbers don’t tell the whole picture. So, when we see someone who has the appearance of a high volume of prescriptions or high numbers on some of these metrics that we look at, we then take 10 charts, 10 patient charts and we look at them more closely. We apply what we call an advocate checklist.

The advocate checklist is an objective list of best practices that have been adapted from the CDC guidelines in addition to local and state rule, including medical board rules and pharmacy board rules in Ohio.

After the advocate checklist is applied, the peer review committee searches for even more context.

We look at what is the diagnosis the opioid is being prescribed for? What is the MME? What are their comorbidity? So do they have other things that might put them at risk for an adverse outcome like diabetes or heart disease? Do they have COPD and maybe at higher risk for respiratory depression with an opioid? We look at if they are co-prescribed other sedating medications like benzodiazepines or other sedating psychiatric medications or muscle relaxants. And then we look to see if any red flags are showing up in the prescribers record. Are they coming to the emergency department for overdoses? Are they running out of their pills quickly and asking for early refills, those types of things.

And then we try to also identify if providers are routinely doing toxicology screens as recommended by the CDC guidelines. And so, we apply this checklist for 10 patients, and then we put together a summary and we present this to our peer review committee. We review that information and determine what the next step is. And sometimes we perform this review and we recognize that boy, maybe the numbers aren't telling the whole picture, and this provider seems to be adhering to all guidelines and doesn't need an intervention.

But that’s not always the case. Sometimes, the committee recognizes patterns of non adherence to CDC guidelines along with other potentially risky prescribing patterns. In those cases, the committee determines if they can provide further recommendations for that provider, and if that recommendation includes an in-person meeting.

If an in-person meeting is decided upon as the best option, it’s a primary goal to make sure that the experience feels like an opportunity to adjust and learn, not a surprise intervention.

JP: Meeting with the provider can be very intimidating and providers often can feel if it's done in a non-constructive way, that they're being called into question, their practice is being called into question, they can feel like their back's up against the wall. And so we really try to be very thoughtful in the way we approach our feedback.

We try to do that as non-confrontational of a way as possible, we try to make sure that they have an advocate in the room. So on our peer review committee, we have members of a multidisciplinary team. So we have emergency physicians, we have primary care physicians, we have surgeons, we have a psychiatrist, an addiction specialist. We also have pain management specialists as well. And so, we try to match up our provider with somebody from their specialty who can act as an advocate for them, and will often involve the chairperson of their department as well, just so that they don't feel like it's us against them.

We asked Dr. Papp to explain the course of the conversation in a standard provider face-to-face review.

JP: Typically the way we approach it is we just share the data first. We let them see what their numbers look like, and we share that data of their prescribing patterns compared to their peers with their peers they identified. And oftentimes when they see that they're clearly an outlier, that in and of itself can be quite eyeopening for providers. They may not really have had any idea that they were prescribing in a manner that was any different from their peers.

And so, we try to just get feedback on the data first, are there things that perhaps might be driving your prescribing patterns to be different from your peers? Are you seeing a different population of patients than your peers? Do you have a population of chronic pain patients that are ... While all of your peers have young patients who don't have any chronic pain.

We've really had some providers who I think have struggled for a long time and really not known how to address this problem that they recognized was going on. And so, those providers tend to really embrace the process and they welcome it, but there's a spectrum .

Dr. Papp told us that most pushback from providers comes from those who have some pain management training themselves. And that can be a difficult situation.

Pain management training was very different a decade or two decades ago and opioids were really the mainstay of treatment for chronic pain for many years.

And, as we learn new information, we have changed and guidelines have changed. And so, it can feel very intimidating, I think and frustrating to have our group provide feedback to those providers because they see themselves as the experts.I think it's vital to have a advocate in the room, somebody who understands the process and can advocate for that provider and work with that provider to really stay compliant with guidelines and get them on a little bit safer path for their patients.

So once this difficult topic has been broached, what’s next? What recommendations or resources are provided to create positive change? It starts with a review of the CDC guidelines around opioid prescribing.

