Variability in Opioid Prescribing Across the Cancer Care Continuum: A Multi-Level Analysis

PROJECT SUMMARY The goal of this proposal is to develop a comprehensive understanding of the scope and key drivers of variations in the quality of opioid management across the cancer care trajectory, and to use this understanding to design a multi-level intervention to improve cancer pain management for future testing. Pain is a common and disabling symptom of cancer, affecting half of patients on treatment, one third of survivors, and over two thirds of those with advanced disease. Despite their risks, opioids remain a cornerstone of managing cancer pain. However, we have demonstrated that opioid management varies widely based on where a patient lives and receives their care, and that some cancer patients receive far fewer and less potent analgesics than others with similar conditions, leading to more severe and debilitating pain. To date, there have been few population-based studies of opioid prescribing among cancer patients and much remains unknown about the patients and communities most affected by poor pain management, and the relative influence of physician, practice, and health system factors. Here we propose a comprehensive analysis of variations in opioid management among Medicare-insured patients across the post-operative, active treatment, survivorship, and end-of-life phases of cancer care. By linking administrative data to comprehensive information about physicians, practices, and health systems, we will examine differences in opioid management across versus within these levels, elucidating key mechanisms by which patient, provider, and medical system factors may undermine quality pain management. The project will be led by a team with expertise in multilevel analyses of healthcare quality and guided by longitudinal engagement of patient stakeholders. After identifying the patients at greatest risk for poor pain management we will use a rigorous 4-phase research process to design a multi-level intervention that targets the most potent and mutable drivers across patient, provider, and health system levels to promote quality pain management. This process will be grounded by qualitative feedback from cancer patients and caregivers and from clinicians, staff and organizational leaders from multiple cancer care systems. This proposal will yield a comprehensive understanding of the scope and root causes of variations in the quality of cancer pain management, and a trial-ready multi-level intervention. Our findings will also have clear implications for policy makers, insurers, and health systems leaders committed to providing high-quality care for cancer patients.