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Managing Pain

Collaborative Care for Chronic Pain

Guideline Information

Guideline title: Collaborative Care for Chronic Pain Report and Guidelines

Publication Status: Active

Date of publication: 2018

Date of last evidence search: 2018

Scope: Patient self-management, minimum standards of care, care team, treatment, population health.

Methods: Current guidelines and literature review and expert consensus

Description: The goals for collaborative care focused on chronic pain with life activity impacts are improved function, increased quality of life, and greater patient autonomy rather than a primary focus on pain relief. The workgroup aimed to define areas within collaborative care unique to chronic pain with life activity impacts while also developing a system to recognize and limit the transition from acute and subacute pain to chronic pain. Ideally, both acute and chronic pain will be managed and treated over time using a systems approach to allow patients to stay within primary care supported by the minimum standards of collaborative care including: patient identification and population management, a care team, a care management function, basing treatments in evidence-informed care, and patient-centered supported self-management.

Supporting Materials

Letter from the Health Care Authority Accepting the Collaborative Care for Chronic Pain Recommendations
Collaborative Care for Chronic Pain Workgroup Charter and Roster

Metrics and Evaluation Tools

To support health system improvement the Bree Collaborative has created score cards that are designed to help measure progress on the implementation of our guidelines. These were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our score cards, find the audience type, or types, that is closest to your organization or area of improvement work and download the document. There may be more than one “audience” type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Score cards are also aligned with the Bree Collaboratives’ self-report data collection efforts. Organizations are not required to report, however anyone can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards.

Primary Care

Primary care Score Card

Health Systems

System Score Card 

Health Plans

Health Plan Score Card_

Employers/Purchasers

Employer_Score Card

Guideline Metrics

The work group did not recommend specific metrics, however audience specific evaluation score cards and other prescribing metrics developed by the Bree Collaborative can be useful. These measures can be found on the Washington State Common Measure Set. For all of these measure a decrease is improvement.

  • New Opioid Patient Days Supply of First Opioid Prescription
    • Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
      Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.
  • New Opioid Patients Transitioning to Chronic Opioids
    • Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
      Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.
  • Patients Prescribed High-Dose Chronic Opioid Therapy
    • Numerator: Number of patients in the population prescribed >60 days’ supply of opioids at >50 mg/day or >90 mg/day MED.
      Denominator: Number of patients in the population prescribed >60 days’ supply of opioids in the calendar quarter.       Report each result as prevalence per 1,000 population, age and sex adjusted.
  • Use of Opioids at High Dosage (HDO)
    • The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

WorkGroup Members

Name Title Organization
Leah Hole-Marshall, JD (chair) Counsel and Chief Strategist Washington Health Benefit Exchange
Ross Bethel, MD Physician Selah Family Medicine
LuAnn Chen, MD, MHA, FAAFP Medical Director Community Health Plan of Washington
Lynn DeBar, PhD, MPH Senior Investigator Kaiser Permanente Washington Health Research Institute
Stuart Freed MD Chief Medical Officer Confluence Health
Andrew Friedman, MD Physiatrist Virginia Mason Medical Center
Mark Murphy, MD President Washington Society of Addiction Medicine
Mary Kay O’Neill, MD, MBA Partner Mercer
Jim Rivard, PT, DPT, MOMT, OCS, FAAOMPT President MTI Physical Therapy
Kari A. Stephens, PhD Assistant Professor – Psychiatry & Behavioral Sciences University of Washington Medicine
Mark Sullivan, MD, PhD Professor, psychiatry; Adjunct professor, anesthesiology and pain medicine University of Washington Medicine
Nancy Tietje Patient Advocate
Emily Transue, MD, MHA Associate Medical Director Washington State Health Care Authority
Michael Von Korff, ScD Senior Investigator Kaiser Permanente Washington Health Research Institute

Dental Opioid Prescribing

Guideline Information

Guideline title: Dental Guidelines on Prescribing Opioids for Acute Pain Management Report

Publication Status: Active

Date of publication: 2017

Date of last evidence search: 2017

Scope: Perioperative period, Intraoperative Period, Postoperative Period prescribing considerations

