P-058 - (Poster #58) Assessing Clinician Compliance with The Office of the Inspector General (OIG) Recommended Follow-Up for Long-Term Opioid Therapy

In 2021, the Center for Disease Control (CDC) estimated that 21% of U.S. adults experienced chronic pain. Although not considered first line, opioids are regularly utilized as a component of chronic pain management. According to the CDC, in 2021 about 22.1% of adults with chronic pain had been prescribed an opioid in the past 3 months. The Veterans Health Administration (VHA) has various guidelines, directives, and memorandums that outline requirements for opioid risk mitigation. VHA Directive 1005 requires that informed consent for long-term opioid therapy for pain management be obtained prior to initiation along with discussion of risks and benefits of therapy. In January 2022, the Office of the Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) published a focused report after evaluation at 36 VHA medical facilities that identified multiple weaknesses, including lack of adequate patient follow-up, resulting in a recommendation that providers follow-up with patients within three months of initiating an opioid therapy. Based on this report, in 2023 the VHA published a memorandum to the OIG CHIP report providing guidance on required actions including the completion of long-term opioid consent, completion of urine drug screening, and completion of data-based risk reviews at opioid initiation.

Purpose/Objectives:

The aim of this quality assurance and quality improvement retrospective review is to identify if providers at the Albany Stratton VA Medical Center are adhering to recommended patient follow-up within adequate time to target future education initiatives. The primary objective of this retrospective quality improvement project is to assess the current compliance of VA clinician follow-up with Veterans within three months after newly initiated long-term opioid therapy at the Albany Stratton VA Medical Center. Secondary objectives included assessment of provider adherence at follow-up and provider assessment of safety and efficacy at follow-up as well as completion of other OIG recommendations including long-term opioid consent completed at opioid initiation, urine drug screen completed within 1 year prior to initiating opioid therapy, and completion of the stratification tool for opioid risk mitigation within three months of initiation. 

Methods:

This is a single-centered retrospective review of adult patients, 18 years or older, prescribed long-term opioid therapy, defined as greater than or equal to a cumulative 90 days’ supply within one year of any opioid prescription.  Information was collected from electronic medical records and recorded using Excel. Veterans were excluded if they were receiving opioids indicated for opioid use disorder, if opioid therapy was initiated prior to July 1, 2022, or prescriptions that originated from a prescriber in the community. The primary outcome was follow-up by the prescriber or a provider from the same clinic, unless otherwise specified, within 90 days of long-term opioid therapy. Information on time to follow-up after opioid initiation, and provider assessment of adherence and efficacy and safety of the intervention was collected. Additionally, patient demographics, pain diagnosis, prescribing provider service, and opioid therapy characteristics were collected. Completion of a long-term opioid consent (LTOC) at initiation, urine drug screen (UDS) performed within 1 year, and completion of a stratification tool for opioid risk mitigation (STORM) note were assessed, all recommendations or guidelines provided by the OIG.

Results:

A total of 159 patients were initially identified for review based on meeting enrollment criteria for chronic opioid therapy between July 1, 2022 to July 1, 2024. Of those patients, 5 were excluded due to off-label opioid use disorder treatment or death prior to the end of the 90-day follow-up period. Additionally, 14 patients were excluded as the prescription for the long-term opioid therapy originated from a community care provider and therefore risk mitigation strategies were not required by a VA provider. A total of 140 patients were included for analysis of which 92% were male with average age of 69 years.

At the time of opioid initiation, 50.7% of patients were opioid naïve prior to starting therapy and 50.0% of patients received more than one opioid non-concurrently within 90 days. There was multiple pain diagnoses identified as an indication for opioid prescriptions. The most common diagnoses included back pain (45.5%) and cancer-related pain (11.0%). The most common opioid initiated for long-term opioid therapy was tramadol (36.4%), followed by hydrocodone/acetaminophen (19.3%), oxycodone (18.6%), and buprenorphine (16.4%). The clinic with the most initial prescriptions for long-term opioid therapy was primary care with 71% of opioids being prescribed by primary care providers.

Assessing the primary outcome, 20% of patients did not have a follow-up within 90 days of opioid initiation. The clinic associated with the most missed follow-ups within 90 days was primary care with 84% of patients without follow-up within 3 months. During follow-up 66.1% of prescribers documented adherence of opioid medication and 65.0% documented monitoring of safety and efficacy. 18.6% of patients had a LTOC completed at initiation, 27.9% of patients had a UDS completed within one year prior to initiation, and 17.9% had a data-based risk review completed at initiation.

Conclusions/Implications for future research and/or clinical care:

The results indicate that majority of providers at the Albany Stratton VAMC adhered to the OIG CHIP recommendations for follow-up within 90 days of long-term opioid therapy initiation. However, 20% did not, which identifies an area for improvement within the facility. Furthermore, provider assessment of adherence, safety, and efficacy of therapy at follow-up is lacking and majority of providers were noncompliant with other OIG recommendations including, completion of a LTOC, UDS, and STORM note. Overall, this quality improvement project provides insight into opioid prescribing practices of providers at the Albany Stratton VAMC in order to highlight future opioid safety initiatives. Although the information is not generalizable to other facilities or patient populations, it remains pertinent that facilities are aware of opioid safety recommendations and ensure that providers are adherent to opioid risk mitigation strategies.