Background: Opioid analgesics are the mainstay for management of malignancy associated pain. A common and debilitating drawback of chronic opioid use is constipation. It increases patient discomfort and morbidity and adds to growing health care costs. The American Society of Clinical Oncology (ASCO) Quality Oncology Practice Initiative (QOPI) is a practice-based quality assessment program with a goal to promote excellence in cancer care by helping practices identifying opportunities for quality improvement (QI). The purpose of this QI project was to improve rates of assessment and management of constipation in patients on chronic opioids for cancer-associated pain.
Methods: The fellowship program of the University of Arkansas for Medical Sciences/Central Arkansas Veterans Healthcare System (UAMS/CAVHS) participated in a spring 2013 QOPI cycle. Standardized scores revealed that constipation at the time of narcotic prescription was assessed 52% of the time at the UAMS/CAVHS program compared with a nationwide fellowship score of 72% and 69% for all oncology practices nationally. To improve assessment of narcotic-associated constipation and sufficiency of bowel regimen prescribed, we established a dedicated fellow-lead team. We then organized monthly meetings with all stakeholders and provided training in assessment and management of opioid-associated constipation. We added mandatory checkboxes in our electronic progress notes to improve participation. Plan-do-study-act (PDSA) cycles were regularly implemented to assess early results and provide additional training and reinforcement to boost adherence. Final chart reviews and patient surveys were performed 6 months after project initiation.
Results: Six months after implementation of the project, we randomly selected 40 patient charts for review. Documentation of assessment of narcotic-associated constipation improved to 92.5% (37/40) compared with 52% at baseline. All the patients who reported constipation (4/4) were started on bowel regimens on the same day of the clinic visit. Additionally, 89% (33/37) of patients on chronic-opioid medications were also on a bowel regimen. Patient surveys showed that 90% (18/20) of patients reported adequate management of constipation, and 80% (16/20) also reported adequate pain management.
Implications: Participation in ASCO QOPI programs can help identify areas in need of QI. Bringing these areas into focus, coupled with reinforcement through PDSA cycles can help improve quality of care provided to oncology patients in a timely manner.
