Analysis of Inpatient Hospice Pharmacist Interventions Within a Veterans Affairs Medical Center

Validated medication deprescribing instruments for patients with palliative care needs: a systematic review

OBJECTIVES

Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes.

METHODS

A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by 2 independent researchers. Experimental and observational studies were eligible for inclusion.

RESULTS

Out of the 5791 studies retrieved, after excluding duplicates (n = 1050), conducting title/abstract screening (n = 4741), and full reading (n = 41), only 1 study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to 2 groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life.

CONCLUSIONS

Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only 1 of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs) and decrease the monthly costs of pharmacotherapy. Nevertheless, the impact on patient safety and humanistic outcomes remain unclear.

Validated medication deprescribing instruments for patients with palliative care needs palliative care: A systematic review

OBJECTIVES

Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes.

METHODS

A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by two independent researchers. Experimental and observational studies were eligible for inclusion.

RESULTS

Out of the 5,791 studies retrieved, after excluding duplicates (n = 1,050), conducting title/abstract screening (n = 4,741), and full reading (n = 41), only one study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to two groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life.

CONCLUSIONS

Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only one of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs) and decrease the monthly costs of pharmacotherapy. Nevertheless, the impact on patient safety and humanistic outcomes remain unclear.

Pharmacists' clinical roles and activities in inpatient hospice and palliative care: a scoping review

BACKGROUND

Pharmacists contribute to medication safety by providing their services in various settings. However, standardized definitions of the role of pharmacists in hospice and palliative care (HPC) are lacking.

AIM

The purpose of this scoping review was to provide an overview of the evidence on the role of pharmacists and to map clinical activities in inpatient HPC.

METHOD

We performed a scoping review according to the PRISMA-ScR extension in CINAHL, Embase, and PubMed. We used the American Society of Hospital Pharmacists (ASHP) Guidelines on the Pharmacist's Role in Palliative and Hospice Care as a framework for standardized categorization of the identified roles and clinical activities.

RESULTS

After screening 635 records (published after January 1st, 2000), the scoping review yielded 23 publications reporting various pharmacy services in HPC. The articles addressed the five main categories in the following descending order: 'Medication order review and reconciliation', 'Medication counseling, education and training', 'Administrative Roles', 'Direct patient care', and 'Education and scholarship'. A total of 172 entries were mapped to the subcategories that were added to the main categories.

CONCLUSION

This scoping review identified a variety of pharmacists' roles and clinical activities. The gathered evidence will help to establish and define the role of pharmacists in inpatient hospice and palliative care.

Evolving Roles of Palliative Care Pharmacists

In this article, we provide an overview of pharmacists' involvement with palliative care, starting with recent history, up to present day. The aim of this review is to highlight advances in the field of palliative care pharmacy and the integral role pharmacists have on the palliative care team. We conclude that despite participating on multidisciplinary palliative care teams for over 20 years, pharmacy still lacks a board certification in palliative care.

Development of Entrustable Professional Activities for Specialist Hospice and Palliative Care Pharmacists

CONTEXT

Entrustable professional activities (EPAs) translate competencies into explicit, practical terms that clearly state the expected roles and responsibilities of clinicians who have achieved proficiency and expertise in a field. EPAs are defined for Hospice and Palliative Medicine physicians but not for other members of Hospice and Palliative Care (HAPC) interprofessional teams, including pharmacists.

OBJECTIVES

The objective of this study was to develop EPAs for HAPC pharmacists.

METHODS

An 11-member workgroup of HAPC pharmacists was convened to develop candidate EPAs using nominal group and modified-Delphi methods. Content validity index was used as a measure of consensus, defined a priori at ≥ 60%. Vetting occurred via intra- and interprofessional stakeholder reactor groups and a national survey of HAPC pharmacists.

RESULTS

Following an iterative process of workgroup and stakeholder consensus-building, 15 HAPC pharmacist EPAs were developed. Among the workgroup, all 15 EPAs reached ≥ 70% consensus, indicating appropriate internal validity. In a national survey of 185 HAPC pharmacists with a 20% response rate, 13 EPAs were rated by most respondents as "essential" and 2 were rated by most respondents as "important but not essential." Respondents indicated the 15 EPA set represented the core professional activities of HAPC pharmacists well (median rating of 5 on a Likert-like scale, IQR 1).

CONCLUSION

Fifteen consensus EPAs describe essential activities of HAPC pharmacists in direct patient care, leadership, education, and scholarship. These EPAs will further guide pharmacist training programs, HAPC services seeking to incorporate a specialized pharmacist on the team, and currently practicing HAPC pharmacists.

The Role of an Inpatient Hospice and Palliative Clinical Pharmacist in the Interdisciplinary Team

Palliative care is a specialized health care service for individuals with serious illness at any stage and can be provided in any setting. Current national consensus developed by palliative care experts recommends the inclusion of pharmacists in an interdisciplinary team (IDT) to provide quality palliative care. However, national registry data report that less than 10% of inpatient palliative teams in the U.S. have a clinical pharmacist. Clinical pharmacists have an impactful role in palliative patients' quality of life by optimizing symptom management, deprescribing, and providing education to the palliative care team as well as patients and their families. In this report, we review the current literature on the role of a palliative pharmacist in an inpatient palliative care setting and compare and contrast this with our own clinical practice, providing case examples about the role of a palliative clinical pharmacist in an interdisciplinary inpatient palliative care setting. Future strategies are needed to increase post-graduate specialized pharmacy residency training in palliative care as well as education on palliative and hospice care in pharmacy schools to support the role of clinical pharmacists in palliative care.

Multidisciplinary intervention incorporating pharmacists in management of opioid-naïve patients with moderate to severe cancer pain

OBJECTIVE

This study aims to investigate the impact of intervention of multidisciplinary team incorporating pharmacists for management of opioid-naïve patients with moderate to severe cancer pain.

METHODS

A retrospective cohort study was conducted to compare pre- and post-multidisciplinary intervention groups in opioid-naïve patients with moderate to severe cancer pain. Primary outcome was the proportions of appropriate pain assessment and opioid titration. Secondary outcomes were pain intensity (PI), length of hospital stay, opioid escalation index percentage (OEI%) and incidences of opioid-related adverse events.

RESULTS

A total of 400 patients were included in the study (pre-intervention, n = 200; post-intervention, n = 200). Continuous improvement in pain assessment and titration was recorded after intervention. Though no substantial differences existed between groups in PI on the day of discharge, post-intervention group was associated with reduced length of hospital stay as well as decreased proportion of subjects with OEI% >5%. As for safety, significant decreases in constipation and vomiting were seen.

CONCLUSION

Findings suggest that interventions of multidisciplinary team incorporating pharmacists could improve cancer pain management for opioid-naïve patients. Pharmacists should be considered as an important member of a multidisciplinary team in good pain management.