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Almost 40% of pediatric residents experience burnout, study finds
, according to two Pediatrics articles highlighted by editor in chief Lewis R. First, MD, MS.
The studies investigated the prevalence and effects of burnout among pediatric residents, and all health care providers, working in intensive care units. They were among those published in 2017 that Dr. First deemed potentially practice changing – ones whose clinical implications may have immediate relevance in your daily work.
“There are a variety of ways to overcome burnout and promote our resiliency that starts with our ability to find joy in caring for children and our lifelong learning” through professional development sessions and academic journals, according to Dr. First, professor and chair of pediatrics at the University of Vermont in Burlington. He also serves as chief of pediatrics at the University of Vermont Children’s Hospital. He spoke at the 2017 annual meeting of the American Academy of Pediatrics and in later interviews.
High prevalence of burnout
The study by Baer et al. found that almost two in five pediatric residents experience burnout, often accompanied by poorer care of patients (Pediatrics. 2017. doi: 10.1542/peds.2016-2163). Using a 7-point Likert scale ranging from “never” to “every day,” 258 residents from 11 different residency programs filled out an anonymous Web-based survey on how often they felt emotional exhaustion (“I feel burnout from my work”) and depersonalization (“I’ve become more callous toward people since I took this job”).
Of the 258 respondents, 39% had burnout, defined as answering affirmatively to either of the above questions with at least “weekly.” Most of the respondents were female, white, and married or in a long-term relationship without children, but the burnout rates did not vary across gender, race/ethnicity, relationship or parental status, or among different characteristics of the residency program and schedule. Higher burnout rates did occur among those feeling sleep deprived.
Those with burnout also had substantially higher odds of providing lower-quality care. Residents with burnout were seven times more likely to make treatment or medication errors not related to inadequate knowledge or experience, six times more likely to feel guilty about how they had treated a patient, more than four times more likely to report having little emotional reaction to a patient’s death, and four times more likely to discharge a patient earlier to make service more manageable. Burned-out residents had more than nine times greater odds of paying “little attention to the social or personal impact of an illness on a patient,” the study showed.
Burnout symptoms and solutions
Symptoms of potential burnout, Dr. First said in an interview, include emotional exhaustion, feeling a loss of meaning in work, feelings of ineffectiveness, a tendency to view people as objects instead of human beings, increasingly poor communication, and poor interpersonal and clinical skills and behaviors.
Other research also has found burnout linked to doctors’ errors, self-reported negative attitudes toward patients, and less time spent with patients, she said. “Thus physicians should be on the lookout for burnout within themselves as well as in their colleagues and medical trainees.”
Both Dr. Baer and Dr. First noted the importance of organizational leadership in preventing burnout.
The Association of Medical School Pediatric Department Chairs is sharing a toolbox of strategies that they have found effective for reducing burnout and developing wellness among physicians, Dr. First said in the interview.
“Some of those suggestions include personal attention to wellness via good nutrition, exercise, mindfulness for emotional self-regulation, and developing supportive relationships,” he noted. In addition to organizational mindfulness programs and ones that foster work-life integration and social activities, prevention programs should “create wellness and resilience, and a sense of pride and meaning in the work that is being done.”
Drs. First also pointed to ways of addressing triggers of burnout:
- Reduce the burden of bureaucratic tasks.
- Examine how many hours physicians spend at home or work at home.
- Improve efficiency, such as in EHR use.
- Provide individuals time to discuss stressors and ways to resolve them collaboratively with peers and leadership.
Burnout risk in the NICU
Similar interventions may help with burnout in neonatal ICUs (NICUs), the focus of the second study Dr. First discussed. Tawfik et al. surveyed 2,760 personnel from 41 NICUs in the United States to learn the prevalence of burnout and how it was associated with NICU organization (Pediatrics. 2017. doi: 10.1542/peds.2016-4134).
Among the 1,934 providers who replied (a response rate of 70%), 27% had burnout; at individual NICUs, burnout prevalence varied from 8% to 43%. The majority of respondents (72%) were registered nurses, followed by respiratory therapists, physicians, neonatal nurse practitioners, and others. The highest burnout rates occurred in NICUs with higher average daily admissions and higher average occupancy – and those using EHRs.
