Transcript Document

Optimal Prescribing Update and
Support (OPUS)
Webinar
July 19, 2012
www.pspbc.ca
Opus Enters the ‘marketplace of Ideas
Opus enters the ‘marketplace of ideas’
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Session Opening
Dr. Ian Schokking, MD
Agenda
 7:00
Welcome and Introductions (30 minutes)
Session Opening
OPUS
e4Pros
Practice Support Program
Provincial Academic Detailing
 7:30
EQIP Portraits (5 min) and Patient Lists (10 min)
 7:45
Statins and PPIs (90 min)
 9:15
Action Period Planning (15 min)
 9:30
Evaluation and Next Steps (30 min)
 10:00
Adjournment
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Triple Aim of OPUS and Pre-approval
 Divisions' Triple Aim
› Outcomes
› Experience
› Costs
 Pre-Approved Special Authority
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Aims of this OPUS Session
 Reflect on our prescribing in light of evidence
 How to use OPUS Registries to pull charts of patients
who might benefit from a change in prescribing
 How to discuss medication changes with patients
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 Introduce Special Authority Pre-Approval pilot study
 What do OPUS leaders need to facilitate sessions?
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OPUS Steps
Session Lead & QLS: Session Lead, Action Period Patient visit: Follow-up QLS:
Medical Office GPs, MOAs discuss GP self-audit of handout or discuss process
Asst prepare portraits & actions charts
key message lessons & results
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Some GPs sign
Special Auth’ty
Pre-Approval
2b
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3b
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Engage community
pharmacist in Best
Possible Med. Hist.
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Introductions
 OPUS and– Dr. Keith White
 e4PROS – Dr. Kendall Ho
 Practice Support Program – Liza Kallstrom
 Provincial Academic Detailing – Dr. Ruth Campbell
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EQIP Portraits
Dana Stanley
Anonymity: ‘Confidential Portraits’
Aggregate Drug Data on Anonymous GP’s practice
GP Code
EQIP
PORTRAIT
GP Code
EQIP
PORTRAIT
Coded MD ID
Coded Envelope
From UVic
Coded MD ID
Rx Portrait for MD
GP address
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Past and Current EQIP Topics
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First line antihypertensives
Statins
Proton pump inhibitors and H2RAs
Blood glucose test strips
Antibiotics for urinary tract infections
Antibiotics for upper respiratory tract infections
Oral medications for type 2 diabetes
Appropriate use of ACE-Is and ARBs
New EQIP topics are accredited for 1.0 Mainpro-M1 credit
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Review of Portraits
 Your personal prescribing portrait was mailed to you.
 If you brought yours, please do NOT show others.
 The goal is self-audit and self-improvement
 Today we will focus on 3 anonymous portraits from BC:
› 1) a median portrait
› 2) a ‘good’ portrait (more consistent with evidence)
› 3) a ‘less good’ portrait (less consistent with evidence)
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Patient Lists
Dr. Shakeel Bhatti
Your ‘Patient List’ with OPUS Column
1 Subset of Hypertension Registry
2 ‘Hyperlidemia’ Registry
3 Cardiovascular Registry Subset
4 Cardiovascular / Anticoagulation
5 Osteoarthritis Registry Subset
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Why Statins and PPIs?
Dr. Keith White
Statins
Dr. Ruth Campbell
Proton Pump Inhibitors (PPIs)
Drs. Ian Schokking and Keith White
Mary Age 40
 After a negative endoscopy and H.Pylori test 2 years ago, this
lady has taken rabeprazole 20 mg daily.
 She has been symptom free for 6 months since losing some
weight.
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Frank Age 35
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Overweight, 3 months ago classic symptoms of GERD at walk-in.
4 week sample of Tecta and a slip for some bloodwork.
Symptoms disappeared, so he did not bother with the bloodwork.
Return to walk-in and got a further month’s sample of Tecta.
Ran out of Tecta and his symptoms back. Loves Mexican food.
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Frederick, Twin brother of Frank
 Same symptoms, so went to a W/I and asked for some Tecta.
