Background: Black cancer patients experience pain. Barriers to opioid medications for pain may include geographic factors. This study examines neighborhood factors associated with difficulties receiving prescription opioids from pharmacies for black cancer patients.
Design: A secondary data analysis of a study on opioid adherence was used to examine neighborhood-level and individual factors related to difficulties filling prescriptions for opioids.
Setting/Subjects: Patients being treated for cancer pain with opioids (n = 104) were recruited. All self-identified as black, were 21 years or older, had cancer diagnoses, and had been prescribed extended release opioids.
Measurements: A seven-item survey to identify problems filling opioids was completed by 98 participants along with a nine-item scale to assess perceived neighborhood characteristics. Scales of neighborhood amenities and neglect were created from the perceived neighborhood characteristics scale using principal components analysis. The 2009–2013 American Community Survey data were used to estimate the census tract percentage of non-Hispanic black residents, residents =25 years of age without a high school degree or equivalent, and households earning below the federal poverty level within the past 12 months.
Results: Nearly 51% reported problems getting their opioids filled: 28% had to wait days and 24% had to return to the pharmacy multiple times. The main theme identified in analysis of an open-ended question was pharmacies not stocking medication. Neighborhood locations that rated higher on the amenities scale were protective for pharmacies sufficiently stocking opioids.
Conclusions: Additional research on pharmacies sufficiently stocking opioid pain and neighborhood perceptions is warranted.
OBJECTIVES: Patients who are no longer eligible for curative treatment often suffer from multiple complaints and require a multidisciplinary treatment approach. We incorporated two pharmacists in the palliative team, one hospital pharmacist and one pharmacist who were trained as a community pharmacist. The objective of our study was to evaluate their contribution to the palliative team.
METHODS: During 13 months, the two pharmacists participated in all regular patient reviews and rounds and were available for individual consultation by all members of the palliative team on a daily basis. Each intervention (consults at request or during the patient rounds) was logged and categorised.
KEY FINDINGS: During the study period, 115 patients were under the care of the palliative treatment team. The pharmacists were actively involved in 107 of these (93%). Pharmacists interventions occurred in 76% of patients, with an average of 1.5 interventions per patient. The most common intervention types were giving general therapeutic advice, starting of a drug for an uncontrolled symptom and stopping a drug that was given as prophylaxis. When comparing the contribution of the hospital pharmacist and the outpatient pharmacist, their interventions overlapped with regard to starting drugs, choice of drugs and side-effect management. However, interventions on parenteral drugs or optimising the route of administration mostly came from the hospital pharmacist, whereas the outpatient pharmacist more often intervened in increasing adherence and stopping drugs.
CONCLUSION: The palliative pharmacist team adds expertise to the palliative treatment team, with an active contribution in 76% of patients.
Objectives: To explore pharmacists’ perspectives on practice, availability, and barriers related to opioids.
Methods: This cross-sectional study evaluated pharmacists’ perspectives on practice, availability, and barriers related to opioids. Electronic surveys were distributed to pharmacists practicing in Georgia via Survey Monkey. The 2 or Fisher Exact test was used to test differences in practice, availability, and barriers with respect to type of pharmacy and location of pharmacy.
Results: Most participating pharmacists practiced in an independent (47%) or community chain pharmacies (37%). The majority checked the Prescription Drug-Monitoring Program (PDMP) on a regular basis (73%), and about a third reported contacting the prescriber prior to dispensing. The most common barrier included concerns about diversion (82%) and illicit use (90%). About two-thirds reported experiencing a shortage of opioids. Significant differences (P < .05) were found between types of pharmacy in dispensing practices, availability, and barriers. No significant differences were found with respect to pharmacy location.
Conclusion: Findings suggest that pharmacists are facing challenges in availability of opioids and are employing stewardship approaches to optimize dispensing practices. This research provides insight regarding broken links in the “pain relief chain” and identifies opportunities to improve the accessibility of opioids when medically indicated. Pharmacists can play an important role in addressing the opioid crisis as well as providing quality care to patients with cancer seeking pain relief.
