54 - Delphi Study of Opioid Stewardship Programs in Hospice Setting

¹University of Maryland School of Pharmacy, Baltimore, MD, USA. ²MedStar Health Palliative Care Medicine, Baltimore, MD, USA

Purpose
Perform a Delphi study to characterize which National Quality Forum (NQF) recommendations have the highest utility in implementation in hospice practice.
Methods
Delphi survey of 13 experts will be conducted to reach a consensus. The inputs will be anonymous to the rest of the expert panel. The questionnaire will include the additional questions regarding the experts' clinical experience. The panel will be asked to 1) rate the utility of each NQF recommendation on 0-5 Likert scale and 2) list top ten recommendations as "top contenders" that were considered most important in hospice practice. In this research, 'utility' was defined as relevance; 2) ability to set metrics and measure outcomes; 3) importance; 4) ease of operationalization in hospice care. Experts will also be encouraged to provide literature, data, and rationale of their responses, which will be distributed back to the group anonymously. In the second round of Delphi, the experts were asked to repeat the utility rating listing the top ten recommendations as "top contenders." The experts were also asked to propose possible metrics to measure the "top contenders" recommendations, which will be explored further in a separate study.
Results
In the first round of Delphi, 18 NQF recommendations averaged higher than 3 on the utility Likert scale and received >25% consensus as the highest priority/importance in hospice setting. The rest of NQF recommendations were excluded from the second round.
In the second round of Delphi, the top ten contending recommendations averaged 4.413 on the utility Likert scale. The top ten recommendations, in descending order, 1) Require ongoing clinician training, education, and engagement to support effective pain management and opioid stewardship for prescribers and care teams 2) Develop core competencies in pain management for members of the interdisciplinary team, including clinicians responsible for and engaged in opioid stewardship 3) Support consistent use of prescription drug monitoring programs (PDMPs) for all prescribers 4) Implement organizational leadership accountability for: Developing processes to address clinicians whose prescribing practices are outliers amongst their peers Developing systems to support the safety of clinicians, patients, and family caregivers around safe storage and disposal of opioids Monitoring for healthcare worker drug diversion and holding staff accountable per organizational policies (e.g., compliance with controlled substance waste procedures) Treating and providing support for healthcare workers who exhibit signs of opioid use disorder (OUD) or drug diversion 5) Engage patients and family caregivers as partners in setting pain management goals based on realistic expectations for safe and effective pain relief and functional outcomes 6) Invest in staff education on appropriate pain management strategies, opioid stewardship, and effective patient communication techniques 7) Invest in staff education on appropriate pain management strategies, opioid stewardship, and effective patient communication techniques 8) Ensure patients’ pain needs are being adequately addressed and clinicians are not discharging or avoiding patients due to complexities involved in pain management 9) When prescribing opioids, promote patient and family caregiver education and awareness of: Drug interactions and side effects, including signs of withdrawal and overdose Safe drug storage and disposal Risks and signs of drug diversion Risks of dependence with opioid therapy – Naloxone availability, indications, and use and 10) Develop and promote the use of standardized risk assessment tools, while understanding their limits in predictive accuracy, to identify vulnerable or at-risk patients prior to prescribing opioids.
Conclusions
The results of this two round Delphi panel showed that the experts found a wide spectrum of NQF recommendations that is most appropriate in hospice practice, ranging all the way from staff education to hospital leadership. Most recommendations that received highest consensus included strong emphasis on staff/patient education, utilization of PDMP, and organizational leadership's role in establishing site-specific protocols for safe drug disposal and drug diversion prevention.