Team-Based Medicine: Incorporating a Clinical Pharmacist into Pain and Opioid Practice Management.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) reports that death from opioids has increased by more than five times since 1999. In response, federal and state organizations have released guidelines recommending best practice standards to combat the opioid epidemic. OBJECTIVE: To evaluate the impact of a clinical pharmacist in a team-based care model on the adherence to best practice standards and access to care for management of patients prescribed chronic opioid therapy (COT). DESIGN: Retrospective chart review study. SETTING: An outpatient physical medicine and rehabilitation clinic in a tertiary hospital. PATIENTS: Three hundred eighty-three patients presenting to the clinic between January 2012 and August 2016 with chronic, noncancer pain. METHODS: Comparison of adherence to best practice standards-including changes in morphine equivalent dose (MED), compliance with urine drug screenings, documentation of medication agreements, initiation of nonopioid medications, and the impact of comorbidities-was analyzed before and after a clinical pharmacist was added to the team. Data were gathered from the electronic medical record and the Prescription Monitoring Program. A control group of patients who did not see the pharmacist and were managed only by the physician section head was also compared to the group of patients managed by a clinical pharmacist. OUTCOME MEASUREMENTS: The primary outcome measurement evaluates the change in MED values over time. Secondary outcome measurements are to review compliance with annual urine drug screening, documentation of the medication agreement, initiation of nonopioid medications by the pharmacist, and assessment of the access to care for patients with chronic opioid therapy needs. RESULTS: A clinically significant reduction in MED with an average decrease of 207 mg was seen after five or more visits with the pharmacist. The pharmacist initiated nonopioid medications at 209 unique patient visits (19.5%). The pharmacist completed 1197 visits during the study time frame, increasing physician access by at least two additional visits per patient per year. Completion of urine drug screens and medication agreement reviews improved over time (P < .001). There was an increase in MED for patients who did not complete this monitoring, whereas the MED remained stable in patients who did complete the monitoring. CONCLUSIONS: The addition of a clinical pharmacist to an interdisciplinary team managing COT patients resulted in a MED reduction after five or more visits with the pharmacist, improved adherence to best practice standards, optimization of opioid and nonopioid medication therapy, and increased patient access. Developing a role for advanced practitioners, such as clinical pharmacist providers, working with patients on COT can result in significant improvements in patient access to care, adherence to best practice standards, and patient safety. LEVEL OF EVIDENCE: III.

Pharmacist prescribing within an integrated health system in Washington.

PURPOSE: Pharmacist prescribing as part of a collaborative drug therapy agreement (CDTA) within an integrated health system in Washington is described. SUMMARY: Virginia Mason Medical Center (VMMC) in Seattle, Washington, uses a team-based care model with broad-based CDTAs to provide quality patient care. The majority of patients are referred to the pharmacist after a diagnosis has been made and a clinical care plan has been started. The pharmacist manages the patient's care within his or her scope of practice as defined by state laws and further detailed by VMMC internal protocols. The pharmacist then documents in the electronic medical record the medication plan of care and other standard elements based on provider note templates. Medication prescribing and laboratory test ordering are the responsibilities of the pharmacist, as are any dosage adjustments or interpretations of laboratory test results. For some chronic diseases, the pharmacist may continue to see the patient indefinitely, replacing physician visits (e.g., for warfarin management). In more episodic care, the pharmacist may see the patient, optimize drug therapy, and then transition the patient back to the referring provider (e.g., for hypertension management). Integrating the pharmacist into the team has helped achieve optimal medication outcomes and increased patient satisfaction scores. CONCLUSION: The addition of the pharmacist into a team-based care model using a CDTA helped achieve optimal medication outcomes and increased patient satisfaction scores in an integrated health system. Integration was successful due to the collaborative support from physician leadership and ongoing physician involvement. Hands-on leadership by the pharmacy department and clinic directors and the health system's adoption of Lean methodology fostered an environment for developing innovative care models.

The cost of treating allergic rhinitis.

Allergic rhinitis is a high-cost, high-prevalence disease. In the year 2000, over $6 billion was spent on prescription medications to treat this illness. Although it is not associated with severe morbidity and mortality, allergic rhinitis has a major effect on the quality of life of the more than 50 million Americans with this illness. Intranasal corticosteroids (INCS) and nonsedating antihistamines (NSAH) are the most common prescription medications for this disease. INCS are recognized as the most effective treatment regimen for chronic symptoms. NSAH are perceived as important in the treatment of patients with mild disease, or as add-on therapy to INCS. When the literature is reviewed, the INCS produce the greatest decrease in total nasal symptom scores, the largest effect size, when compared with NSAH. Both classes of medications produce similar effects on concurrent allergic conjunctivitis. Further recent studies indicate that the INCS are also superior when used on an as-needed basis, and that there is little clinical benefit from the addition of loratadine to intranasal fluticasone. INCS have lower average wholesale prices as a class than the NSAH. Since the INCS are the dominant medication in efficacy studies and cost less, cost-effectiveness studies always favor intranasal corticosteroids.