All Patients That Remained On Opioids and Engaged ISOMP ( Group A , N = 17 )
TABLE 4 : Analysis of Patients Remaining on Opioids ( Group A ) Prior To ISOMP During ISOMP Change % Diff
Paired T- Test P-Value ( Two-sided )
Number of Months ( 38 ) 19 19 0 0.00 % N / A
Patient Encounters Total Number of Encounters 156 146 -10 -6.41 % p = 0.5401 Total Number of Opioid-Related Encounters 78 94 16 20.51 % p = 0.0681
Total Number of Encounters not Related to Opioid Management
78 52 -26 -33.33 % p = 0.1765
Work RVUs Total Work RVUs for all Encounters 168.37 240.69 72.32 42.95 % p = 0.0004
Total Work RVUs for Opioid-Related Encounters
Total Work RVUs for Encounters not Related to Opioid Management
88.90 188.10 99.20 111.59 % p < 0.00001
79.47 52.59 -26.88 -33.82 % p = 0.1380
Average Work RVUs Per Encounter 1.08 1.65 0.57 52.78 % p < 0.00001
Average Work RVUs Per Opioid-Related Encounter
Average work RVUs per encounter not related to opioid management
1.14 2.00 0.86 75.53 % p < 0.00001
1.019 1.012 -0.007 -0.69 % p = 0.1499
ISOMP = Intentional Structured Opioid Monitoring Protocol ; RVU : relative value unit ; p < 0.05 is significant
wean . Work RVU declined by -47.39 %, -47.55 % and -46.89 % after that transition .
DISCUSSION CLINICAL IMPACT
The overall impact of the ISOMP ’ s 38 % decrease in patients using opioids has been previously documented . 8 Granular benefits of the daily and global schedules can also be observed . Table 2 details the changes seen in the specific ISOMP day schedule . Overall numbers of patients seen decreased by 24.82 %. This decrease was primarily driven by a 62.08 % decrease in non-opioid visits , allowing for 6.83 opioid management visits to be conducted each ISOMP day . The non-opioid visits changed in nature as they were primarily acute visits following implementation and problembased chronic medical management visits prior to the change . This decrease in visit quantity was useful in allowing for increased provider attention to every measure required to appropriately manage opioids for non-malignant pain . Furthermore , compliance with opioid visits increased significantly , evidenced by a drastic 72.75 % drop in the no-show rate . While the impact of the ISOMP on the monthly opioid management day is understandable , the impact of a singular day each month on the physician ’ s overall practice is surprising . Despite no other practice parameters being changed over this time , the overall visits stayed relatively stable , but global no-show visits dropped 12.14 % ( Table 3 ).
When the cohorts of patients treated with opioids ( Group A ) and weaned from opioids ( Group B ) are analyzed , the clinical benefits are more pronounced . Group A had a decrease in non-opioid visits over that time by 33.33 % ( Table 4 ), thereby demonstrating that isolating opioid management into their own visits minimizes the schedule clutter from fewer unscheduled non-opioid visits . Greater benefits were seen for Group B , as they required 24.04 % fewer total visits ( Table 5a ). Maximal benefit was discovered once weaning occurred ( Table 5b ) as total visits per month for this group decreased 44.99 % and pain related visits decreased in frequency from 3.23 visits per months to 1.79 visits per month . Not only did the ISOMP impact clinical outcomes of decreased opioid burden , but
it also decreased clinician schedule crowding for patients treated with opioids while still decreasing global no-show rates .
PRACTICE FINANCIAL IMPACT
To best evaluate the sustainability of ISOMP , it was important to ensure that financial productivity was not diminished . Work RVU , the component of total visit RVU attributable to physician effort , was thought to be the best indicator of physician effort and reimbursement . 10-12 Total work RVU for the entire ISOMP period increased despite a decrease in overall visits over a matched baseline ( Table 3 ). It was verified that there were no changes in the work RVU values during the period between 2011 through 2014 for the EM codes 99212 , 99213 , 99214 , and 99215 using the Centers for Medicare and Medicaid Services physician fee schedule search . There was also no change in the number of hours worked by the provider during this time . Sustainability was further supported by increases in payments received and charges generated after ISOMP initiation . Although these values are subject to external influences such as third-party reimbursement or delays in payment , over-
West Virginia Medical Journal • September 2022 • 23