Browsing by Author "Kahler, Zachary P."

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    Effect Of A “No Superuser Opioid Prescription” Policy On ED Visits And Statewide Opioid Prescription
    (eScholarship Publishing, University of California, 2017-08) Kahler, Zachary P.; Musey, Paul I.; Schaffer, Jason T.; Johnson, Annelyssa N.; Strachan, Christian C.; Shufflebarger, Charles M.; Emergency Medicine, School of Medicine
    Introduction The U.S. opioid epidemic has highlighted the need to identify patients at risk of opioid abuse and overdose. We initiated a novel emergency department- (ED) based interventional protocol to transition our superuser patients from the ED to an outpatient chronic pain program. The objective was to evaluate the protocol’s effect on superusers’ annual ED visits. Secondary outcomes included a quantitative evaluation of statewide opioid prescriptions for these patients, unique prescribers of controlled substances, and ancillary testing. Methods Patients were referred to the program with the following inclusion criteria: ≥ 6 visits per year to the ED; at least one visit identified by the attending physician as primarily driven by opioid-seeking behavior; and a review by a committee comprising ED administration and case management. Patients were referred to a pain management clinic and informed that they would no longer receive opioid prescriptions from visits to the ED for chronic pain complaints. Electronic medical record (EMR) alerts notified ED providers of the patient’s referral at subsequent visits. We analyzed one year of data pre- and post-referral. Results A total of 243 patients had one year of data post-referral for analysis. Median annual ED visits decreased from 14 to 4 (58% decrease, 95% CI [50 to 66]). We also found statistically significant decreases for these patients’ state prescription drug monitoring program (PDMP) opioid prescriptions (21 to 13), total unique controlled-substance prescribers (11 to 7), computed tomography imaging (2 to 0), radiographs (5 to 1), electrocardiograms (12 to 4), and labs run (47 to 13). Conclusion This program and the EMR-based alerts were successful at decreasing local ED visits, annual opioid prescriptions, and hospital resource allocation for this population of patients. There is no evidence that these patients diverted their visits to neighboring EDs after being informed that they would not receive opioids at this hospital, as opioid prescriptions obtained by these patients decreased on a statewide level. This implies that individual ED protocols can have significant impact on the behavior of patients.
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    Outpatient treatment of low-risk venous thromboembolism with monotherapy oral anticoagulation: patient quality of life outcomes and clinician acceptance
    (Dove Press, 2016-04-15) Kline, Jeffrey A.; Kahler, Zachary P.; Beam, Daren M.; Department of Emergency Medicine, IU School of Medicine
    BACKGROUND: Oral monotherapy anticoagulation has facilitated home treatment of venous thromboembolism (VTE) in outpatients. OBJECTIVES: The aim of this study was to measure efficacy, safety, as well as patient and physician perceptions produced by a protocol that selected VTE patients as low-risk patients by the Hestia criteria, and initiated home anticoagulation with an oral factor Xa antagonist. METHODS: Patients were administered the Venous Insufficiency Epidemiological and Economic Study Quality of life/Symptoms questionnaire [VEINEs QoL/Sym] and the physical component summary [PCS] from the Rand 36-Item Short Form Health Survey [SF36]). The primary outcomes were VTE recurrence and hemorrhage at 30 days. Secondary outcomes compared psychometric test scores between patients with deep vein thrombosis (DVT) to those with pulmonary embolism (PE). Patient perceptions were abstracted from written comments and physician perceptions specific to PE outpatient treatment obtained from structured survey. RESULTS: From April 2013 to September 2015, 253 patients were treated, including 67 with PE. Within 30 days, 2/253 patients had recurrent DVT and 2/253 had major hemorrhage; all four had DVT at enrollment. The initial PCS scores did not differ between DVT and PE patients (37.2±13.9 and 38.0±12.1, respectively) and both DVT and PE patients had similar improvement over the treatment period (42.2±12.9 and 43.4±12.7, respectively), consistent with prior literature. The most common adverse event was menorrhagia, present in 15% of women. Themes from patient-written responses reflected satisfaction with increased autonomy. Physicians' (N=116) before-to-after protocol comfort level with home treatment of PE increased 48% on visual analog scale. CONCLUSION: Hestia-negative VTE patients treated with oral monotherapy at home had low rates of VTE recurrence and bleeding, as well as quality of life measurements similar to prior reports.