Methods: Current guidelines and literature review and expert consensus

Description: This is an easy‐to‐use reference to help dentists, oral surgeons, and others follow a set of clinical guidelines  and access supporting evidence and resources in the appendices to align opioid prescribing with current evidence. We recommend revising office‐prescribing practices as necessary to be consistent with this guideline, the American Dental Association (ADA) statement, and the Centers for Disease Control and Prevention (CDC) guideline. We also recommend considering the feasibility of embedding key practices from these guidelines into electronic health record systems. Lastly, we recommend educating office staff and patients about the risks and benefits of opioids, individualizing pain management strategies for each patient’s clinical situation, and avoiding “just in case” prescribing.

Supporting Materials

Letter from the HCA Accepting Dental Prescribing Guidelines
Opioid Guideline Implementation Charter
Agency Medical Directors Group Interagency Guideline on Prescribing Opioids for Pain
AMDG Guideline Summary

Metrics and Evaluation Tools

To support health system improvement the Bree Collaborative has created score cards that are designed to help measure progress on the implementation of our guidelines. These were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our score cards, find the audience type, or types, that is closest to your organization or area of improvement work and download the document. There may be more than one “audience” type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Score cards are also aligned with the Bree Collaboratives’ self-report data collection efforts. Organizations are not required to report, however anyone can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards.

Health Systems, Dental Care Providers

Health System Evaluation Score Card Health System Score Card _ dental Rx

Health and Dental Plans

Health Plan Evaluation Score Card Health Plan Score Card _ Dental Rx

Guideline Metrics

New Opioid Patient Days Supply of First Opioid Prescription

Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.

New Opioid Patients Transitioning to Chronic Opioids

Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.

Use of Opioids at High Dosage (HDO)

The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year. (Bree Collaborative recommendations: track for adolescents)

Examples of Implementation - NEW!

Changing Dental Opioid Prescribing Practices Through Education and Monitoring

This project was a collaboration between Delta Dental of Washington, two of their largest purchasers, the Acora Foundation, and Healthentic. One purchaser voiced an interest in addressing prescribing practices for individuals under the age of 25.  After looking at the data, the problem that Delta Dental identified was that a small percentage of their contracted dentists were routinely prescribing quantities of opioid medications that were inconsistent with published best-practice guidelines.

Delta Dental used Bree Collaborative guidelines, along with other information on best practices, to design an intervention consisting of patient education, provider education, and provider monitoring and consulting. During the course of their intervention, a second purchaser group was added, providing opportunities for further impacting over-prescribing of opioids for youth during dental encounters.

A summary of their work can be found HERE. More information on the outcomes and examples of their interventions materials will be posted as they become available.

WorkGroup Members

Name Title Organization
Chris Baumgartner Director Prescription Monitoring Program Washington State Department of Health
David Buchholz, MD Medical Director Premera Blue Cross
Rolf Christensen, DDS Dental Urgent Care Clinic Director University of Washington School of Dentistry
Tom Dodson, DMD, MPH Professor & Chair, Oral and Maxillofacial Surgery University of Washington School of Dentistry
Gary Franklin, MD, MPH (Chair) Medical Director Washington State Department of Labor and Industries
Charissa Fontinos, MD Deputy Chief Medical Officer Washington State Health Care Authority
Bea Gandara, DDS Professor University of Washington School of Dentistry
Frances Gough, MD Chief Medical Officer Molina Healthcare
Dan Kent, MD Chief Medical Officer UnitedHealthcare
Kathy Lofy, MD Chief Science Officer Washington State Department of Health
Jaymie Mai, PharmD Pharmacy Manager Washington State Department of Labor and Industries
Theresa Madden, DDS, MS, PhD Fellow International College of Dentists
Ron Marsh, DDS Member Washington State Dental
Quality Assurance Commission
Mellani McAleenan, JD Director of Government Relations Washington State Dental Association
Shirley Reitz, PharmD ‎Clinical Pharmacist Client Manager OmedaRx, Cambia
Gregory Rudolph, MD Addiction Medicine Swedish Pain Services
Mark Stephens President Change Management Consulting
David Tauben, MD Chief of Pain Medicine University of Washington Medical Center
Gregory Terman MD, PhD Professor Department of Anesthesiology and Pain Medicine and the Graduate Program in Neurobiology and Behavior, University of Washington
Michael Von Korff, ScD Senior Investigator Kaiser Permanente Washington Research Institute