In clinical practice, pharmacists are continually required to improve their knowledge and expertise; however, the postgraduate education system for professional development cannot be confidently stated to be well established. The establishment of a systematic and multifaceted educational curriculum should be useful to improve home care and pharmacists' contribution; therefore, we developed a curriculum in collaboration with the university faculty of pharmaceutical sciences, department of pharmacy in hospital, and the Fukuoka Pharmaceutical Association. Class topics were extracted from the "Kanwa-Iryou-Yakugaku", edited by the Japanese Society for Pharmaceutical Palliative Care and Sciences. The items are necessary to perform palliative care as a pharmacist. A class schedule of 6 days (24 classes in total) was formulated. Questionnaires on comprehension degree before and after each class were provided to the participants. Comprehension was assessed on a scale of 1 to 10, where "I do not understand at all" was 1 and "I understand enough" was 10. The average recovery rates of questionnaires from each class were 92.6 % and 88.9 % before and after class, respectively. The average number of participants who completely answered the questionnaire before and after class was 45.6; therefore, these data were analyzed. Comprehension degree on each topic had significantly increased after attendance of all classes (p < 0.01). The comprehension degree of participants of the medical science of palliative care did greatly improve. Consequently, it is clear that the standard education model constructed was meaningful for the professional development of pharmacists in palliative care medicine.
Palliative care services offered in the United States have grown substantially since the year 2000. These types of services have been shown to improve a patient's quality of life when presented with a serious or life-threatening disease or illness. An important characteristic of a quality palliative care service is the presence of an interdisciplinary team to utilize different areas of expertise to address multiple aspects of patient care. An important member of this team is the pharmacist. The services presented in this interprofessional education and practice guide describe pharmacist-delivered palliative care services offered in an institutional ambulatory palliative care setting from 2012 to 2018.
Clinical pharmacy interventions have been shown to improve medication therapy, prevent undesirable side effects, and improve patients' clinical outcomes in a number of settings; however, limited data exist to characterize clinical pharmacy specialist (CPS) providers' interventions in an inpatient hospice Veteran Affairs (VA) setting. The primary objective of this quality improvement (QI) project was to quantify the number and types of pharmacy interventions implemented from the Pharmacists Achieve Results with Medications Documentation (PhARMD) tool for inpatient hospice patient encounters in a VA medical center. A total of 453 interventions during 185 patient care encounters were documented by CPS providers between September 1, 2016, and December 31, 2016. These interventions were documented across 32 unique patients, with an average of 14.2 interventions made per patient during this period. CPS providers frequently intervened to optimize pharmacotherapy for the treatment of pain (42.38%), terminal agitation (5.08%), and nausea (3.97%). Additionally, CPS providers played a significant role in the deprescribing of medication by discontinuing drugs no longer indicated (18.3%). These results substantiate the valuable contribution to patient care that the CPS providers make in optimizing symptom management and deprescribing at end-of-life. Future studies are needed to characterize the potential cost savings of CPS provider services in the inpatient hospice setting.
Background: There is no nationwide data on polypharmacy in palliative care in Japan. In this study, the research committee of the Japanese Society for Pharmaceutical Palliative Care and Sciences conducted an online survey on polypharmacy and inappropriate prescriptions involving its members who worked as hospital pharmacists.
Methods: The online questionnaire included questions about hospital pharmacist interventions for cancer patients who regularly used six or more drugs during a two-month period from October to November 2017.
