Patient and Provider Education on Pain in Cancer: A Cost-Saving Intervention

An experiment by an integrated healthcare delivery system to document personalized pain management goals (PPGs) for patients in oncology clinics lowered documented pain and simultaneously reduced treatment costs. While achieving a pain level of zero may not be possible, the authors suggest that achieving the patient’s PPG is a good start.

As part of Park Nicollet Health Services quality improvement course, a team that included a medical oncologist, oncology nurse practitioner, oncology nurse, pharmacist, statistician, computer programmer, and quality improvement leaders, documented pain values from the electronic health records (EHR) for oncology patients in the of outpatient clinics, to document:

• Pain levels during a predetermined 18-month period
• Reporting and achievement of PPG
• Monthly tabulation of opioid prescriptions

Following analysis of this data, the researchers introduced a pain intervention that included patient education on pain management (using a handout), clinician education on opioid cost effectiveness, and instituting a nursing protocol to document PPGs. The patient education handout detailed appropriate opioid use and complications associated with using opioids, such as constipation. Physician education included a combination of a discussion with a palliative care physician and cost information data on various opioids, extracted from a hospital pharmacy.

The study determined that 15% of patient encounters reported moderate to severe pain. While PPGs were marked at 16% prior to the intervention, in June 2014, it crossed the 70% mark a year following the introduction of the intervention in the oncology clinic, in June 2015. The authors write that the actual achievement of a PPG per EHR data was at 84% at that point in time.

Prescribing practices saw a simultaneous change, with a significant downturn observed in the prescription of high-cost opioids following clinician education on the cost of these medications. While low-cost and high-cost opioids were prescribed at the same rate prior to the intervention, June 2015 saw double the number of low-cost opioid prescriptions (n = 71), compared with high-cost prescriptions (n = 35)—a 10% drop in the prescription of high-cost opioids.

The authors believe that a PPG is a much better strategy over the standard pain measure that is commonly used in oncology clinics, considering that each patient will have unique pain thresholds. The authors write that PPGs can improve patient satisfaction because they signify to the patient that their physician is listening to their concerns and is focused on providing them with personalized quality care.

The authors also note an indirect impact of the intervention on workflow efficiency and a shift in the nurses focus away from prior-authorization requests (due to the use of low-cost opioids) and toward patient care. An average saving of 90-minutes that a nurse has to spend on processing prior authorizations (at least 3 of these each week), is 90 minutes added to patient care, the authors point out.

The researchers plan to track patient-reported outcomes through a symptom assessment tool that exports data to the patient’s HER for use at the point of care, auto-generate flags on uncontrolled pain, and underlying causes for why patients need to continue treatment on high-cost medications.

Reference

Zylla D, Larson A, Chuy G, et al. Establishment of personalized pain goals in oncology patients to improve care and decrease costs [published online January 3, 2017]. J Oncol Pract. doi: 10.1200/JOP.2016.017616.