Awards

Award winners for Best Practices in Dental Opioid Prescribing:

Long-term Opioid Prescribing Management

Guideline Information

Guideline title: Long-term Opioid Prescribing Management Report and Guidelines

Publication Status: Active

Date of publication: 2019

Date of last evidence search: 2019

Scope: Patient engagement; assessment; treatment plan development; treatment pathways; reimbursement; collaborative care

Methods: Current guidelines and literature review and expert consensus

Description: Providers managing patients on long-term opioid therapy should start with patient engagement followed by thorough assessment and careful deliberation regarding an appropriate treatment pathway. Management should be individualized and should focus, in addition to reducing the intensity of pain, on goals of improving function and quality of life, and optimizing patient independence, while avoiding serious adverse outcomes.

Supporting Materials

Letter from the Health Care Authority Accepting the Postoperative Prescribing Guidelines
Letter from the HCA Accepting Dental Prescribing Guidelines
Letter from Health Care Authority Accepting Opioid Prescribing Metrics
Opioid Guideline Implementation Charter
Agency Medical Directors Group Interagency Guideline on Prescribing Opioids for Pain
AMDG Guideline Summary

Metrics and Evaluation Tools

To support health system improvement the Bree Collaborative has created score cards that are designed to help measure progress on the implementation of our guidelines. These were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our score cards, find the audience type, or types, that is closest to your organization or area of improvement work and download the document. There may be more than one “audience” type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Score cards are also aligned with the Bree Collaboratives’ self-report data collection efforts. Organizations are not required to report, however anyone can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards.

Delivery Site and Health Systems

Health System Score Card Health System Score Card LT Rx

Health Care Professionals

Health Care Providers Score Card Provider Score Card _LT Rx

Health Plans

Health Plan Score Cards Health Plan Score Card _ Long term Rx

Guideline Metrics

The work group did not recommend specific metrics, however other prescribing metrics developed by the Bree Collaborative can be useful. These measures can be found on the Washington State Common Measure Set. For all of these measure a decrease is improvement.

  • New Opioid Patient Days Supply of First Opioid Prescription
    • Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
      Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.
  • New Opioid Patients Transitioning to Chronic Opioids
    • Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
      Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.
  • Patients Prescribed High-Dose Chronic Opioid Therapy
    • Numerator: Number of patients in the population prescribed >60 days’ supply of opioids at >50 mg/day or >90 mg/day MED.
      Denominator: Number of patients in the population prescribed >60 days’ supply of opioids in the calendar quarter.       Report each result as prevalence per 1,000 population, age and sex adjusted.
  • Use of Opioids at High Dosage (HDO)
    • The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

Workgroup Members

Name Title Organization
Gary Franklin, MD, MPH (Co-Chair) Medical Director Washington State Department of Labor and Industries
Charissa Fotinos, MD (Co-Chair) Deputy Chief Medical Officer Washington State Health Care Authority
Andrew Saxon, MD (Co-Chair) Director, Center of Excellence in Substance Abuse Treatment and Education (CESATE) VA Puget Sound Health Care System
Rose Bigham and Cyndi Hoenhous (Co-Chairs) Patient Advocates Washington Patients in Intractable Pain
Pamela Stitzlein Davies, MS, ARNP, FAANP Nurse Practitioner Departments of Neurology & Nursing, University of Washington
Andrew Friedman, MD Physical Medicine and Rehabilitation Virginia Mason Medical Center
Kelly Golob, DC Chiropractor Tumwater Chiropractic Center
Dan Kent, MD Chief Medical Officer UnitedHealthcare
Kathy Lofy, MD Chief Science Officer Washington State Department of Health
Jaymie Mai, PharmD Pharmacy Manager Washington State Department of Labor and Industries
Mark Murphy, MD Addiction Medicine and Pain Management MultiCare Health System
Anne Blake-Nickels Patient Advocate
Gregory Rudolph, MD Addiction Medicine Swedish Pain Services
Jennifer Davies-Sandler Patient Advocate
Mark Stephens President Change Management Consulting
Mark Sullivan, MD, PhD Psychiatrist University of Washington
David Tauben, MD Chief of Pain Medicine University of Washington Medical Center
Gregory Terman MD, PhD Professor Department of Anesthesiology and Pain Medicine and the Graduate Program in Neurobiology and Behavior, University of Washington
John Vassall, MD, FACP Physician Executive for Quality and Safety Comagine Health
Michael Von Korff, ScD Senior Investigator Kaiser Permanente Washington Research Institute
Mia Wise, DO Medical Director, Collaborative Healthcare Solutions Premera Blue Cross