“Don’t assume that just because you use the EHR every day means you know how best to use this tool to improve your efficiency and effectiveness in generating and deriving information on your patients,” Dr. First said in the interview. He encouraged physicians to find out what resources their institutions might offer to help, such as EHR hospital teams or office support who can look at providers’ EHR usage, and show them shortcuts and time-savers to improve efficiency based on their usage patterns.
“Nursing burnout was more sensitive to the setting than physician burnout, especially in regard to average daily admissions, late transfer numbers, nursing hours per patient day, and mortality per 1,000 infants,” Dr. First noted.
Interestingly, burnout prevalence was not associated with the proportion of high-risk patients seen in the NICUs, the number of attending physicians in the unit, or whether the institution was a teaching hospital or not, he said.
Dr. First listed strategies to reduce burnout risk in NICUs that the study authors also described: expressing thankfulness each day, focusing on positive events at the start or end of each day, performing random acts of kindness for colleagues and staff, and encouraging providers to identify the strengths in one another.
Addressing burnout requires efforts from everyone
“Given the potential effects of burnout on patient care and professionalism and physician wellness, it is important for physicians to speak up if they have concerns about burnout in their colleagues,” Dr. Baer said in the interview.
Burnout is common, she said, occurring in more than half of physicians at some point in time, so a doctor experiencing it is almost certainly not alone among colleagues.
“Physicians can work together and with their leadership to prevent and mitigate the effects of burnout by promoting personal and professional wellness, effective teamwork, and reducing the administrative burdens that impact time spent directly with patients and have been demonstrated to contribute to physician burnout,” Dr. Baer noted.
She also pointed to the need to address it in medical education, given the downstream risks of burnout on the next generation of physicians.
“Medical schools and residency and fellowship programs should address the risks and signs of burnout, as medical students and trainees are likely seeing signs of burnout in some of their physician teachers and mentors,” Dr. Baer said in the interview.
Some burnout among providers may be inevitable at times, but it’s important to continue looking for ways to combat it.
“We need to do more to remind each other of why we chose our profession, and how good it makes us feel to strive to make a difference in our patients and families each and every day,” Dr. First said in the interview.
Dr. First reported having no disclosures and no external funding. The residents’ study by Baer et al. was funded by the Boston Children’s Hospital’s Fred Lovejoy Resident Research Award and a grant from the Health Resources and Services Administration. The NICU study by Tamfik et al. was funded by the National Institutes of Health, grants from the National Institute of Child Health and Human Development, and the Jackson Vaughan Critical Care Research Fund. The authors of both studies had no relevant financial disclosures.
, according to two Pediatrics articles highlighted by editor in chief Lewis R. First, MD, MS.
The studies investigated the prevalence and effects of burnout among pediatric residents, and all health care providers, working in intensive care units. They were among those published in 2017 that Dr. First deemed potentially practice changing – ones whose clinical implications may have immediate relevance in your daily work.
“There are a variety of ways to overcome burnout and promote our resiliency that starts with our ability to find joy in caring for children and our lifelong learning” through professional development sessions and academic journals, according to Dr. First, professor and chair of pediatrics at the University of Vermont in Burlington. He also serves as chief of pediatrics at the University of Vermont Children’s Hospital. He spoke at the 2017 annual meeting of the American Academy of Pediatrics and in later interviews.
High prevalence of burnout
The study by Baer et al. found that almost two in five pediatric residents experience burnout, often accompanied by poorer care of patients (Pediatrics. 2017. doi: 10.1542/peds.2016-2163). Using a 7-point Likert scale ranging from “never” to “every day,” 258 residents from 11 different residency programs filled out an anonymous Web-based survey on how often they felt emotional exhaustion (“I feel burnout from my work”) and depersonalization (“I’ve become more callous toward people since I took this job”).
Of the 258 respondents, 39% had burnout, defined as answering affirmatively to either of the above questions with at least “weekly.” Most of the respondents were female, white, and married or in a long-term relationship without children, but the burnout rates did not vary across gender, race/ethnicity, relationship or parental status, or among different characteristics of the residency program and schedule. Higher burnout rates did occur among those feeling sleep deprived.
