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Timothy C. Cox, MD, FACPTim Sparling, DNP, RN, AGPCNP-BC, ACHPN
Bronson Battle Creek Cancer Care Center
Pain Management for Physicians
Objectives
O Examine QOPI measures. O Learn Bronson Cancer Care Center’s process.O Discuss rational & interventions to improve
outcomes. O Share relevance and applicability to other clinics.
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Take-aways from presentation
QOPI Pain MeasuresO CORE 3-6e:
O Pain assessed by second office visit (and most recent 2 visits)
O Pain intensity quantified by second office visit (and most recent 2 visits)
O Plan of care for moderate/severe pain quantifiedO Pain addressed appropriately
O EOL 35-38:O Pain assessed on either of last two visits before deathO Pain intensity quantifiedO Plan of care for moderate/severe pain quantified O Pain addressed appropriately
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The Why of Pain Management?
O Increasing evidence that better symptom control leads to better survival
O 59% of patients undergoing anticancer therapy have pain
O 63% of patients with advanced or metastatic cancer have pain
O 33% of patients have pain after completion of curative treatment
O More than 1/3 patients rated pain moderate-severe
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Better Medicine
(Van den Beuken-van Everdigen et al., 2007)
Reimbursement
O Value Based ReimbursementO 1. Pain addressed appropriately (Core #6d, #6e &
End of Life #38)O 2. Smoking/tobacco cessationO 3 Hospice, palliative care referral/services
O MIPSO 1. Oncology: Medical and Radiation: Pain Intensity
Quantified
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Better Reimbursement
LMOR Region
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Pain addressed appropriately by second office visit and during the most recent office visits (measure 6e CORE module)
Prop
ortio
n
Practice Number and Comparative GroupsSource: ASCO-QOPI data: Fall 2014, Spring & Fall 2015, Spring 2016
LMOR Region
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Pain addressed appropriately on either of the two visits before death (measure 38 End of Life Module)
Prop
ortio
n
Practice Number and Comparative GroupsSource: ASCO-QOPI data: Fall 2014, Spring & Fall 2015, Spring 2016
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Rate_Spring2014 Rate_Spring2015 Rate_Fall2016 Rate_Spring2017
Pain by 2nd Office Visit
Pain assessed by second office visit
Pain intensity quantified by second office visit
Plan of care for moderate/severe pain documented
Pain addressed appropriately (defect-free measure, CORE3, CORE4a, and CORE5)*
Results
Source: ASCO-QOPI data: By module, Spring 2014-Spring 2017
Results, continued
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Rate_Spring2014 Rate_Spring2015 Rate_Fall2016 Rate_Spring2017
Pain at Two Most Recent Visits
Pain assessed on either of the two most recent office visits
Pain intensity quantified on either of the two most recent office visits
Plan of care for moderate/severe pain documented on either of the two most recent office visits
Pain addressed appropriately on either of the two most recent office visits (defect-free measure, CORE6a, CORE6b, and CORE6c)
Pain addressed appropriately by second office visit and during most recent office visits (defect-free measure, CORE6 and CORE6d)
Source: ASCO-QOPI data: By module, Spring 2014-Spring 2017
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
Rate_Spring2014 Rate_Spring2015 Rate_Fall2016 Rate_Spring2017
Pain Management at End of Life
Pain assessed on either of the last two visits before death
Pain intensity quantified on either of the last two visits before death
Plan of care for moderate/severe pain documented on either of the last two visits before death
Pain addressed appropriately (defect-free measure, EOL35, EOL36a, and EOL37)*
Results, continued
Source: ASCO-QOPI data: By module, Spring 2014-Spring 2017
Our process started . . .
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10,000 Foot ViewO March 11, 2016 EBP Pain Management Pathway discussed at Providers
meeting O Recommendations taken to the providers meeting March 25, 2016 for
review of preliminary pain pathway.O Pathway reviewed and supported at the March 31, 2016 Quality
Committee
PathwayO 1.Nurse reports pain scores to physician or APPO 2.Physician/APP prescribe preferred medication O 3.Follow up phone call made by provider’s RN 3 business daysO 4. Physician or APP makes dose adjustments as neededO 5. Follow up phone call made by physician’s RN again 3 business days
O Results analyzed 1 month out and then quarterly by Quality Committee, as well as re-education of staff on pain management updates.