Low Back Pain Management

Guideline Information

Guideline title: Low Back Pain Management Report and Guidelines

Publication Status: Needs minor revisions – to be scheduled

Date of publication: 2013

Date of last evidence search: 2013

Scope: pain evaluation and management; identification of psychosocial risks; patient communication, public awareness,

Methods: Current guidelines and literature review and expert consensus

Description: This report summarizes those best practices and presents guidelines for hospitals, clinics, individual providers, public health, purchasers/employers and health plans. Significant variation exists in the diagnosis and treatment of patients with new onset or persistent acute LBP, with high utilization rates for many costly modalities that have not been shown to improve health outcomes Increased implementation of evidence-based guidelines and best practices, use of screening tools, patient education, and financial incentives are all necessary to improve the quality of LBP care and health outcomes while reducing inappropriate care and costs. Some of the guidelines have been identified as high priority to aid in implementation efforts.

Supporting Materials

Letter from Health Care Authority Accepting TKR/THR Bundle, Warranty, and Spine Report
Public Comments Summary: Spine/Low Back Pain Report and Recommendations
Original Spine SCOAP Recommendation to HCA (Adopted January 2013)
Workgroup Charter
Letter from Health Care Authority Accepting Spine SCOAP and Cardiology Recommendations

Metrics and Evaluation Tools

To support health system improvement the Bree Collaborative has created score cards that are designed to help measure progress on the implementation of our guidelines. These were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our score cards, find the audience type, or types, that is closest to your organization or area of improvement work and download the document. There may be more than one “audience” type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Score cards are also aligned with the Bree Collaboratives’ self-report data collection efforts. Organizations are not required to report, however anyone can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards.

Delivery Site and Health Systems

Health System Evaluation Score Card Health System score card _ Low back pain

Health Plans

Health Plan Evaluation Score Card Health Plan Score Card_low back pain

Guideline Metrics

The work group did not recommend specific metrics, however audience specific evaluation tools and other prescribing metrics developed by the Bree Collaborative can be useful. These measures can be found on the Washington State Common Measure Set. For all of these measure a decrease is improvement.

  • New Opioid Patient Days Supply of First Opioid Prescription
    • Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
      Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.
  • New Opioid Patients Transitioning to Chronic Opioids
    • Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
      Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.
  • Patients Prescribed High-Dose Chronic Opioid Therapy
    • Numerator: Number of patients in the population prescribed >60 days’ supply of opioids at >50 mg/day or >90 mg/day MED.
      Denominator: Number of patients in the population prescribed >60 days’ supply of opioids in the calendar quarter.       Report each result as prevalence per 1,000 population, age and sex adjusted.
  • Use of Opioids at High Dosage (HDO)
    • The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

WorkGroup Members

Member Title Organization
Dan Brzusek, DO Physiatrist Northwest Rehab Association
Neil Chasan Physical Therapist Sport Reaction Center
Andrew Friedman, MD Physiatrist Virginia Mason
Leah Hole-Curry, JD Medical Administrator WA State Labor & Industries
Heather Kroll, MD Rehab Physician Rehab Institute of Washington
Chong Lee, MD Spine Surgeon Group Health Cooperative
Mary Kay O’Neill, MD, MBA (Chair) Executive Medical Director Regence Blue Shield
John Robinson, MD, SM Chief Medical Officer First Choice Health
Michael Von Korff, ScD Psychologist & Researcher Group Health Research Institute
Kelly Weaver, MD Physiatrist The Everett Clinic

