Part V – Multiple Provider Episodes
BY JIM HUIZENGA, M.D. AND CHIEF CLINICAL OFFICER OF APPRISS HEALTH
Series Introduction – Appriss Health has long held that chronic pain and addiction (substance use disorder) are separate medical conditions and that each deserve a unique clinical approach. We have spent years developing clinical decision support tools and in doing so have obtained the feedback from countless medical professionals, including many pain providers. Through those providers we have also heard (directly and indirectly) from many chronic pain patients as well.
To continue this conversation, over a long series of blog posts, we will explore our approach to benefit/risk assessment, data presentation, and clinical support…and how they relate to our goal of creating a usable and balanced, clinical viewpoint that protects access to care while highlighting areas of risk that clinicians and patients should be aware of.
Time for just a bit of review.
So far we’ve introduced the concept of benefit and risk, delved deeper into the types of risk, further evaluated dependence and addiction, and had an overview on prescription drug monitoring programs (PDMPs). The high level information presented thus far will generally be understood by any provider who cares for patients and will be applied almost subconsciously during clinical decision making.
Opposite this higher level information are discrete knowledge elements, or what I like to call metrics. Metrics represent measurable items that can sometimes be expected to be applied concretely to medical decision making. One example of an opioid metric is 90 morphine milligram equivalents (MME), which some believe is an upper limit daily dose recommended by the CDC*. Another example of a long standing metric is some quantity of prescribers that some believe equates to “doctor shopping” or more appropriately described in today’s lexicon as “multiple provider episodes” (MPEs). In our last post, we looked at how one research study found that five or more providers in the previous year was associated with a four-fold increased risk of death.
A closer look at the MPE metric.
First, the study mentioned above was completed using data from 2006 and definitely predates our current fentanyl and heroin crisis, so this study is perhaps more relevant to patients who primarily use prescription opioids, as was the trend in 2006. Second, the study found that 63% of deaths were associated with diversion (using illicit prescription opioids) and about 21% were associated with MPEs of five or more providers. Unfortunately, a PDMP program cannot catalogue diverted medications for obvious reasons, but there is a known pathway between a first exposure of opioids via a prescription that for some leads to misuse and abuse of prescribed opioids that then leads use of illicit medications with ever increasing risk. As we will find out in a later blog post, machine learning can be used to find trends in a patient’s PDMP prescription history that are associated with follow-on illicit use.
Important limitations of using MPEs to assess risk:
- Sometimes patients see multiple providers from a large group practice, and often cannot control how many providers they receive prescriptions from. CMS actually recognizes this in their opioid safety approach and in 2018 stated that “Prescribers associated with the same single TIN [Tax ID Number] are counted as a single prescriber.”
- MPEs are intended to apply to patients who see multiple prescribers in an attempt to obtain more medication than a single provider would provide. If a patient sees multiple providers but doesn’t overlap the prescriptions then it doesn’t really matter, at least according to the intent of this metric. Note that as an emergency physician, I often see patients who have little option in who they see for care and the vast majority of these patients (my patients) are not simply “shopping” around (again, I really don’t like this term).
- MPEs are counted over a period of time, sometimes for a year. There is an obvious time component that matters here as a year can be a long time. For instance, if patient A saw four different doctors in January and then a single doctor for the next 11 months and patient B saw one prescriber from January to November and then four new prescribers in December, they have both met the same MPE criteria, but they are obviously in markedly different situations (from the viewpoint of December looking backwards).
Summary of the above:
- There are lots of metrics being proposed that are intended to guide clinician behavior
- MPEs is one of many
- MPEs can have a variety of definitions
- The intent of the MPEs threshold (i.e. more than five prescribers in a year) is to identify patients at risk because they may be attempting to obtain more medications than appropriate
- Many patients may meet this threshold even though they are not attempting to obtain more medications than appropriate.
What’s a provider to do?
It’s easy to count the number of prescribers in a given time period, but that number may not actually be relevant to the patient. Of course, you can talk to the patient to get more detail, but, in my experience patients usually want to talk about their current health problems… Not spend lots of time on the details of their doctor visits in the past year.
As it turns out there is a fairly simple method to raise awareness to when MPEs might be relevant, and importantly, when they may not be relevant. The phrase “a picture is worth a thousand words” comes to mind, and that is the subject of our next post. Here’s a preview…this is Appriss Health’s idea of what a “picture” of prescription data should look like (note that all names are fictitious):
*The CDC Guideline for Prescribing Opioids for Chronic Pain specifically state “the recommendations are for primary care clinicians who are prescribing opioids for chronic pain.” Although the information in the guidelines are relevant for all clinicians, in my opinion, they weren’t intended for chronic pain professionals. Chronic pain professionals often care for patients who have severe disease and who may require higher doses of medications for the best quality of life. Regardless, the CDC’s guidelines don’t recommend a hard stop at 90 MME, they recommend that clinicians “should avoid increasing dosage to ≥ 90 MME/day or carefully justify a decision to titrate dosage to ≥ 90MME/day.”
To read more on this series:
- Part I – Benefit and Risk
- Part II – Risk Defined
- Part III – Dependence and Addiction
- Part IV – PDMPs
- Part V – Multiple Provider Episodes
- Part VI – PDMP Visualization
- Part VII – Interpreting PDMP Visualizations
- Part VIII – Scoring PDMP Data
- Part IX – Understanding How PDMP Data is Scored
- Part X – Machine Learning
- Part XI – Epilogue