Results: Of 2618 hospital pharmacists, 359 responded (13.7%). With regard to cancer patients receiving opioids, 40.9 and 22.3% of the respondents replied that percentages of patients prescribed six or more regular medications were "40-69%" and "70-99%," respectively. Regarding patients on polypharmacy, 73.0% of the respondents reported a low or moderate rate of inappropriate prescriptions, with responses such as "long-term administration of irresponsible or aimless medications", "adverse drug reactions," and "duplication of the pharmacological effect". Furthermore, 24.2, 46.8, and 23.4% of respondents replied that the rates of drug reduction due to pharmacist recommendations were "0", "1-39%", and "more than 40%," respectively. Pharmacist interventions decreased the use of inappropriate medications, including antiemetics, gastrointestinal medications, and hypnotic sedatives, and reduced or prevented adverse drug reactions such as extrapyramidal symptoms, delirium, and sleepiness. Similar results were obtained for cancer patients who did not use opioids. However, the rates of cancer patients on polypharmacy and with reduction of inappropriate medications by pharmacist interventions were significantly higher in cancer patients receiving opioids. Finally, recommendations of board-certified pharmacists in palliative pharmacy contributed to a decrease in the use of inappropriate medications in cancer patients on polypharmacy (p = 0.06).
Conclusion: This nationwide survey clarified pharmacist interventions for polypharmacy in palliative care in Japan. Our data showed frequent polypharmacy in cancer patients receiving opioids, and benefits of pharmacist interventions, especially by board-certified pharmacists in palliative pharmacy, for reducing inappropriate medications and improving adverse drug reactions.
Objective: To determine if pharmacy students participating in simulation-based scenarios reported fewer learning needs about the transition from acute to end-of-life (EOL) care compared to students participating in solely case-based scenario delivery.
Methods: Four end-of-life cases were developed for both paper-based case study and simulation delivery. Pharmacy students on three distant campuses were exposed to the case study approach while four teams of nine to ten pharmacy students were exposed to simulated versions of the same cases. A validated questionnaire was administered before and after exposure to assess end-of-life care learning needs. Results were analyzed following a Bonferroni-adjustment for multiple testing.
Results: The case study groups produced similar pre/post changes on the questionnaire. After results were pooled and compared to the simulation only group, significantly higher changes in pre/post scores were found for the simulation group.
Conclusion: Pharmacy students exposed to simulated EOL scenarios experienced significantly reduced learning needs following the scenarios, unlike their classroom-based counterparts.
BACKGROUND: Polypharmacy may be particularly burdensome near the end of life, as patients "accumulate" medications to treat and prevent multiple diseases.
OBJECTIVE: To evaluate associations between polypharmacy, symptom burden, and quality of life (QOL) in patients with advanced, life-limiting illness (clinician-estimated, 1 month-1 year).
DESIGN: Secondary analysis of baseline data from a trial of statin discontinuation.
PARTICIPANTS: Adults with advanced, life-limiting illness.
MAIN MEASURES: Polypharmacy was assessed by summing the number of non-statin medications taken regularly or as needed. Symptom burden was assessed using the Edmonton Symptom Assessment Scale (range 0-90; higher scores indicating greater symptom burden) and QOL was assessed using the McGill QOL Questionnaire (range 0-10; higher scores indicating better QOL). Linear regression models assessed associations between polypharmacy, symptom burden, and QOL.
KEY RESULTS: Among 372 participants, 47% were age 75 or older and 35% were enrolled in hospice. The mean symptom score was 27.0 (standard deviation (SD) 16.1) and the mean QOL score was 7.0 (SD 1.3). The average number of non-statin medications was 11.6 (SD 5.0); one-third of participants took = 14 medications. In adjusted models, higher polypharmacy was associated with higher symptom burden (coefficient 0.81; p < .001) and lower QOL (coefficient - .06; p = .001). Adjusting for symptom burden weakened the association between polypharmacy and QOL (coefficient - .03; p = .045) without a significant interaction, suggesting that worse quality of life associated with polypharmacy may be related to medication-associated symptoms.
CONCLUSIONS: Among adults with advanced illness, taking more medications is associated with higher symptom burden and lower QOL. Attention to medication-related symptoms and shared decision-making regarding deprescribing are warranted in this setting.