Awards

Award winners for Best Practices in Low Back Pain Treatment

Opioid Prescribing Metrics

Guideline Information

Guideline title: Opioid Prescribing Metrics Report and Guidelines

Publication Status: Active

Date of publication: 2017

Date of last evidence search: 2017

Scope: Definitions, metrics descriptions

Methods: expert consensus

Description: The metrics were designed to be limited in number, have a strategic focus, and to be used for quality improvement. The first six metrics focus on guideline-concordant prescribing including chronic opioid use, opioid dose, concurrent chronic sedative use and transition from short-term to long-term opioid use. The last three metrics focus on mortality, overdose morbidity, and prevalence of opioid use disorder.

Supporting Materials

Opioid NDC include
Opioid NDC exclude
Letter from Health Care Authority Accepting Opioid Prescribing Metrics
Opioid Guideline Implementation Charter
Agency Medical Directors Group Interagency Guideline on Prescribing Opioids for Pain
AMDG Guideline Summary

Metrics and Evaluation Tools

To support health system improvement the Bree Collaborative has created score cards that are designed to help measure progress on the implementation of our guidelines. These were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our score cards, find the audience type, or types, that is closest to your organization or area of improvement work and download the document. There may be more than one “audience” type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Score cards are also aligned with the Bree Collaboratives’ self-report data collection efforts. Organizations are not required to report, however anyone can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards.

Delivery Site and Health Systems

Health System Evaluation Score Card

Health Care Professionals

Health Plans

Health Plan Evaluation Score Card

Washington State Agencies

Private and Public Purchasers

Guideline Metrics

The work group did not recommend specific metrics, however other prescribing metrics developed by the Bree Collaborative can be useful. These measures can be found on the Washington State Common Measure Set. For all of these measure a decrease is improvement.

  • New Opioid Patient Days Supply of First Opioid Prescription
    • Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
      Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.
  • New Opioid Patients Transitioning to Chronic Opioids
    • Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
      Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.
  • Patients Prescribed High-Dose Chronic Opioid Therapy
    • Numerator: Number of patients in the population prescribed >60 days’ supply of opioids at >50 mg/day or >90 mg/day MED.
      Denominator: Number of patients in the population prescribed >60 days’ supply of opioids in the calendar quarter.       Report each result as prevalence per 1,000 population, age and sex adjusted.
  • Use of Opioids at High Dosage (HDO)
    • The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

WorkGroup Members

Name Title Organization
Chris Baumgartner Director Prescription Monitoring Program Washington State Department of Health
David Buchholz, MD Medical Director Premera Blue Cross
Gary Franklin, MD, MPH (Chair) Medical Director Washington State Department of Labor and Industries
Charissa Fontinos, MD Deputy Chief Medical Officer Washington State Health Care Authority
Deb Fulton-Kehoe, PhD, MPH Epidemiologist University ofWashington
Frances Gough, MD Chief Medical Officer Molina Healthcare
Dan Kent, MD Chief Medical Officer UnitedHealthcare
Kathy Lofy, MD Chief Science Officer Washington State Department of Health
Jaymie Mai, PharmD Pharmacy Manager Washington State Department of Labor and Industries
Mark Murphy, MD Family Medicine and Addiction Medicine MultiCare
Shirley Reitz, PharmD ‎Clinical Pharmacist Client Manager OmedaRx, Cambia
Gregory Rudolph, MD Addiction Medicine Swedish Pain Services
Mark Stephens President Change Management Consulting
David Tauben, MD Chief of Pain Medicine University of Washington Medical Center
Gregory Terman MD, PhD Professor Department of Anesthesiology and Pain Medicine and the Graduate Program in Neurobiology and Behavior, University of Washington
Michael Von Korff, ScD Senior Investigator Kaiser Permanente Washington Research Institute

Awards

Award winners for Best Practices in Opioid Prescribing Metrics:

Opioid Prescribing in Older Adults

Guideline Information

Guideline title: Opioid Prescribing in Older Adults Report and Guidelines

Publication Status: Active

Date of publication: July 2022

Date of last evidence search: 2022

Scope: acute prescribing, intermittent opioid therapy, co-prescribing opioids with CNS-active medications, non-opioid pharmacologic pain management, non-pharmacologic pain management, tapering or deprescribing. 

