Your suffering/pain management – or lack of pain management – during your hospitalization should not be a measurement of patient satisfaction about their care in the hospital ?
March 28, 2016
The Honorable Sylvia Mathews Burwell
Secretary, Department of Health & Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Madam Secretary:
Prescription drug abuse has reached epidemic proportions with devastating
effects on families across America. In many states, it has also fostered a heroin
crisis, overwhelming our communities and families with often tragic
consequences. Recently, the Centers for Disease Control and Prevention (CDC)
announced that deaths from opioid pain relievers as a result of misuse and abuse
have soared over the last fifteen years.1 Moreover, the CDC reports that
healthcare providers wrote 259 million prescriptions for painkillers in 2012,
enough for every American adult to have a bottle of pills.2 It is alarming that
Americans consume opioids at a greater rate than any other nation, including
twice as many opioids per capita as Canada.3 The seemingly unending supply of
prescription opioids is subject to misuse and diversion, which has become one of
the foremost public health challenges facing our nation.
Of the over 136 million patient visits annually to the nation’s emergency
departments, 42% of these visits are related to painful conditions. While
emergency physicians write a considerable number of prescriptions for opioids,
we account for less than 5% of all opioid prescriptions in the US. In addition,
most are immediate release, the quantity in each prescription is generally
quite low, and refills are rare.
We also act as a bridge in the primary care system on nights, weekends, holidays,
and other times when a primary care provider is not available. We are often the
only access that patients have. Pain treatment centers regularly refer patients to
the emergency department if the patient has not followed the agreed upon
treatment plan and, as emergency physicians we must, by the EMTALA law,
evaluate every patient who presents to our departments.
1 CDC Newsroom Archives. “Drug overdose deaths hit record numbers in 2014,” December 18,
2015. Accessed from http://www.cdc.gov/media/releases/2015/p1218-drug-overdose.html.
2 “Opioid Painkiller Prescribing.” CDC Vital Signs. Accessed from
http://www.cdc.gov/vitalsigns/opioid-prescribing/.
3 Paulozzi, Leondard. “Vital Signs: Variation Among States in Prescribing of Opioid Pain
Relievers and Benzodiazepines – United States, 2012,” Morbidity and Mortality Weekly Report
2012. Accessed from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6326a2.htm.
In spite of the multiple efforts the Federal government (CDC’s revised guidelines, FDA’s Risk Evaluation and Mitigation Strategy, ONDCP educational sessions, CMS, etc.) has undertaken to tackle this crisis, we must point to a glaring issue that has worked at cross purposes not only for hospitals but soon for emergency physicians. Patient experience/satisfaction surveys are important, particularly regarding issues of treating patients with dignity and respect, but questions about pain have resulted in unintended consequences and the pursuit of high patient-satisfaction scores may actually lead health professionals and institutions to practice bad medicine by honoring patient requests for unnecessary and even harmful treatments.
On the hospital side, CMS operates the Hospital Value-Based Purchasing Program which includes a survey (HCAHPS) where discharged patients respond to questions including, “During this hospital stay, how often was your pain well-controlled?” and “During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?” Less than satisfactory patient perception scores will contribute to CMS reducing hospital DRG payments starting in 2016.
Similar questions are included in third draft version of the CMS’ Emergency Department Patient Experience of Care. (EDPEC Survey 3.0) which the pilot test administered between 2-42 days after patients were treated and released. After ACEP submitted written comments to the first two versions, providing CMS with specific wording to change the pain questions, the third version now asks “during this ED visit did you have any pain, did the doctors and nurses try to help reduce your pain, and did you get medicine for pain?”
Any questions which provide an opportunity for patients to express dissatisfaction because they didn’t get the drugs they sought, provide disincentives for physicians to prescribe non-opioid analgesics which will negatively affect their scores. This has been an issue for years with private surveys such as Press Ganey4. And, it is certainly not addressing important aspects of the opioid crisis that the government is expending tremendous resources to combat.
As DHHS continues to refine measures to reward quality care in the Medicare program, it is critical to correctly measure the quality being rewarded. Currently, there is no objective diagnostic method that can validate or quantify pain. Development of such a measure would surely be a worthwhile endeavor. In the meantime, we are concerned that the current evaluation system may inappropriately penalize hospitals and physicians who, in the exercise of medical judgment, opt to limit opioid pain relievers to certain patients and instead reward those who prescribe opioids more frequently.
4 Gunderman, Richard. “When Physicians’ Careers Suffer Because They Refuse to Prescribe Narcotics,” The Atlantic 2014, http://www.theatlantic.com/health/archive/2013/10/when-physicians-careers-suffer-because-they-refuse-to-prescribe-narcotics/280995/
We urge the Department to undertake a robust examination of whether there is a
connection between these measurements and potentially inappropriate prescribing patterns, and, until that is completed, we urge you to remove pain questions from the various CAHPS surveys. We appreciate your prompt consideration of this request, and will work with you at any time to address these serious public health challenges.
Sincerely,
Jay A. Kaplan, MD, FACEP
President
Filed under: General Problems
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