Opioid Risk Stratification in an Outpatient Palliative Care Clinic (TH310B)

Abstract

•List common barriers of implementing a process for opioid risk stratification in an outpatient palliative care clinic.•Explain why opioid risk stratification is important within the outpatient palliative care population.•Interpret the results of a statistical process control (SPC) chart and understand when to consider using a SPC chart for a QI project. Approximately a quarter of patients in academic cancer centers are at high risk for opioid abuse.1,2 At Dana-Farber Cancer Institute, we sought to create a high-reliability process within our palliative care clinic that risk stratifies our patients for opioid abuse using the Opioid Risk Tool (ORT). Our aim was to increase ORT completion rate from 0% to 70% for eligible new consults. Our primary outcome measure was the percentage of ORT completed among eligible consults. Eligible consults were defined as new consults seen in the outpatient palliative care clinic who were prescribed opioids by their oncologist or palliative care provider. Charts were audited retrospectively to determine if the ORT was completed. We used a statistical process control (SPC) chart to track percentage of completed ORT over time and to differentiate between special cause and common cause variation. We implemented multiple Plan-Do-Study-Act (PDSA) cycles that included clinician education about ORT documentation within our electronic medical record, asking patients to complete a written version of the ORT, and empowering clinic assistants (CAs) to help patients complete the ORT. From November 2017 to May 2018, the average ORT completion rate among new consults (n=231) was 52%. We achieved special cause variation with the written ORT and incorporating CAs into the workflow but were unable to establish a high-reliability process. Among patients seen in palliative care clinic who are still alive and are prescribed an opioid (n=412), 22% have completed an ORT. Among patients who have completed the ORT, 77.78% are considered low risk, 15.56% are medium risk, and 6.67% are high risk for opioid abuse per the ORT scale. Implementing a high-reliability process for evaluating risk of opioid abuse in an outpatient palliative care clinic can be a complex endeavor that requires cohesive, multi-disciplinary teamwork.