Methods: Current guidelines and literature review and expert consensus

Description: This guideline focuses on specific concerns regarding opioid use in older adults, but does not encompass all aspects of opioid prescribing. For additional guidance on opioid prescribing, refer to previous Bree Collaborative opioid guidelines.

Metrics and Evaluation Tools

To support health system improvement the Bree Collaborative has created score cards that are designed to help measure progress on the implementation of our guidelines. These were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our score cards, find the audience type, or types, that is closest to your organization or area of improvement work and download the document. There may be more than one “audience” type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Score cards are also aligned with the Bree Collaboratives’ self-report data collection efforts. Organizations are not required to report, however anyone can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards.

Delivery Site and Health Systems

Health System Score Cards Health System Score Card_Opioid OA

Health Care Professionals

Provider Evaluation Score Card Provider score card_Rx OA

Health Plans

Health Plan Evaluation Score Card Health Plan Score Card_Opioid Rx

Guideline Metrics

The work group did not recommend specific metrics, however other prescribing metrics developed by the Bree Collaborative can be useful. These measures can be found on the Washington State Common Measure Set. For all of these measure a decrease is improvement.

  • New Opioid Patient Days Supply of First Opioid Prescription
    • Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
      Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.
  • New Opioid Patients Transitioning to Chronic Opioids
    • Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
      Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.
  • Patients Prescribed High-Dose Chronic Opioid Therapy
    • Numerator: Number of patients in the population prescribed >60 days’ supply of opioids at >50 mg/day or >90 mg/day MED.
      Denominator: Number of patients in the population prescribed >60 days’ supply of opioids in the calendar quarter.       Report each result as prevalence per 1,000 population, age and sex adjusted.
  • Use of Opioids at High Dosage (HDO)
    • The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

Workgroup Members

Name Title Organization
Gary Franklin, MD, MPH (Co-chair)
Jason Fodeman, MD
Jaymie Mai, PharmD		 Medical Director
Assistant Medical Director
Pharmacy Manager		 WA Department of Labor and Industries
Darcy Jaffe, MN, ARNP, NE-BC, FACHE (Co-chair) Senior Vice President, Safety & Quality WA Hospital Association
Mark Sullivan, MD, PhD (Co-chair) Professor of Psychiatry and Behavioral Sciences University of Washington
Judy Zerzan-Thul, MD, MPH (Co-chair) Chief Medical Officer WA Health Care Authority
Carla Ainsworth, MD, MPH Provider Iora Primary Care – Central District
Rose Bigham Patient Advocate
Denise Boudreau, PhD, RPh, MS Senior Scientific Investigator Kaiser Permanente Washington Health Research Institute
Siobhan Brown, MPH, CPH, CHES
Yusuf Rashid, RPh		 Senior Analyst, Health Systems Innovation
VP of Pharmacy and Vendor Relationship Management		 Community Health Plan of Washington
Pamela Stitzlein Davies, MS, ARNP, FAANP Adult/Geriatric Nurse Practitioner University of Washington / Seattle Pacific University
Elizabeth Eckstrom, MD Division of General Internal Medicine and Geriatrics Oregon Health Sciences University
James Floyd, MD Internal Medicine University of Washington School of Medicine
Nancy Fisher, MD Ex Officio Member
Debra Gordon, RN, DNP, FAAN Department of Anesthesiology and Pain Medicine University of Washington School of Medicine
Shelly Gray, PharmD School of Pharmacy University of Washington
Blake Maresh, MPA, CMBE Deputy Director, Office of Health Professions Washington State Department of Health
Wayne McCormick, MD Division of Gerontology and Geriatric Medicine University of Washington
Kushang Patel, MD Anesthesiology and Pain Medicine University of Washington
Elizabeth Phelan, MD Department of Geriatrics University of Washington
Dawn Shuford-Pavlich Home and Community Services Division Department of Social and Health Services
Angela Sparks, MD Medical Director Clinical Knowledge Development & Support Kaiser Permanente Washington
Gina Wolf, DC Chiropractor Wolf Chiropractic Clinic