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RN Assessment Screen
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Step 1: Mild pain(rating 1-3)
Step 2: Moderate(rating 4-6)
Step 3: Severe(rating 7-10)
3 Step Analgesic Ladder for Pain Management
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Valuable Resources for PracticesO American Pain Society website: Pain management and dosing guide (free):
http://americanpainsociety.org/uploads/education/PAMI_Pain_Mangement_and_Dosing_Guide_02282017.pdf
O American Pain Society, Principles of Analgesic Use, Pocket Guide: http://apps.americanpainsociety.org/Default.aspx?TabID=251&productId=11764514
O ASCO: Website/PDF & Iphone/tablet versionsO BCBS Compassion and Support @ EOL: free Guides and links:
http://www.compassionandsupport.org/index.php/for_professionals/pain_managementO CAPC Links: (some free): https://www.capc.org/providers/palliative-care-resources/quick-links/O City of Hope, Palliative Care: Website/PDF: http://prc.coh.org/default.aspO City of Hope & Nursing Research & Education: (Free-what was used in presentation)
http://prc.coh.org/NRE%20Pain%20Card%20revised%209.29.16.Final%20%20CR.pdfO Fast Facts!!!! Amazing, most free, Iphone/Android: https://www.mypcnow.org/fast-factsO (Free) Opioid Conversion Calculator: http://www.globalrph.com/narcoticonv.htmO NCCN: Website/PDF & Iphone/tablet versionsO Opioid Pocket Prescribing Guide: https://www.capc.org/shop/catalogue/prescribing-opioids-a-
pocket-reference-pack-of-25_4/http://www.aacn.nche.edu/elnec
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Future ConferencesO American Academy of Hospice and Palliative Medicine, Annual Assembly:
http://aahpm.org/meetings/assembly
O Oct 12-15: MD Anderson: 21rst Annual Interdisciplinary Conference on Supportive Care, Hospice and Palliative Medicine with Board Review: https://www.mdanderson.org/education-training/professional-education/cme-conference-management/conferences/20th-annual-interdisciplinary-conference-on-supportive-care--hos.html & https://www.mdanderson.org/education-training/professional-education/cme-conference-management/conferences/updates-in-hospice-and-palliative-medicine-and-intensive-board-r.html
O American Pain Society: Scientific Summit, Understanding Pain Mechanisms: http://americanpainsociety.org/annual-meeting/2018-scientific-summit
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Thank you
O Dr. Timothy Cox’s contact information: [email protected], cell 589-295-9159
O Dr. Tim Sparling’s contact information: [email protected], cell 269-720-8382
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O American Nurses Association. (2015). Nursing scope and standards of practice, 3rd ed. Silver Spring, MD: Author.
O American Nurses Association & Hospice and Palliative Nurses Association. (2014). Palliative nursing: scope and standards. Silver Springs, MD: American Nurses Association.
O Bostwick, J. (2012). Blurred boundaries: the therapeutics and politics of medical marijuana. Mayo Clinic Proceedings,87(2), 172-186.
O Drayer RA et al. Barriers to better pain control in hospitalized patients. JPSM 1999; 17:434-440.
O Einstein, D.J., Gregas, M., Lynch, J., McDermott, D.F., & Buss, M.K. (2017). Improving end-of-life care: Palliative care embedded in an Oncology Clinic specializing in targeting and immune-based therapies. Journal of Oncology Practice: Retrieved from http://ascopubs.org/doi/full/10.1200/JOP.2016.020396
O Ferrell BA. Pain management in elderly people. JAGS 1991; 39:64-73.
O Heiskanen, T., Mätzke, S., Haakana, S., Gergov, M., Vuori, E., & Kalso, E. (2009). Transdermal fentanyl in cachectic cancer patients. Pain, 144(1-2), 218-222. doi: 10.1016/j.pain.2009.04.012.
O Hutchinson, RW et al. Evaluation of a behavioral assessment tool for the individual unable to self-report pain. Am J Hospice and Palliative Med 2006; 23(4):328-31.O McCarberg, B. Stanos, S. Key patient assessment tools and treatment strategies for pain management. Pain Practice 2008; 8(6):423-432.
O Mersky, H. (1979). Classification of chronic pain: descriptions of Chronic pain syndromes and definitions of pain terms. Pain, S 3 Pt.2, S215-S221.
O National Consensus Project for Quality Palliative Care. (2013). Clinical practice guidelines for quality palliative care, 3rd edition. Pittsburgh, PA: NCP. http://www.nationalcoalitionhpc.org/guidelines-2013/
O Paice, J.A., Portenoy, R., Lacchetti, C., Campbell, T., Cheville, A., Citron, M. et al. (2016). Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. Journal of Clinical Oncology, 34(27), 3325-45
O Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacological management. New York, NY: Mosby Elsevier.
O Serlin RC et al. When is cancer pain mild, moderate or severe; Grading pain severity by its interference with function. Pain 1995; 61:277.
O Van den Beuken-van Everdigne, M.H., de Rijke, J.M., Kessels, A.G., Schouten, H.C., van Kleef, M. (2007) Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Annals of Oncology, (9): 1437-1449.
O https://doi-org.proxy.lib.ohio-state.edu/10.1093/annonc/mdm056
O Ward SE et al. Patient-Related Barriers to Management of Cancer Pain. Pain 52:319-324, 1993.
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Palliative Care Requirements
O COC: Standard 2.4: https://www.facs.org/quality-programs/cancer/coc/standards
O NAPBC, Support and Rehabilitation: https://www.facs.org/~/media/files/quality%20programs/napbc/2014%20napbc%20standards%20manual.ashx
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Assessment and DocumentationOPQRSTU
O Onset O Palliation/Precipitation O Quality/QuantityO Region/RadiationO Symptoms/SeverityO Temporal/TimingO U-how does it affect the patient?
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Additional Resources (A. Vallerand, 2011)
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Quick Bios: Dr. Cox
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• Bachelor’s Degree: University of Michigan • University of Rome, Rome, Italy• Residency: St. John Hospital and Medical Center,
Detroit• Oncology/Hematology Fellowship: William
Beaumont Hospital, Royal Oak
Quick Bios: Dr. Sparling
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• Bachelor’s of Nursing University of Phoenix• Doctorate of Nursing Practice: Wayne State University• Board certified Adult-Gerontology Primary Care Nurse
Practitioner• Advanced Certification in Hospice and Palliative Nursing• Post-Doc Study at City of Hope• Certified End of Life Nursing Education Consortium
teacher• Part-time faculty at Ohio State University and Kent State
University
