Eric Weil

The opioid epidemic and new legislation in Massachusetts: Time for a culture change in surgery?

B etween 1999 and 2008, the rate of overdose deaths from prescription opioid pain relievers (OPR) in the United States increased 4-fold. This alarming increase in OPR-related death rate was paralleled by a simultaneous increase in the sales of OPR, and also an increase in the rate of admissions for opioid use disorder treatment nationally. Since then, the OPR overdose epidemic continued to worsen, with unintentional drug overdose now becoming the leading cause of accidental death in the United States, killing more Americans than motor vehicle crashes or firearms. Prescription opioids account for the greatest number of drug-related deaths in the United States: of 47,055 drug overdose deaths in 2014, 18,893 were related to OPR and 10,574 to heroin. Among individuals who have used an OPR for a nonmedical reason, 69% report getting the medication from a friend or relative, the majority of whom received the original prescriptions from a single physician. Massachusetts has been hit particularly hard by the opioid epidemic. In 2013, poisoning and overdoses were the leading cause of injury in the state, accounting for 37% of deaths, compared with falls and motor vehicle crashes that accounted for 20% and 11% of injury deaths, respectively. Examination of this trend reveals the driving role opioids have played in these trends: from 2009 to 2013, the rate of opioid overdoses in Massachusetts increased from 9.6 per 100,000 people to 14.2 per 100,000 people. In addition to the death toll, for every opioid overdose death in Massachusetts, there were twice as many hospitalizations and 4 times as many emergency room visits for nonfatal opioid overdose, resulting in a substantial burden on the healthcare system. In response to the opioid epidemic, Massachusetts Governor Baker proposed a comprehensive legislation in late 2015. After multiple revisions, The STEP Act, an act relative to Substance use, Treatment, Education, and Prevention, was signed into effect in March 2016. The law detailed several components focused on OPR prescription. Table 1 illustrates some of the key parts of the law that surgeons in Massachusetts not only need to understand but also need to legally abide by. Although it is likely too early to fully understand the new opioid law in Massachusetts, interpret its mandates, or even get a sense of the degree to which it will be strictly enforced, 1 thing is now clear: our current approach to acute perioperative pain relief, as surgeons, needs to change. The predominant opioid-centric habits and traditions of OPR prescriptions in surgical fields have partially contributed to the epidemic, and a culture change in perioperative pain management is needed. Such a change will not be fast or easy and will require funds and resources, as it will probably affect multiple aspects of the surgical patient care that we cannot yet fathom, including current surgical and clinic workflow, patient expectations for perioperative pain, and the patient’s care satisfaction. Patientcentered outcomes including patients’ perception of the quality of care they receive [eg, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores] might be negatively affected by limiting OPR use unless patients’ expectations are addressed and managed a priori. Several experts understandably debate the misconception that prescribing more opioids creates better patient satisfaction, but the message remains clear either way: preoperative empathetic discussions with the patients to optimize their coping mechanisms and the design of pathways for pain management that are not opioid-centric are both essential. The Massachusetts General Hospital (MGH) is one of the 2 major hospitals of Partners Healthcare, the largest private employer and the biggest healthcare provider in the Boston Metropolitan area, serving more than a third of its population. MGH and its physician organization, the Massachusetts General Physicians Organization (MGPO), recognizing the need for a comprehensive strategy to support patients and prescribing physicians alike, established a multidisciplinary opioid task force in late 2015 with one of its goals being to provide guidance regarding the use of opioid

Patient Population Loss At A Large Pioneer Accountable Care Organization And Implications For Refining The Program

There is an ongoing move toward payment models that hold providers increasingly accountable for the care of their patients. The success of these new models depends in part on the stability of patient populations. We investigated the amount of population turnover in a large Medicare Pioneer accountable care organization (ACO) in the period 2012-14. We found that substantial numbers of beneficiaries became part of or left the ACO population during that period. For example, nearly one-third of beneficiaries who entered in 2012 left before 2014. Some of this turnover reflected that of ACO physicians-that is, beneficiaries whose physicians left the ACO were more likely to leave than those whose physicians remained. Some of the turnover also reflected changes in care delivery. For example, beneficiaries who were active in a care management program were less likely to leave the ACO than similar beneficiaries who had not yet started such a program. We recommend policy changes to increase the stability of ACO beneficiary populations, such as permitting lower cost sharing for care received within an ACO and requiring all beneficiaries to identify their primary care physician before being linked to an ACO.

Communicate, don't litigate: The Schwartz Center Connections Program

Little is known about effective educational approaches intended to reduce malpractice risk by improving communication with patients and among multidisciplinary teams in outpatient settings in order to prevent diagnostic delays and errors. This article discusses a prospective, controlled educational intervention that aimed to open lines of communication among teams in two disciplines: identifying how and why communication lapses occur between disciplines and with patients, and articulating strategies to avert them.

Development and Implementation of a Collaborative Team Care Model for Effective Insulin Use in an Academic Medical Center Primary Care Network

Improving glycemic control across a primary care diabetes population is challenging. This article describes the development, implementation, and outcomes of the Diabetes Care Collaborative Model (DCCM), a collaborative team care process focused on promoting effective insulin use targeting patients with hyperglycemia in a patient-centered medical home model. After a pilot, the DCCM was implemented in 18 primary care practices affiliated with an academic medical center. Its implementation was associated with improvements in glycemic control and increase in insulin prescription longitudinally and across the entire population, with a >1% reduction in the proportion of glycated hemoglobin >9% at 2 years after the implementation compared with the 2 years prior (P < .001). Facilitating factors included diverse stakeholder engagement, institutional alignment of priorities, awarding various types of credits for participation and implementation to providers, and a strong theoretical foundation using the principles of the collaborative care model.