Awards

Award winners for Best Practices in Opioid Prescribing in Older Adults:

Palliative Care

Guideline Information

Guideline title: Palliative Care Report and Guidelines

Publication Status: Active

Date of publication: 2019

Date of last evidence search: 2019

Scope: Definitions; spreading awareness of palliative care; clinical best practice; revision of benefit structure.

Methods: Current guidelines and literature review and expert consensus

Description: These guidelines present steps for adoption for individual stakeholder groups including patients and family members, specialty palliative care, health care systems, health plans, and the Washington State Health Care Authority on pages 5-11. Palliative care is further defined, including information on best practices for spreading awareness, clinical components of high-quality palliative care, differences between primary and specialty palliative care, and when to refer to specialty palliative care. Goals of care conversations are discussed and reimbursement strategies are outlined. Finally, quality metrics are outlined.

Supporting Materials

Letter from the HCA Accepting the Palliative Care Recommendations
Palliative Care Charter and Roster

Metrics and Evaluation Tools

To support health system improvement the Bree Collaborative has created score cards that are designed to help measure progress on the implementation of our guidelines. These were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our score cards, find the audience type, or types, that is closest to your organization or area of improvement work and download the document. There may be more than one “audience” type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Score cards are also aligned with the Bree Collaboratives’ self-report data collection efforts. Organizations are not required to report, however anyone can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards.

Delivery Site and Health Systems

Health System Evaluation Score Card Health System Score Card _ Palliative Care

Health Care Professionals

Primary Care Providers and sub-speciality providers PC Score Card _ Pallative Care

Specialty care providers Specialty care Score Card _ Palliative

Health Plans

Health Plan Evaluation Score Card Health Plan Score Card _ Pallative Care

Washington State Health Care Authority

Washington State HCA Score Card WA HCA Score Card _ Palliative

Private and Public Purchasers

Employer and purchaser score cards Purchasers Score Card _ Pallative Care

Guideline Metrics

The work group did not recommend specific metrics, however other prescribing metrics developed by the Bree Collaborative can be useful. These measures can be found on the Washington State Common Measure Set. For all of these measure a decrease is improvement.

  • New Opioid Patient Days Supply of First Opioid Prescription
    • Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
      Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.
  • New Opioid Patients Transitioning to Chronic Opioids
    • Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
      Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.
  • Patients Prescribed High-Dose Chronic Opioid Therapy
    • Numerator: Number of patients in the population prescribed >60 days’ supply of opioids at >50 mg/day or >90 mg/day MED.
      Denominator: Number of patients in the population prescribed >60 days’ supply of opioids in the calendar quarter.       Report each result as prevalence per 1,000 population, age and sex adjusted.
  • Use of Opioids at High Dosage (HDO)
    • The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

Workgroup Members

Member Title Organization
John Robinson, MD, SM (Chair) Chief Medical Officer First Choice Health
Lydia Bartholomew, MD Senior Medical Director, Pacific Northwest Aetna
George Birchfield, MD Inpatient Hospice EvergreenHealth
Raleigh Bowden, MD Director Okanogan Palliative Care Team
Mary Catlin, MPH Senior Director Honoring Choices, Washington State Hospital Association
Randy Curtis, MD, MPH Director, Cambia Palliative Care Center of Excellence University of Washington Medicine
Leslie Emerick Director of Public Policy Washington State Hospice and Palliative Care Organization
Ross M Hays, MD Director, Palliative Care Program Seattle Children’s
Greg Malone, MA, Mdiv, BCC Mgr Palliative Care Services, & Spiritual Care Provider Swedish Medical Center
Kerry Schaefer, MS Strategic Planner for Employee Health King County
Bruce Smith, MD Medical Director of Providence Hospice of Seattle Providence Health and Services
Richard Stuart, DSW Psychologist Swedish Medical Center – Edmonds Campus
Stephen Thielke, MD Geriatric Psychiatry University of Washington
Cynthia Tomik, LICSW Manager, Palliative Care EvergreenHealth
Gregg Vandekieft, MD, MA Medical Director for Palliative Care Providence St. Peter Hospital
Hope Wechkin, MD Medical Director, Hospice and Palliative Care EvergreenHealth

