Consensus recommendations from the strategic planning summit for pain and palliative care pharmacy practice

Development and validation of a performance-based palliative care assessment tool for student pharmacists

INTRODUCTION

Integration of hospice and palliative care principles within pharmacy curricula is essential to fill the need of pharmacist training in this growing specialty. A formalized assessment tool to evaluate skill development does not exist for student pharmacists specific to palliative care. The objective of this study was to develop a valid and reliable, palliative care-focused, performance-based assessment tool for student pharmacists.

METHODS

Eight academic palliative care (PC) pharmacists were recruited for the workgroup to perform domain development, validation, tool creation, and reliability testing for this performance-based assessment tool. Hospice and palliative care clinical pharmacist entrustable professional activities (EPAs) served as the framework. Content validity testing utilized content validity index and scale universal agreement (S-CVI/UA) to determine level of agreement for activities included in the tool. Student volunteers completed a standardized patient case and workgroup members served as raters during the reliability testing phase. Interrater reliability was measured through calculation of Fleiss Kappa scores for each activity.

RESULTS

Out of 14 EPAs, nine were deemed "essential" to include in the tool. Thirty-four supporting activities for the nine essential EPAs were drafted. Two rounds of content validity testing were necessary to achieve S-CVI/UA of 0.9593. Consensus was reached from workgroup members for activities deemed necessary to include in the tool after questionnaire distribution utilizing a Fleiss Kappa cutoff >0.6.

CONCLUSIONS

This validated tool will afford colleges and schools of pharmacy with PC curricula an opportunity to assess student achievement of PC-specific skills and evaluate curricular effectiveness.

Development of PharmPAL: A Collaborative Practice Pharmacy Clinic in Ambulatory Palliative Care

BACKGROUND

Increased access to interprofessional palliative care is needed in ambulatory oncology settings. To achieve this, Dana-Farber Cancer Institute launched a collaborative drug therapy management clinic, PharmPAL, where credentialed advanced practice pharmacists lead independent patient visits.

METHODS

As part of a pilot project focused on clinical innovation, we analyzed PharmPAL referrals and pharmacist interventions between July 2020 and June 2021. We extracted referral patterns, patient hospitalizations, and deaths from the electronic medical record. Outpatient palliative care clinicians completed a survey to determine pharmacist needs and overall satisfaction with PharmPAL.

RESULTS

From July 2020 to June 2021, PharmPAL constituted 4.7% (299/6305) of all outpatient palliative care encounters. Most palliative care clinicians (86% [6/7]) reported a desire to increase PharmPAL availability. No patient hospitalizations or deaths were attributed to PharmPAL visits.

CONCLUSION

PharmPAL increased access to palliative care services. All clinicians reported satisfaction with PharmPAL. We continue to assess the impact PharmPAL has on clinic operations and provider satisfaction.

Role of clinical pharmacist in the palliative care of adults and elderly patients with cancer: A scoping review

OBJECTIVE

We conducted this scoping review to map and summarize scientific evidence on the role of clinical pharmacists in the palliative care of adults and elderly patients with cancer.

DATA SOURCES

A literature search was performed in MEDLINE, PubMed Central, Embase, Web of Science, Scopus, and BVS/BIREME for studies published until November 22nd, 2020. Studies that reported work experiences adopted by clinical pharmacists in the palliative care of adults and elderly patients with cancer were included. Two independent authors performed study selection and data extraction. Any disagreements were resolved by discussion with the third and fourth authors. The pharmacist interventions identified in the included studies were described based on key domains in the DEPICT v.2.

DATA SUMMARY

A total of 586 records were identified, of which 14 studies fully met the eligibility criteria. Most of them were conducted in the United States of America (n  =  5) and Canada (n  =  5) and described the workplace of the pharmacist in clinic/ambulatory (n  =  10). Clinical pharmacists performed several activities and provided services, highlighting medication review (n  =  12), patient and caregivers education (n  =  12), medication histories and-or medication reconciliation (n  =  6). The pharmacist interventions were mostly conducted for patients/caregivers (n  =  13), by one-on-one contact (n  =  14), and by face-to-face (n  =  13). Pharmacists were responsible mainly for change or suggestion for change in therapy (n  =  12) and patient counselling (n  =  12). Pharmacist interventions were well accepted by the clinical team. Overall, studies showed that pharmacists, within an interdisciplinary team, had significant impacts on measured outcomes.