 Symptoms were unaffected by the Tecta. Went for the blood test,
and was H.Pylori +ve.
 Treated with an HP Pac, and his symptoms became worse.
 Loves a big breakfast when he wakes up.
 After you explain about rebound, and chat with him about lifestyle
modification, continued on Tecta once daily.
 Appreciates PPI is adjunct to diet & exercise, not a replacement.
 3 months later he has lost 10 pounds and has elevated the end of
his bed. What now?
 After explain to Frederick that his pill is enteric coated and must
be taken one hour before breakfast, symptoms recede and he can
work on his diet etc.
 2 months later he is symptom free.
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Mrs. Smith Age 47.
 Had a GI Bleed due to an NSAID induced ulcer which bled.
 Treated successfully and now comes to you to discuss her future
management.
 Has RA and really needs her NSAID.
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Mr. Jones Age 55.
 Has new onset dyspeptic symptoms.
 Takes Toradol 10mg tid for back pain.
 Recovering narcotic addict: takes the Toradol because it is nonnarcotic and the literature from the Drug Rep states it is as
effective as codeine.
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Dorothy, age 74.
 Had surgery for a perforated sigmoid colon, due to a diverticular
abscess.
 Became septic and spent some time in ICU.
 Was given IV pantoprazole to prevent “Stress Ulcers”.
 Had been on oral pantoprazole for a year before her illness, for
dyspepsia.
 Developed Ventilator Associated Pneumonia and C.Difficile.
 Has been discharged on pantoprazole 20mg. Dail.
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Action Period Planning
Dr. Keith White
Aims: your goal
for Action Period
Measures: How
am I progressing?
Change Ideas:
What you plan to
do/test
Start
Small and
Grow
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We want to provide the most
appropriate drug at the right time for
the most appropriate duration.
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What does OPUS
mean for you?
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Action Period Expectations
Photos courtesy of jscreationzs
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Aims: What are we Trying to Accomplish?
Answer the following questions:
Which medications?
Statins and PPIs
What do you want to achieve?
Review for appropriateness
For whom? (everyone or just a subpopulation)
All regular patients
By When? (commit to a date)
March 1st, 2012
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Examples
 To improve the prescribing of statins and PPI’s for Dr.
McConville’s regular patients, such that all patients who are
currently on a Statin or PPI are reviewed for appropriateness by
March 1st 2012.
To prescribe a Statin for all patients who meet indications but are
not currently on a Statin and have not previously declined or not
tolerated Statin use.
 By March 31st, 2012, we aim to improve the duration of PPI
treatment for Dr. Blair’s patients, such that all patients who are
prescribed a PPI are reviewed within 4-8 weeks of commencing
treatment for:
› Continuation,
› Change, or
› Discontinuation
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Practice Measures
How will you know a change is an improvement?
Examples:
Count patients for whom statin is changed.
Count number of PPIs tapered, stopped, switched.
Count number of antihypertensives switched.
Count number of patients who start anticoagulant.
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Examples – Dr. McConville
 % of patients currently on a Statin or PPI who have had their
medication reviewed during an office visit.
 % of patients who have had PPI or Statin reviewed for whom
medication was discontinued.
 % of patients who meet indications for statin who are prescribed a
statin.
Note: Excluding those who have declined previously or
discontinued use.
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Examples – Dr. Blair
 % of patients who are listed as being on PPI treatment for over 48wks from EQIP portrait whose PPI is reviewed.
 % of patients whose medication is reviewed that have:
› No change
› Attempted discontinuation
› Recommended for gastroscopy
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Where will you Record your Counts?
 Make notes in margin of registry-patient list?
 Make a bar chart? Check boxes on the bar chart?
 Can you use your EMR? How will you output the results?
 Counts on a tick sheet (e.g. back of patient handout pad)? (see
examples)
 How will you display and share your data? (preferably graphs)
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Change Ideas:
What changes can you
make that will result in
improvement?
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Examples – Dr. McConville
What will you try?
Who needs to be involved?
When will you Start?
Review patient list for those
that should be on statin and
are not.
