Big Brother is Watching our ED Rate of Follow-up Care for Opioid Use Disorder

February 26, 2019 6:27 PM | Sally Winkelman (Administrator)

by Bobby Redwood, MD, MPH

George Orwell’s 1984 really gave big brothers a bad rap. Sure, you can view the Healthcare Effectiveness Data and Information Set (HEDIS) as our government overlords squeezing the art (and fun) out of emergency medicine…but I tend to view their role as that of a real big brother. Big brothers can be overbearing, they smack us when we’re acting the fool, but they also keep us out of trouble and help us navigate tricky areas of our practice.

Enter HEDIS measure “FUA”: Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence.

We all know that the opioid epidemic in Wisconsin is getting out of hand and we all see these patients suffering from maladaptive behavior, overdose, and withdrawal. From the 20,000-foot view, in 2016, 20.1 million Americans over 12 years of age (about 7.5% of the population) were classified as having a substance use disorder and in 2017, 70,200 Americans died from an opioid overdose. When and how is this epidemic going to end? No one knows when it will end of course, but we have a pretty good idea how the ED can help:

As luck would have it, our big brother HEDIS is here to help us stay on track in terms of getting patients access to MAT. The two rates reported in the 2017 FUA measure are:

  • ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
  • ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).

The literature unequivocally shows that timely follow-up care for patients with OUD who were seen in the ED is associated with a reduction in substance use, future ED use, and hospital admissions. Unfortunately, the 2017 HEDIS data on FUA has just been released and only about 10% of adult OUD patients are getting follow-up care within a week of their ED visit and only 13% are getting that care within 30 days of their ED visit. We can do better and the solution is an ED to MAT care pathway.

The arguments against starting an ED to MAT care pathway are abundant: its not the ED’s role, we can’t get started without PCP follow-up spots, the burden of getting a DEA X-waiver is unreasonable, my ED is going to turn into a buprenorphine clinic, etc, etc, etc.

I’ll let you all in on a secret… an ED to MAT care pathway is fulfilling for providers and is not hard to operationalize:

  • Step 1: Find two primary care physicians in your area who can reserve two Monday appointments and two Tuesday appointments for patients requesting MAT.
  • Step 2: Ask patients to stop using their opioids 48 hours before their allotted appointment time and provide them with a starter prescription of clonidine 0.2mg BID (#10) and Zofran 4mg ODT prn (#10) to help stave off early withdrawal symptoms.

If your ED group is willing to get X-waivered, you can get more sophisticated and actually prescribe a buprenorphine starter pack from the ED. To learn how this all works:

  • Check out WACEP/WHA’s webinar: Buprenorphine 101: Demystifying Medication Assisted Treatment in Wisconsin (link); and/or 
  • Register for the WACEP Spring Symposium, where we break down the details of an ED to MAT care pathway at our hot topics roundtable.
  • For an easy to follow protocol, check out this excellent resource that applies to both the ED and clinic setting. 

2019 is going to be the year for ED to MAT care pathways in the Wisconsin. Your hospital administrators have likely already heard about the FUA HEDIS measure and (if it has not already) it will likely be showing up in your ED soon. We at WACEP urge you to stay ahead of the curve and start saving lives now: watch the webinar, print out the protocol, go to the conference, and get your X-waiver! Let’s make our big brother proud.