CONCLUSIONS

In recent years, there have been advances in the role of the pharmacist in palliative care of patients with cancer and there are great opportunities in this field. They play an important role in managing cancer pain and other symptoms, as well as resolving drug related problems. We encourage more research to be carried out to strengthen this field and to benefit patients with advanced cancer with higher quality of life.

What predicts pharmacists' engagement with opioid-outcome screening? Secondary analysis from an implementation study in community pharmacy

Background Pharmacists have a key role to play in identifying and responding to emerging clinical problems with prescribed opioids. A pilot study in Australia examined the implementation of screening and brief intervention (Routine Opioid Outcome Monitoring [ROOM]) to identify and respond to opioid-related problems in community pharmacies. In this implementation study, the rate of screening varied considerably between pharmacies. Objective The aim of this study was to examine pharmacist characteristics associated with implementation of ROOM. Setting Community pharmacies in Victoria and New South Wales, Australia. Methods We implemented a validated computer-facilitated screening (ROOM), combined with brief intervention for opioid-related problems based on a widely accepted framework for monitoring outcomes. In this analysis, we examined the correlates of ROOM completion for individual pharmacists. Negative binomial regression was used to identify baseline predictors of greater screening, with the number of ROOM screens as the dependent (outcome) variable and pharmacist demographics, knowledge, confidence and comfort responding to prescription opioids problems, and attitudes towards evidence based practice examined as independent (predictor) variables. Main outcome measure Number of screens completed by an individual pharmacist as reported in follow-up surveys by pharmacist. Results Fewer years of practice was associated with a greater number of screenings conducted. On average, each additional decade of practice was associated with a 31% (95% CI 0%, 53%) reduction in the number of screenings undertaken by pharmacists. A multivariable analysis revealed that each additional decade practicing, lower knowledge of naloxone and lower confidence in identifying unmanaged pain were all independently associated with reduced engagement in screening after controlling for other variables. Conclusion Findings from this pilot study identified potential barriers to implementing opioid outcome monitoring. Further studies could test different groups of community pharmacists' experience of different barriers when implementing monitoring outcomes with prescribed opioids, to inform future implementation and clinical practice.

The Need for Palliative Care in Pharmacy Education

There is a growing need for palliative care pharmacists in the United States. There is also a gap in the education of palliative care for pharmacy students. To address both, pharmacy schools must develop and disseminate palliative care-focused experiences, including traditional didactic lectures, problem-based learning, interactive skills, laboratory- and web-based experiences. This commentary presents the need for palliative care-focused experiences in the Doctor of Pharmacy (PharmD) degree program, and how schools can take smaller steps to tackle this issue.

Multicentered Study Evaluating Pharmacy Students’ Perception of Palliative Care and Clinical Reasoning Using Script Concordance Testing

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.

Commentary on a participatory inquiry paradigm used to assess EOL simulation participant outcomes and design

Care at the end-of-life has attracted global attention, as health care workers struggle with balancing cure based care with end-of-life care, and knowing when to transition from the former to the latter. Simulation is gaining in popularity as an education strategy to facilitate health care provider decision-making by improving communication skills with patients and family members. This commentary focuses on the authors’ simulation evaluation process. When data were assessed using a participatory inquiry paradigm, the evaluation revealed far more than a formative or summative evaluation of participant knowledge and skills in this area of care. Consequently, this assessment strategy has ramifications for best practices for simulation design and evaluation.

The future of pain pharmacy: driven by need

Background

Opioid prescribing has increased by ~400% over the past 20 years in the US and has been correlated with dramatic increases in accidental overdose-related deaths. Emerging evidence of serious dose-dependent side effects of opioid analgesics has led to recommendations from multinational pain societies and governments to decrease opioid doses and increase referrals to pain specialists. Demand for pain specialists of all types has increased; however, training programs for health care professionals struggle to satisfy this need.

Objective

The purpose of this article is to highlight the role of clinical pharmacy specialists in pain management and to discuss available residency training programs and subspecialties within each program.