Those with burnout also had substantially higher odds of providing lower-quality care. Residents with burnout were seven times more likely to make treatment or medication errors not related to inadequate knowledge or experience, six times more likely to feel guilty about how they had treated a patient, more than four times more likely to report having little emotional reaction to a patient’s death, and four times more likely to discharge a patient earlier to make service more manageable. Burned-out residents had more than nine times greater odds of paying “little attention to the social or personal impact of an illness on a patient,” the study showed.
Burnout symptoms and solutions
Symptoms of potential burnout, Dr. First said in an interview, include emotional exhaustion, feeling a loss of meaning in work, feelings of ineffectiveness, a tendency to view people as objects instead of human beings, increasingly poor communication, and poor interpersonal and clinical skills and behaviors.
Other research also has found burnout linked to doctors’ errors, self-reported negative attitudes toward patients, and less time spent with patients, she said. “Thus physicians should be on the lookout for burnout within themselves as well as in their colleagues and medical trainees.”
Both Dr. Baer and Dr. First noted the importance of organizational leadership in preventing burnout.
The Association of Medical School Pediatric Department Chairs is sharing a toolbox of strategies that they have found effective for reducing burnout and developing wellness among physicians, Dr. First said in the interview.
“Some of those suggestions include personal attention to wellness via good nutrition, exercise, mindfulness for emotional self-regulation, and developing supportive relationships,” he noted. In addition to organizational mindfulness programs and ones that foster work-life integration and social activities, prevention programs should “create wellness and resilience, and a sense of pride and meaning in the work that is being done.”
Drs. First also pointed to ways of addressing triggers of burnout:
- Reduce the burden of bureaucratic tasks.
- Examine how many hours physicians spend at home or work at home.
- Improve efficiency, such as in EHR use.
- Provide individuals time to discuss stressors and ways to resolve them collaboratively with peers and leadership.
Burnout risk in the NICU
Similar interventions may help with burnout in neonatal ICUs (NICUs), the focus of the second study Dr. First discussed. Tawfik et al. surveyed 2,760 personnel from 41 NICUs in the United States to learn the prevalence of burnout and how it was associated with NICU organization (Pediatrics. 2017. doi: 10.1542/peds.2016-4134).
Among the 1,934 providers who replied (a response rate of 70%), 27% had burnout; at individual NICUs, burnout prevalence varied from 8% to 43%. The majority of respondents (72%) were registered nurses, followed by respiratory therapists, physicians, neonatal nurse practitioners, and others. The highest burnout rates occurred in NICUs with higher average daily admissions and higher average occupancy – and those using EHRs.
“Don’t assume that just because you use the EHR every day means you know how best to use this tool to improve your efficiency and effectiveness in generating and deriving information on your patients,” Dr. First said in the interview. He encouraged physicians to find out what resources their institutions might offer to help, such as EHR hospital teams or office support who can look at providers’ EHR usage, and show them shortcuts and time-savers to improve efficiency based on their usage patterns.
“Nursing burnout was more sensitive to the setting than physician burnout, especially in regard to average daily admissions, late transfer numbers, nursing hours per patient day, and mortality per 1,000 infants,” Dr. First noted.
Interestingly, burnout prevalence was not associated with the proportion of high-risk patients seen in the NICUs, the number of attending physicians in the unit, or whether the institution was a teaching hospital or not, he said.
Dr. First listed strategies to reduce burnout risk in NICUs that the study authors also described: expressing thankfulness each day, focusing on positive events at the start or end of each day, performing random acts of kindness for colleagues and staff, and encouraging providers to identify the strengths in one another.
Addressing burnout requires efforts from everyone
“Given the potential effects of burnout on patient care and professionalism and physician wellness, it is important for physicians to speak up if they have concerns about burnout in their colleagues,” Dr. Baer said in the interview.
Burnout is common, she said, occurring in more than half of physicians at some point in time, so a doctor experiencing it is almost certainly not alone among colleagues.
“Physicians can work together and with their leadership to prevent and mitigate the effects of burnout by promoting personal and professional wellness, effective teamwork, and reducing the administrative burdens that impact time spent directly with patients and have been demonstrated to contribute to physician burnout,” Dr. Baer noted.
She also pointed to the need to address it in medical education, given the downstream risks of burnout on the next generation of physicians.
