Topic 13-14 D

Q-1

Cost-effective care is essentially the incentive to provide efficient, valuable care for the patient (Razavi et al., 2021); (Syed & Lazo-Belangue, 2021). So essentially this can be re-conveyed in a manner that we all have heard Dr. Barkley say in our review; "Cheapest, Quickest test or option". Essentially, in a scenario where a CT is warranted, but there is an alternative test available that provides the same information the only difference would come from the cost (Razavi et al., 2021). So at first glance, it seems that cost is the only measure, and the alternative test would be cheaper, but there are other questions that arise (Razavi et al., 2021). Is the CT available right now, how long will the test take, and can it be read now (Razavi et al., 2021). While going through these questions, another test could also check off the boxes as well (Razavi et al., 2021).

An example could be acute cholecystitis, while a CT would show the most definition and information on an exam, an ultrasound could also be comparable (Razavi et al., 2021). When we run through the criteria, an ultrasound is cheaper, more readily available, and a quicker read of a test, which achieves the goal of gathering the appropriate information (Razavi et al., 2021).

If we apply this thought process to not only radiological procedures but to all aspects of medicine, we are then practicing cost-effective care and achieving the same results (Razavi et al., 2021). The same application is applied by all healthcare providers, and as a secondary responsibility of the NP, we could be leaders in applying cost-effective health care by coaching other providers to do the same.

References: Razavi, M., O'Reilly-Jacob, M., Perloff, J., Buerhaus, P. (2021). Drivers of Cost Differences Between Nurse Practitioner Attributed Medicare Beneficiaries. Wolters Kluwer. Feb 2021- V. 59, 2, p. 177-194. 10.1097/MLR.0000000000001477 Syed, S., Barot, N., & Lazo-Belangue, J. (2021). Ethical, Compassionate, and Cost-Effective Approach to Health Care Decisions of Unrepresented Patients: A Bioethics Quality Improvement Project. JOURNAL OF THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY, 62(4), 330–336.

Q-2

One of the biggest health system measures I would like to put into place and implement to assure addictive behaviors are identified and the risk of opioid dependency is mitigated is to reduce the overall supply actually available to a patient. The ideology is that if a patient has less available to them, for example, a 7 day supply instead of a 30 day supply, the temptation, and risk of overuse is diminished (Barglow, 2018). Another way to approach this is to reduce the overall supply in general, which means to reduce the number of prescriptions given out to patients or make it harder to actually order for patients without meeting previous criteria of a pain step-ladder (Barglow, 2018). For example, starting with the lowest level of pain medication like Tylenol or ibuprofen for an injury would be appropriate, then if they fail, to slowly escalate to a drug like a tramadol, a non-opiate NSAID (Barglow, 2018).

The state of Florida has taken a similar approach to the opiate issue and dependency by restricting the overall supply from a maximum of 30 days to a maximum of 3 days for acute pain along with a referral to a pain management physician or clinic (FloridaTakeControl, 2020). There has also been a database created that everyone who receives an opiate prescription is placed in, so any physician in the state of Florida has access to and can check if the prescription has been overused, or attempted to be filled at multiple pharmacies (FloridaTakeControl, 2020).

When patients need more than the prescribed amount or a higher dosage, referral to a pain management clinic or physician is the most appropriate in these cases (Barglow, 2018);(FloridaTakeControl, 2020). These clinics still follow the same rules as the CDC guidelines on pain control and prescriptions, but have a more in-depth pain management ladder and more therapies available and at their disposal (Barglow, 2018);(FloridaTakeControl, 2020). Some statistics that back up the prescription limit is that on average, new opiate prescriptions were down 16% per month since inception, which has led to a significant decline in new prescriptions and by effect, a decline in current opiate users (FloridaTakeControl, 2020). However, another effect that was anticipated was that for a short period of time, ER admits for a withdrawal-type disease did elevate for a few weeks post new law implementation (FloridaTakeControl, 2020).

In my opinion, this was a law that was made for the greater good, by ripping off the bandaid we forced a massive decrease in supply with some side effects, but achieved a favorable outcome.

References: Barglow, P. (2018). Commentary: The opioid overdose epidemic: Evidence-based interventions. The American Journal on Addictions, 27(8), 605–607. https://doi-org.lopes.idm.oclc.org/10.1111/ajad.12823 FloridaTakeControl (2020). Opiate Laws. Florida Department of Health. Retrieved from: https://www.flhealthsource.gov/FloridaTakeControl/patients#:~:text=a.,to%20a%207%20%E2%80%93%20day%20supply.

Q-3

This is a tough question for me as I am not familiar with opioid dependence programs. I feel like most providers either try to avoid these patients or just give in to what they want. Unfortunately, these opioid dependent patients do need help and guidance that most healthcare workers and providers can not provide. Often, these patients are not even identified. To begin with providers must identify these patients as opioid dependent. To effectively treat and manage an individual’s dependence on opioids, one must first have a valid and reliable diagnostic instrument for identifying the affected population. This would be my approach to begin to treat opiod addicted patients. One screening tool widely used is rapid opioid dependence screen (RODS).

The RODS is a brief, 8-item measure designed to assess dependence for opioid drugs. Like the MINI, all response options are coded in a dichotomous yes/no format. The first item assesses lifetime use of the following eight types of opioids: heroin, methadone, buprenorphine, morphine, MS Contin, Oxycontin, oxycodone, and other opioid analgesics. Next, Items 2 to 8 measure physiological, behavioral, and cognitive factors associated with opioid use. A “no” response to all eight drug types in Item 1 results in an immediate outcome of non-dependence, skipping Items 2 through 8. Participants with an affirmative response to at least one drug type in Item 1, however, proceed to answer Items 2 through 8. A diagnosis of opioid dependence is made if three or more affirmative responses are given (Altice & Springer, 2015).

Rapidly and correctly identifying individuals with opioid dependence, by having access to a reliable and brief screening assessment tool, will not only facilitate access and entry into evidence-based treatment but also likely reduce the generalization of HIV transmission among people who. Rapid screening will result in quick diagnosis and treatment initiation that will also contribute to reductions in morbidity and mortality associated with opioid dependence (e.g., overdose, skin and soft tissue infections, pneumonia, trauma, criminal justice problems, unemployment) and conditions that are related with opioid use, such as viral hepatitis and other sexually transmitted infections (Thabane & Samaan, 2016). 

 

 

Altice, F. L., & Springer, S. A. (2015). Validation of a Brief Measure of Opioid Dependence: The Rapid Opioid Dependence Screen (RODS). Journal of correctional health care: the official journal of the National Commission on Correctional Health Care, 21(1), 12–26. https://doi.org/10.1177/1078345814557513

Thabane, L., & Samaan, Z. (2016). Pain and Opioid Addiction: A Systematic Review and Evaluation of Pain Measurement in Patients with Opioid Dependence on Methadone Maintenance Treatment. Current drug abuse reviews, 9(1), 49–60. https://doi.org/10.2174/187447370901160321102837