Methods

We surveyed all eleven accredited pharmacy postgraduate year two (PGY-2) Pain and Palliative Care Residency programs in the US. Program information was derived from interviews with residency directors, current residents, program brochures, and residency Web sites. Data collected included core, elective, and longitudinal rotations, with the time frame dedicated to each experience. Primary practice areas, as well as inpatient vs outpatient focus, were also documented. Additionally, a review of the available literature was completed to determine the areas in greatest need for future pain specialists.

Results

Pharmacy pain specialists have been referenced as highly effective additions to interdisciplinary pain management teams. Pharmacists provide expertise in complex pain medication management, which remains the primary focus of most chronic pain encounters. The PGY-2 programs surveyed differ considerably, with the majority providing significant emphasis to either acute pain management or palliative care with brief or limited exposure to chronic pain management. Four of the eleven programs require 2 months of chronic pain management; however, only two of the eleven programs identify chronic pain management as a primary practice setting.

Discussion

Pain specialists in all fields are in high demand; however, the need for health care professionals specialized in chronic pain management probably exceeds that for professionals specialized in acute pain management and palliative care combined. This disparity between disease prevalence and specialty training programs is not reflected in the current residency training structure, nor have additional training programs arisen to fill this critical need.

Conclusion

Health care systems will continue to struggle to meet the demands of patients with chronic pain until significant emphasis is placed on the education and training of health care professionals in this area. Clinical pharmacy should aim to meet this demand through the expansion of PGY-2 training programs and improved didactic education in pharmacy school that reflects the increased need for chronic pain specialists.

A qualitative exploration of perceived key knowledge and skills in end-of-life care in dementia patients among medical, nursing, and pharmacy students

BACKGROUND

The steady increase in the number of people living and dying with dementia, coupled with the recent focus on quality of care, has highlighted the importance of dementia training for health care professionals. This exploratory study aimed to discover which skills health care students felt were important in providing quality end-of-life care to dementia patients.

METHODS

Ninety-four medicine, nursing, and pharmacy students participated in a larger study using open-ended and closed questions to explore attitudes related to caring for dementia patients at the end of life. This study looks at the student responses to an open-ended question regarding the skills and knowledge they believe are needed to provide end-of-life care to dementia patients. Individual responses were reviewed by the researchers, coded into key issues, and tabulated for frequency of occurrences and group differences.

RESULTS

Several common issues emerged: knowledge, patience, empathy, understanding, family involvement, compassion, medication knowledge, respect/patient autonomy, communication, quality of life, and patient education. Significant differences were observed among the participant groups on the following issues: Patience and understanding (pharmacy students mentioned these issues less frequently than medical and nursing students), compassion (medical students mentioned this issue more frequently than pharmacy students), and medication knowledge (pharmacy students mentioned this issue more frequently than medical and nursing students).

CONCLUSIONS

Different health care disciplines (in-training) value different skill sets for the provision of dementia care at the end-of-life. As health care education for dementia patients at the end of life is expanded, it will be important to understand which skills both patients and health care students value.

[Pharmacist perception of the use of analgesics and their practice on mild-moderate pain. DOLOR-OFF survey]

Objetivo

Determinar la percepción del farmacéutico comunitario sobre el uso de analgésicos y evaluar la práctica farmacéutica en dolor leve-moderado prestada en farmacias comunitarias españolas.

Diseño

Se realizó un estudio observacional transversal, método encuesta, entre abril y septiembre de 2013.

Emplazamiento

Un total de 696 farmacias comunitarias de 20 comunidades autónomas españolas.

Participantes

Farmacéuticos comunitarios con experiencia profesional mínima de un año.

Mediciones principales

Caracterización de la demanda de analgésicos, del usuario de analgésicos y de la intervención farmacéutica en dolor leve-moderado desde la perspectiva del farmacéutico comunitario.