We walk through the summary of their prescribing and share with them, this is how you're prescribing fits into the guidelines that the CDC recommends and or how you're prescribing is compared to state medical board and pharmacy board rules. And then we will just make sure that they have a good understanding of what those rules and guidelines are because some folks may not be up to date on the guidelines. And so, we just want to make sure that they do know exactly what the guidelines are, what the medical board rules state.

The next offerings include opportunities for further education.

One of my favorite tools for providers is an online safer prescribing course called the scope of pain. And I have no investment in this group, but I think they're really wonderful. It's a free online program and it's basically a couple of hour CME course where you can review best practice for safer prescribing. And again, it's free. And so, we recommend that to all of our providers who are going through the peer review process. We also will refer them to a, and we'll offer to pay for them to attend a Case Western Reserve intense safer prescribing course that lasts about three days. I think it costs a few hundred dollars and our office foots the bill for it.

We also recommend that they do a buprenorphine DEA waiver course, because we recognize that a lot of the patients that they've been prescribing to may have some addiction issues that need to be addressed. And I think one of the things that we've learned from our providers is that they don't really necessarily know what to do once they identify that their patient is struggling with addiction. And so giving them that tool, that extra tool and training on how to care for a patient with addiction and how to prescribe buprenorphine for medication assisted treatment can really add another tool in their toolbox when they're prescribing to a patient and they recognize that an addiction is present.

Lastly, a pain management pharmacist is available to work with providers.

JP: ...who will work with our providers, review, do a chart review, look at the prescriptions for opioids as well as other medications that the patient may be on and provide feedback and make recommendations for weaning the opioids.

While the peer review process is, by definition, a process created for shaping provider behavior at its core, troubling information about patients can also present itself during this process.

I'm sure you can imagine, when we're doing this process and we're doing these patient chart reviews, we often identify patients who may be at immediate risk. So, that may be because they're either on a very high dose of an opioid, they may be on a high dose of an opioid plus a benzodiazepine. Sometimes, we identify that on a tox screen there is illicit substances that have not been addressed. So those patients, we really want to work with the provider to get that patient either weaned off of the opioid or into some addiction treatment.

And so, the parallel process that collaborates with our peer review is our controlled substance case manager. And so, we have a utilization review nurse who does all of the peer reviews and when she identifies a patient who looks like they might need a referral or some other intervention, she will hand that patient off to our case manager. And that process moves forward outside of the peer review process.

That being said, Dr. Papp and the office of opioid safety strongly discourage stopping prescriptions abruptly.

We recognize that that leads to withdrawal in many cases and can lead patients to feel very isolated, potentially seek drugs on the street. And so, doing things in a very slow, methodical and thoughtful way is really important to helping not only maintain the patient relationship, but also to keeping that patient safe and away from illicit drugs during the process.

So what can you do if you’re concerned about the opioid prescribing levels of a caregiver-- as a fellow physician, or as a patient yourself, or even as a loved one of a patient?

In our institution, they can certainly come to the office of opioid safety, send us a message, say, hey, I'm concerned about a provider, and we're happy to do a review. Since we started a peer review process, we have gotten feedback from and referrals for providers, really through a number of routes. We've gotten confidential referrals from concerned family members. We've gotten confidential referrals from legal. We have gotten referrals from the pharmacy. If they have noticed that a particular provider is prescribing far more than their peers.

Dr. Papp says that providers themselves should feel absolutely free to seek out the guidance and resources of the office of opioid safety as well.

We have had providers approach us and say, I'm concerned about a patient or a number of patients and I just, I need help. I don't know how to wean the opioids, I don't know what to do now that I've identified that my patient has an addiction and would like to get some of those resources of your office.

Next time on OnePath…

We talk to pharmacist Amanda Benedetti and Dr. Mike Harrington about pain management and the role of the pharmacist.

OnePath with Metrohealth is a production of Evergreen Podcasts, produced, written, and engineered by Hannah Rae Leach and mixed by Sean Rule-Hoffman. Special thanks to Mike Tobin, Karolyn Tibayan, Joan Papp, Joya Riffe, and the entire Department of Opioid Safety in making this show possible.