NIH TRIAL REGISTRY NUMBER: ClinicalTrials.gov Identifier for Parent Study - NCT01415934.
PURPOSE: The purpose of the study was to evaluate the impact on pain management by multidisciplinary palliative care team (mPCT) and the team pharmacist.
METHODS: Patients who were admitted to palliative care unit (PCU) for at least 7 days between April 2014 and December 2015 were included. The mPCT consisted of a physician, a pharmacist, nurses, and non-clinical support staff. The team was on charge of pain management of patients who were admitted to PCU. Pain intensity was assessed at 3 time points in each patient; 1 week before PCU admission (day -7), on the day of admission (day 0), and 1 week after admission (day 7) using 0 to 10 numerical rating scale (NRS). Analgesic use was evaluated with 6 categories based on National Comprehensive Cancer Network and Korean pain management guidelines. Pain intensity and analgesic use appropriateness were compared at day -7, day 0, and day 7 for the patients who were admitted to the PCU.
RESULTS: Pain intensity decreased significantly on day 7 of PCU admission compared to it on day 0 (NRS: 4.05 vs 2.66, P < .001). A significant negative correlation was found between pain intensity and the proper use of analgesics ( r = -0.407; P < .001, r = -0.309; P = .001, r = -0.241; P = .009, on day -7, day 0, day 7, respectively).
CONCLUSION: The mPCT contributed to the reduction of inappropriate use of analgesics and improved pain control. Pharmacist intervention appeared to have improved pain control in patients under palliative care. Each team member's role should be individualized and developed further.
C'est en février dernier que la 5e édition du Guide pratique de soins palliatifs de l'Association des pharmaciens en établissements de santé du Québec (A.P.E.S.) a été publié en version numérique. Cette publication est le fruit du travail bénévole des membres du Regroupement de pharmaciens experts (RPE) en soins palliatifs de l'A.P.E.S. Qui sont-ils ? Quel est cet ouvrage ?
BACKGROUND: The importance of medication reconciliation and the pharmacist's role within the interdisciplinary team at the point of transition to home hospice is understudied. A transitions of care pilot initiative was developed to streamline the transition for patients at end of life from inpatient cancer center care to home hospice. The initiative consisted of using a hospice discharge checklist, pharmacist-led discharge medication reconciliation in consultation with the primary team responsible for inpatient care, review of discharge prescriptions, and facilitation of bedside delivery of discharge medications.
METHODS: This was a single-center, prospective, pilot initiative. The objectives of this study were to characterize pharmacist interventions at the time of transition, to assess changes in hospice organizations' perceptions of discharge readiness, and to evaluate differences in representation rates with the implementation of the pilot discharge process.
RESULTS: Fifteen patients in the preimplementation period and 12 patients in the postimplementation period were included. One hundred eleven pharmacist interventions were captured, an average of 9.3 interventions per patient, with an acceptance rate of 82.9% by providers. There was a statistically significant ( P = .035) improvement in hospice organizations' perceptions of discharge readiness. There was no difference in 30-day representation rates postdischarge ( P = 1).
CONCLUSION: This well-received pilot initiative demonstrated an improvement in local hospice's perception of patient readiness for discharge and a high percentage of accepted pharmacist interventions during discharge medication reconciliation. A larger sample size of patients and longer follow-up period may be needed to demonstrate statistically significant improvements in representation rates postintervention.
OBJECTIVE: To establish a return on investment (ROI) for a pharmacist position on a hospital-based palliative care (PC) team.
BACKGROUND: Utilizing a pharmacist to provide PC services is often overlooked as a solution to physician shortages. Integration of a pharmacist into PC teams yields a favorable ROI.
METHODS: A 16-month retrospective review comparing PC patients at two hospitals with consultative PC teams. The PC teams at the two facilities had identical full-time equivalent team members, except for a PC pharmacist at Facility 1. The PC pharmacist's ROI was calculated based on cost savings created by utilizing the PC pharmacist as a physician extender and costs attributable to preventable adverse drug events (pADEs) identified by the PC pharmacist.