Resultados

En base a la práctica farmacéutica el 45% de los pacientes con dolor acuden a la farmacia a retirar un medicamento con receta médica. La patología más consultada es el dolor de cabeza (35%). El 21% de los usuarios de analgésicos se automedican. El ibuprofeno y el paracetamol son los fármacos más utilizados. El 39% de los farmacéuticos afirman seguir un protocolo de indicación. Se encontró correlación entre la experiencia profesional del farmacéutico y los indicadores de proceso de indicación (Fisher p < 0,05). El 88% de los farmacéuticos verifican 2 indicadores del servicio de dispensación. El 15% de los farmacéuticos derivan al médico.

Conclusiones

Se diferencian 3 grupos mayoritarios de usuarios de analgésicos según solicite el servicio de indicación, dispensación o se automedique. Se requiere una mayor formación de los farmacéuticos en protocolos de dolor individualizados a los perfiles de pacientes identificados y en criterios de derivación al médico, que permitan asegurar de manera sistemática la utilización correcta de analgésicos y la obtención de resultados clínicos positivos.

The importance of medical education in the changing field of pain medicine

Suffering chronic pain is a global epidemic that requires a closer look on how we are educating trainees to become more effective in pain management. The vast majority of medical professionals will encounter treatment of pain throughout their career. Our current system for educating these medical professionals is flawed in a number of ways. Improving pain education will narrow the gap between over and under treatment of acute and chronic pain. Reviews have demonstrated dissatisfaction among practitioners throughout the world on how pain education is currently conducted. Changing the educational process will require support from several areas: medical educators, clinicians, policymakers, administrators and several other organizations.

Application of opioid analgesia concepts in a third-year pharmacy student skills laboratory on three campuses

The objective of this study was to evaluate the effects of a skills laboratory exercise focused on principles of opioid analgesia on the knowledge, attitudes, and self-perceived skills of third-year (P3) pharmacy students on three campuses of the University of Georgia College of Pharmacy. The study evaluated the effects of a 2-hour skills laboratory exercise focused on technical aspects of opioid analgesia and included three stations: programming a pump to deliver a fentanyl drip/Richmond Agitation Sedation Scale (RAAS) scoring, using an equianalgesic dosing table, and compounding a patient-controlled analgesia syringe. A 12-item, online survey was distributed 2 weeks prior (pre-intervention) to the analgesia skills laboratory. A 2-hour laboratory was delivered on each campus and the survey was administered again (post-intervention) at the conclusion of the laboratory. One hundred and thirty-five students (93%) completed the pre- and post-intervention surveys. Significant changes (P < .05) between pre- and post-intervention scores were observed in two of five (40%) of the knowledge, all four (100%) of the self-perceived skills, and all three (100%) of the attitude items. Intercampus differences between pre- and post-intervention scores were minor. The authors concluded that skills laboratory exercises can effectively change the attitudes and self-perceived skill level of P3 pharmacy students and reinforce previously acquired knowledge.

A blueprint of pain curriculum across prelicensure health sciences programs: one NIH Pain Consortium Center of Excellence in Pain Education (CoEPE) experience

To improve U.S. pain education and promote interinstitutional and interprofessional collaborations, the National Institutes of Health Pain Consortium has funded 12 sites to develop Centers of Excellence in Pain Education (CoEPEs). Each site was given the tasks of development, evaluation, integration, and promotion of pain management curriculum resources, including case studies that will be shared nationally. Collaborations among schools of medicine, dentistry, nursing, pharmacy, and others were encouraged. The John D. Loeser CoEPE is unique in that it represents extensive regionalization of health science education, in this case in the region covering the states of Washington, Wyoming, Alaska, Montana, and Idaho. This paper describes a blueprint of pain content and teaching methods across the University of Washington's 6 health sciences schools and provides recommendations for improvement in pain education at the prelicensure level. The Schools of Dentistry and Physician Assistant provide the highest percentage of total required curriculum hours devoted to pain compared with the Schools of Medicine, Nursing, Pharmacy, and Social Work. The findings confirm the paucity of pain content in health sciences curricula, missing International Association for the Study of Pain curriculum topics, and limited use of innovative teaching methods such as problem-based and team-based learning.

PERSPECTIVE

Findings confirm the paucity of pain education across the health sciences curriculum in a CoEPE that serves a large region in the United States. The data provide a pain curriculum blueprint that can be used to recommend added pain content in health sciences programs across the country.