Pharmacist Pain E-Consults That Result in a Therapy Change
Related: The Rapid Rise of e-Consults Across Specialty Care
Although the e-consult program at the BPVAHCS consisted solely of a physician and a pain specialty pharmacist, the purpose of this project was to evaluate the characteristics of recommendations made by a pharmacist and the percentage of consults that resulted in a therapy change. The physician was responsible for separate consults, and their recommendations were not collected. However, it is important to recognize that the pain specialty pharmacist and physician performed identical roles on the team, each recommending both pharmacologic and nonpharmacologic treatment options in every consult.
Related Programs
The VA Boston Healthcare System (VABHS) is composed of 3 main facilities and 5 CBOCs across eastern Massachusetts. Although veterans in the eastern part of the state are able to receive primary care at a CBOC, specialty care is provided primarily at 2 of the main locations in the Boston area. Therefore, the VABHS began an e-consult program in order to facilitate patient access to specialty providers for patients unable to participate in a face-to-face visit.
The purpose of the VABHS study was to examine the implementation and provider perception of an e-consult program within a large VA system, to provide timely patient access to specialty care. The pilot program was initiated in 2 specialty clinics in 2011 but expanded to 12 specialty clinics within 9 months. The specialty clinics included allergy, cardiology, endocrinology, gastroenterology, hematology, infectious disease, nephrology, oncology, palliative care, pulmonary disease, rheumatology, and sleep medicine. Outcomes of the VABHS e-consult program revealed that a majority of PCPs were satisfied with the use of e-consults, whereas specialists were less satisfied. The PCP-perceived benefits to patients included avoidance of unnecessary travel, faster clinical input, and avoidance of unnecessary copays.9
Like the VABHS, the use of pain e-consults at BPVAHCS helps reduce the burden of face-to-face clinic visits and eliminate accessibility barriers for veterans. This study differs from the VABHS in that PCPs requested onetime consults focused solely on pain management. The pain specialty pharmacist at BPVAHCS did not provide longitudinal care; measure patient outcomes, such as satisfaction, reduction in pain, or improved functionally; or examine provider satisfaction. Additionally, unlike the BPVAHCS program, there was no indication whether a pharmacist played a role in the program.9
Other studies have explored the role of a pain pharmacist in the inpatient setting offering consults on patient-controlled analgesia and in patients with a history of substance abuse.10,11 Another recent study similarly looked at the effectiveness of a pharmacist-led medication review in chronic pain management. The aim was to assess patient outcomes: decrease in pain intensity and improvement in physical functioning.12 Another study involving a nurse and pharmacist-led chronic pain clinic in a primary care setting conducted in England showed improvement in patient-reported pain and reduction in secondary referrals.13
Limitations
Limitations of the study included short study duration (6 months); use of a newly implemented E-Consult Pain Service; lack of pharmacist follow-up on acceptance/rejection of their recommendation; inability to determine patient outcome(s), as consults were for a single point in time, regarding a therapy recommendation; lack of access to non-VA medications; and patient refusal to change current pain regimen.
Patient refusal inhibited providers from implementing therapy changes recommended by the pharmacist and therefore could have negatively impacted study outcomes. Raw data were used for this study, and there were no statistical analyses conducted. Furthermore, lack of other formal e-consult programs within BPVAHCS to compare the acceptance/rejection of pharmacist recommendations for other conditions and lack of a third-party review of pharmacist recommendations to ensure standard of care may have limited this study.
Future Research
As the E-Consult Pain Service continues, research regarding the value of the pain specialty pharmacist may be warranted. Additional research is needed to identify the reasons that recommendations were accepted or ignored, whether the recommendations were beneficial to the patients, and the PCPs’ perception on the usefulness of a pain e-consult program. When the program started, 14% of patients at BPVAHCS were taking opioids. The pain e-consult program handled a small percentage of these patients.
The authors considered proactively reviewing all patients on > 100 mg morphine equivalents of opioids daily but did not have adequate staff to support the review. It may be helpful to identify those patients taking opioids but do not have a consult. The role of the pain e-consult pharmacist may be expanded to assist PCPs, including leading patient education classes to explain the concept and purpose of the opioid treatment agreement; reinforcing expected behaviors and outcomes of patients prescribed opioids; assisting providers with interpreting UDSs and notifying providers of aberrant behaviors; and educating providers on opioid risk mitigation through seminars or academic detailing.