RESULTS: An annual ROI of 1.2 to 2.9 million dollars was calculated, $125,760 from physician time saved and $1.1-2.8 million dollars from pADEs. A statistically significant difference in rates of pADEs was realized between the PC pharmacist and non-PC pharmacists at Facility 1 as well as between pharmacists at Facility 1 (PC pharmacist and non-PC pharmacists) and pharmacists at Facility 2 (non-PC pharmacists).
CONCLUSION: A PC pharmacist's unique qualifications and perspective contribute to the value of care provided to PC patients. A favorable ROI that exceeds a pharmacist's annual salary was demonstrated in this analysis.
As palliative care (PC) moves upstream in the course of serious illness and the development of drugs and their indications rapidly expand, PC providers must understand common drug indications and adverse effects to ensure safe and effective prescribing. Pharmacists, experts in the nuances of medication management, are valuable resources and colleagues for PC providers. This article will offer PC providers 10 useful clinical pharmacy tips that PC pharmacists think all PC providers should know for safe and effective symptom management. Close collaboration with or addition of a trained pharmacist to your PC team can improve clinical care for all PC patients.
The use of multiple drugs is often referred to as polypharmacy, although this term has not been precisely defined. Frequently, drugs are used unwisely in multiple combinations increasing the risk of adverse reactions, or for the long-term prevention of diseases in patients with a short life expectancy who, therefore, will not benefit from them. The reflection on this has led to the introduction of the concept of deprescription. There are many reasons for the inappropriate drug prescription and barriers to reduce medications. Tools were developed to help prescribers to limit the number of prescribed drugs that patients are taking. Several studies have shown that deprescription of some drugs is possible and safe and can even have a positive influence on wellbeing, cognitive function, falls, and admission to a hospital. Deprescription should be individualized and carried out, as far as possible, in agreement with patients and their families. A six-step method for deprescription is proposed.
Palliative care is defined by the World Health Organization as "an approach that improves the quality of life of patients and their families facing the problem(s) associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychoscial and spiritual".
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INTRODUCTION: Palliative care uses a team approach, including physicians, nurses, social workers, chaplains, and pharmacists. The pharmacist's role within palliative care teams is increasing and initial favorable outcomes have been reported.
METHODS: This retrospective study evaluated adult hospitalized patients seen by a part-time palliative care specialist pharmacist as part of the palliative care consultation team at an academic health system during a 15-month period between September 1, 2015, and March 30, 2017. Our study's objective is to identify patterns of an inpatient palliative care pharmacist's interventions and outcomes and evaluate the impact of pharmacist involvement on patient hospital length of stay (LOS), length from admission to palliative care consult (LTC), and time from consult to discharge or death (CTD).
RESULTS: The palliative care pharmacist was on service 35% of the time and saw 26.4% of the patient seen by the palliative care team (n = 341 out of 1293). Each patient received an average of 3.5 interventions with an average of 4.1 documented outcomes. The most common interventions were optimizing palliative medication regimen and providing education; most common outcomes were implementation of a change in palliative medication regimen and education of healthcare professionals. Overall, patients seen by the palliative care pharmacist were younger (p < 0.05), more likely to be female (p < 0.05), and more likely to have a primary palliative consultation reason listed as “pain” (p < 0.005). LOS, LTC, and CTD were significantly longer for patients seen by palliative care pharmacist.
CONCLUSION: Pharmacist interventions and outcomes were predominantly related to optimizing symptoms by changes in medication regimen and education of healthcare professionals. A subanalysis of patients with known date of first pharmacist visit found significantly improved LOS, LTC, and CTD for patients with early access to palliative pharmacy (in addition to the other members of the palliative team) compared to those without early access.
BACKGROUND: Pharmacists have a key role to play in optimisation of medication regimens and promotion of medication safety. The role of specialist pharmacists as part of the multidisciplinary palliative care team, especially in the primary care setting, is not widely recognised.