“Medical schools and residency and fellowship programs should address the risks and signs of burnout, as medical students and trainees are likely seeing signs of burnout in some of their physician teachers and mentors,” Dr. Baer said in the interview.
Some burnout among providers may be inevitable at times, but it’s important to continue looking for ways to combat it.
“We need to do more to remind each other of why we chose our profession, and how good it makes us feel to strive to make a difference in our patients and families each and every day,” Dr. First said in the interview.
Dr. First reported having no disclosures and no external funding. The residents’ study by Baer et al. was funded by the Boston Children’s Hospital’s Fred Lovejoy Resident Research Award and a grant from the Health Resources and Services Administration. The NICU study by Tamfik et al. was funded by the National Institutes of Health, grants from the National Institute of Child Health and Human Development, and the Jackson Vaughan Critical Care Research Fund. The authors of both studies had no relevant financial disclosures.
, according to two Pediatrics articles highlighted by editor in chief Lewis R. First, MD, MS.
The studies investigated the prevalence and effects of burnout among pediatric residents, and all health care providers, working in intensive care units. They were among those published in 2017 that Dr. First deemed potentially practice changing – ones whose clinical implications may have immediate relevance in your daily work.
“There are a variety of ways to overcome burnout and promote our resiliency that starts with our ability to find joy in caring for children and our lifelong learning” through professional development sessions and academic journals, according to Dr. First, professor and chair of pediatrics at the University of Vermont in Burlington. He also serves as chief of pediatrics at the University of Vermont Children’s Hospital. He spoke at the 2017 annual meeting of the American Academy of Pediatrics and in later interviews.
High prevalence of burnout
The study by Baer et al. found that almost two in five pediatric residents experience burnout, often accompanied by poorer care of patients (Pediatrics. 2017. doi: 10.1542/peds.2016-2163). Using a 7-point Likert scale ranging from “never” to “every day,” 258 residents from 11 different residency programs filled out an anonymous Web-based survey on how often they felt emotional exhaustion (“I feel burnout from my work”) and depersonalization (“I’ve become more callous toward people since I took this job”).
Of the 258 respondents, 39% had burnout, defined as answering affirmatively to either of the above questions with at least “weekly.” Most of the respondents were female, white, and married or in a long-term relationship without children, but the burnout rates did not vary across gender, race/ethnicity, relationship or parental status, or among different characteristics of the residency program and schedule. Higher burnout rates did occur among those feeling sleep deprived.
Those with burnout also had substantially higher odds of providing lower-quality care. Residents with burnout were seven times more likely to make treatment or medication errors not related to inadequate knowledge or experience, six times more likely to feel guilty about how they had treated a patient, more than four times more likely to report having little emotional reaction to a patient’s death, and four times more likely to discharge a patient earlier to make service more manageable. Burned-out residents had more than nine times greater odds of paying “little attention to the social or personal impact of an illness on a patient,” the study showed.
Burnout symptoms and solutions
Symptoms of potential burnout, Dr. First said in an interview, include emotional exhaustion, feeling a loss of meaning in work, feelings of ineffectiveness, a tendency to view people as objects instead of human beings, increasingly poor communication, and poor interpersonal and clinical skills and behaviors.
Other research also has found burnout linked to doctors’ errors, self-reported negative attitudes toward patients, and less time spent with patients, she said. “Thus physicians should be on the lookout for burnout within themselves as well as in their colleagues and medical trainees.”
Both Dr. Baer and Dr. First noted the importance of organizational leadership in preventing burnout.
The Association of Medical School Pediatric Department Chairs is sharing a toolbox of strategies that they have found effective for reducing burnout and developing wellness among physicians, Dr. First said in the interview.
“Some of those suggestions include personal attention to wellness via good nutrition, exercise, mindfulness for emotional self-regulation, and developing supportive relationships,” he noted. In addition to organizational mindfulness programs and ones that foster work-life integration and social activities, prevention programs should “create wellness and resilience, and a sense of pride and meaning in the work that is being done.”
Drs. First also pointed to ways of addressing triggers of burnout:
- Reduce the burden of bureaucratic tasks.
- Examine how many hours physicians spend at home or work at home.
- Improve efficiency, such as in EHR use.
- Provide individuals time to discuss stressors and ways to resolve them collaboratively with peers and leadership.