Review PPI and statin
patients for those that need
to have a discontinuation or
change discussion.
Dr. McConville
December 1st
Dr. McConville
December 1st
Flag charts for follow-up
conversation on statin or PPI
MOA
December 12th
Dr. McConville
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Examples – Dr. Blair
What will you try?
Review the patient list and
compare patients who:
 Meet guidelines
 Don’t meet but need to
be review
 Need to be discontinued
Flag charts for those that
need a review of PPI at next
visit.
Discuss changing or
discontinuing PPIs with
flagged patients.
Who needs to be involved?
When will you start?
Dr. Blair
December 1st
Dr. Blair – List of patients to
flag
MOA – flag charts
Dr. Blair
December 12th
December 13th (or first
flagged patient to come in)
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What is your Action Plan?
What is your Aim?
Which medications?
Time frame that is reasonable
A goal to shoot for
What are your Measures?
Keep it to a manageable number
Leverage data you have available to you
How will you collect your data
What are your next steps?
Who needs to be involved
Commit to a start date
Start Small
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Example of an Action Period Test of Change
What will you do with your statin patients?
1. Review patient in OPUS Lists #2 or #3 and
identify patients who could start or stop statins.
2. Flag patient charts or call in patients you think
would benefit from medication review.
3. Discuss the benefit of statins with patients using
patient handouts.
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Example of an Action Period Test of Change
1. What will you do with PPI patients?
2. Review patient on OPUS List #5 and confirm
patients on a PPI for longer than 8 weeks
3. Flag patient charts or call in patients you think
would benefit from medication review
4. Discuss with patients the idea of tapering and
eventually stopping their PPI therapy
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Patient hand-out: Put Out the Fire (RxFacts, Harvard)
Alternate Rx pad: Step-down of medicines (NPS)
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Action Period Report
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Action Period Expectations
 Try tests of change.
 Track your progress.
 EQIP resources available via phone.
 Monthly support call.
 Materials available at:
http://www.gpscbc.ca/psp_opus
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Examine your OPUS Patient Registries Before QLS
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Your patient list is NOT to be viewed by others.
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Did your list reflect your practice reasonably well?
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Were you surprised by the number of patients listed?
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Do you have any questions about the list?
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Patient List with OPUS Column
1 Subset of Hypertension Registry
2 ‘Hyperlidemia’ Registry
3 Cardiovascular Registry Subset
4 Cardiovascular / Anticoagulation
5 Osteoarthritis Registry Subset
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Table Discussions:What Patients do you Want Listed?
Lists #2 and #3: ‘Hyperlipidemia’ Registry
 Discuss 3 types of patients:
 Women with no previous CVD events, taking statins.
 Low-risk men with no CVD events, taking statins.
 Men or women with CVD history not taking statins.
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Table Discussions: What Patients do you Want Listed?
List #5: ‘GERD/dyspepsia’
 Discuss 3 types of patients:
 Long-term regular users of PPIs, without NSAIDs.
 Long-term regular users of PPIs, with NSAIDs.*
 Long-term episodic users of PPIs.
* e.g. Osteoarthritis Registry, not Rheumatoid Arthritis
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Patient Perspective
 How will these practice changes you have just identified impact
your patients?
› Direct costs to patient
› Patient preferences and barriers to changing medication
› Relationship with you or other care givers
› What else?
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Communicating Changes to Patients
 How will you contact the patient about changing the prescription?
 Suggested wording to discuss the prescription change with the
patient, including addressing their concerns and discussing how
drug change will occur
 What patient materials do you need to help make practice
changes?
 What barriers do you expect to encounter?
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General
Dr. Ian Schokking
Compensation
GP participation
Prototype
Webinar #1
1 session = $407.81
Action Period
1 session = $407.81
Support call
1 hour = $100
Webinar #2
1 session = $407.81
Maximum billing for GP
$1323.43
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Next Steps
 Schedule date for
› webinar session
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› support call
Web-based Support Materials http://www.gpscbc.ca/psp_opus
Contact Information for PSP Coordinators
Sessional payment
Complete evaluation forms
Listserv: [email protected]
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