Prescribing for Perioperative Pain

Guideline Information

Guideline title: Prescribing for Post-operative Pain Report and Guidelines

Publication Status: Active

Date of publication: 2018

Date of last evidence search: 2018

Scope: Clinical guidelines based on time of recovery; additional considerations for children and adolescents.

Methods: Current guidelines and literature review and expert consensus

Description: In addition to prescribing the appropriate amount of opioids for a given procedure, it is important that the surgeon provide education for the patient and caregivers about realistic expectations for postoperative pain management, functional recovery activities, and timely reduction in opioid use as well as providing instruction for safe storage and disposal of opioids as specified in the 2015 AMDG Guideline.

Supporting Materials

Letter from the Health Care Authority Accepting the Postoperative Prescribing Guidelines
Opioid Guideline Implementation Charter
Agency Medical Directors Group Interagency Guideline on Prescribing Opioids for Pain
AMDG Guideline Summary

Metrics and Evaluation Tools

To support health system improvement the Bree Collaborative has created score cards that are designed to help measure progress on the implementation of our guidelines. These were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our score cards, find the audience type, or types, that is closest to your organization or area of improvement work and download the document. There may be more than one “audience” type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Score cards are also aligned with the Bree Collaboratives’ self-report data collection efforts. Organizations are not required to report, however anyone can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards.

Delivery Site and Health Systems

Acute Prescribing Health System Score Card

Guideline Metrics

The work group did not recommend specific metrics, however audience specific evaluation tools and other prescribing metrics developed by the Bree Collaborative can be useful. These measures can be found on the Washington State Common Measure Set. For all of these measure a decrease is improvement.

  • New Opioid Patient Days Supply of First Opioid Prescription
    • Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
      Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.
  • New Opioid Patients Transitioning to Chronic Opioids
    • Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
      Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.
  • Patients Prescribed High-Dose Chronic Opioid Therapy
    • Numerator: Number of patients in the population prescribed >60 days’ supply of opioids at >50 mg/day or >90 mg/day MED.
      Denominator: Number of patients in the population prescribed >60 days’ supply of opioids in the calendar quarter.       Report each result as prevalence per 1,000 population, age and sex adjusted.
  • Use of Opioids at High Dosage (HDO)
    • The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

Workgroup Members

Name Title Organization
Chris Baumgartner Director Prescription Monitoring Program Washington State Department of Health
Gary Franklin, MD, MPH (Chair) Medical Director Washington State Department of Labor and Industries
Charissa Fontinos, MD Deputy Chief Medical Officer Washington State Health Care Authority
Deb Gordon, DNP, RN, FAAN Teaching Associate, Co-director, Pain Service, Anesthesiology & Pain Medicine Harborview Medical Center
Frances Gough, MD Chief Medical Officer Molina Healthcare
Dan Kent, MD Chief Medical Officer UnitedHealthcare
Kathy Lofy, MD Chief Science Officer Washington State Department of Health
Jaymie Mai, PharmD Pharmacy Manager Washington State Department of Labor and Industries
Shirley Reitz, PharmD ‎Clinical Pharmacist Client Manager OmedaRx, Cambia
Gregory Rudolph, MD Addiction Medicine Swedish Pain Services
Mark Stephens President Change Management Consulting
David Tauben, MD Chief of Pain Medicine University of Washington Medical Center
Gregory Terman MD, PhD Professor Department of Anesthesiology and Pain Medicine and the Graduate Program in Neurobiology and Behavior, University of Washington
Michael Von Korff, ScD Senior Investigator Kaiser Permanente Washington Research Institute
Mia Wise, DO Medical Director, Collaborative Healthcare Solutions Premera Blue Cross

Awards

Award winners for Best Practices in Opioid Prescribing for Post-operative Pain:

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