AIM: To explore the perspectives of stakeholders about the gaps in the current model of community palliative care services in relation to medication management and to assess their opinions pertaining to the role of a specialist palliative care pharmacist in addressing some of those gaps.
DESIGN: Qualitative study utilising three focus groups involving 20 stakeholders. Thematic analysis was carried out using a framework approach and interpreted in the context of the Chronic Care Model for improving primary care for patients with chronic illness.
SETTING/PARTICIPANTS: Setting was a large regional Australian palliative care service. Participants included palliative care consumers and clinicians specifically patients, caregivers, physicians, nurses and pharmacists.
RESULTS: Five major themes emerged from the focus groups: access to resources, medicines and information; shared care; challenges of polypharmacy; informal caregiver needs and potential roles of a palliative care pharmacist. Gaps in access to medicines/resources, training for generalist practitioners, communication between treating teams and lack of support for patients and carers were cited as factors adversely impacting medication management in community-based palliative care.
CONCLUSION: While community-based palliative care is an essential aspect of meeting the health care demands of an ageing society, the current model has several gaps and limitations. An appropriately qualified and skilled pharmacist within the palliative care team may help to address some of the gaps in relation to medication access and appropriateness.
BACKGROUND: Palliative care patients consistently nominate home as their preferred care environment. This is challenging without support from laycarers, especially if patients require subcutaneously administered symptom relief. Laycarers typically lack confidence with this task and request professional guidance.
AIM: To explore differences in laycarers' confidence in administering subcutaneous injections depending upon whether a laycarer, registered nurse or pharmacist prepared injections for subsequent administration by laycarers.
DESIGN: Prospective randomized controlled trial with three intervention arms: laycarer prepares, labels and stores injections; registered nurse prepares injections; and pharmacist prepares injections for later administration by laycarer.
SETTING/PARTICIPANTS: In all, 93 laycarers, from 24 urban and rural community services, completed the study.
RESULTS: The primary outcome of interest was laycarer confidence with injection administration; analysis of variance revealed no significant differences between the three intervention arms; mean values ranged from 5.9 to 6.1 out of 7 (F(2, 90) = 0.50, p = 0.61). Comparison of confidence after laycarer preparation versus other (nurse or pharmacist) was not statistically significant (t = 0.7, df = 90, p = 0.49). Averaged over intervention arms, confidence levels increase significantly with injecting experience, from 5.3 to 6.1 (F(1, 75) = 47.6, p < 0.001).
CONCLUSION: Upskilled laycarers can confidently administer subcutaneous injections for loved ones, regardless of who prepares injections. This finding can improve patient outcomes and potentially decrease unwanted admissions to inpatient facilities.
INTRODUCTION: As the role of the pharmacist on the transdisciplinary palliative care team grows, the need for adequate instruction on palliative care and clinical reasoning skills in schools of pharmacy grows accordingly.
METHODS: This study evaluates second- and third-year pharmacy students from 6 accredited schools of pharmacy that participated in surveys before and after the delivery of a didactic palliative care elective. The survey collected student demographics, perceptions of the importance of and student skill level in palliative care topics. The script concordance test (SCT) was used to assess clinical decision-making skills on patient cases. Student scores on the SCT were compared to those of a reference panel of experts.
RESULTS: A total of 89 students completed the pre-/postsurveys and were included in data analysis. There was no statistically significant difference in student perceived importance of palliative care skills before and after the elective. Students from all 6 institutions showed significant increase in confidence in their palliative care skills at the end of the course. There was also a significant improvement across all institutions in clinical reasoning skills in most of the SCT questions used to assess these skills.
CONCLUSIONS: Students choosing an elective in palliative care likely do so because they already have an understanding of the importance of these topics in their future practice settings. Delivery of a palliative care elective in the pharmacy curriculum significantly increases both student confidence in their palliative care skills and their clinical reasoning skills in these areas.