Burnout risk in the NICU
Similar interventions may help with burnout in neonatal ICUs (NICUs), the focus of the second study Dr. First discussed. Tawfik et al. surveyed 2,760 personnel from 41 NICUs in the United States to learn the prevalence of burnout and how it was associated with NICU organization (Pediatrics. 2017. doi: 10.1542/peds.2016-4134).
Among the 1,934 providers who replied (a response rate of 70%), 27% had burnout; at individual NICUs, burnout prevalence varied from 8% to 43%. The majority of respondents (72%) were registered nurses, followed by respiratory therapists, physicians, neonatal nurse practitioners, and others. The highest burnout rates occurred in NICUs with higher average daily admissions and higher average occupancy – and those using EHRs.
“Don’t assume that just because you use the EHR every day means you know how best to use this tool to improve your efficiency and effectiveness in generating and deriving information on your patients,” Dr. First said in the interview. He encouraged physicians to find out what resources their institutions might offer to help, such as EHR hospital teams or office support who can look at providers’ EHR usage, and show them shortcuts and time-savers to improve efficiency based on their usage patterns.
“Nursing burnout was more sensitive to the setting than physician burnout, especially in regard to average daily admissions, late transfer numbers, nursing hours per patient day, and mortality per 1,000 infants,” Dr. First noted.
Interestingly, burnout prevalence was not associated with the proportion of high-risk patients seen in the NICUs, the number of attending physicians in the unit, or whether the institution was a teaching hospital or not, he said.
Dr. First listed strategies to reduce burnout risk in NICUs that the study authors also described: expressing thankfulness each day, focusing on positive events at the start or end of each day, performing random acts of kindness for colleagues and staff, and encouraging providers to identify the strengths in one another.
Addressing burnout requires efforts from everyone
“Given the potential effects of burnout on patient care and professionalism and physician wellness, it is important for physicians to speak up if they have concerns about burnout in their colleagues,” Dr. Baer said in the interview.
Burnout is common, she said, occurring in more than half of physicians at some point in time, so a doctor experiencing it is almost certainly not alone among colleagues.
“Physicians can work together and with their leadership to prevent and mitigate the effects of burnout by promoting personal and professional wellness, effective teamwork, and reducing the administrative burdens that impact time spent directly with patients and have been demonstrated to contribute to physician burnout,” Dr. Baer noted.
She also pointed to the need to address it in medical education, given the downstream risks of burnout on the next generation of physicians.
“Medical schools and residency and fellowship programs should address the risks and signs of burnout, as medical students and trainees are likely seeing signs of burnout in some of their physician teachers and mentors,” Dr. Baer said in the interview.
Some burnout among providers may be inevitable at times, but it’s important to continue looking for ways to combat it.
“We need to do more to remind each other of why we chose our profession, and how good it makes us feel to strive to make a difference in our patients and families each and every day,” Dr. First said in the interview.
Dr. First reported having no disclosures and no external funding. The residents’ study by Baer et al. was funded by the Boston Children’s Hospital’s Fred Lovejoy Resident Research Award and a grant from the Health Resources and Services Administration. The NICU study by Tamfik et al. was funded by the National Institutes of Health, grants from the National Institute of Child Health and Human Development, and the Jackson Vaughan Critical Care Research Fund. The authors of both studies had no relevant financial disclosures.
Gastrografin offers an alternative to surgery for SBO
LAKE BUENA VISTA, FLA. – Gastrografin significantly decreased the need for an operation in small bowel obstruction (SBO) patients, even among patients who had never undergone abdominal surgery, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“Small bowel obstruction is a common clinical problem in the United States, with 15 out of 100 admissions for abdominal pain related to SBO,” said Morgan Collom, DO, surgical resident at Medical City Fort Worth (Tex.). “Many studies conclude that [operative exploration] is not needed and it is feasible to perform nonoperative conservative management, yet still argue that small obstruction in a virgin abdomen patient should undergo mandatory exploration to avoid missing a diagnosis of malignancy.”
Investigators studied 601 SBO patients admitted to one of 14 institutions included in an EAST database between February 2015 and December 2016 for this prospective study.
Of those included, 500 had previous abdominal surgery and the others had never had surgery. Gastrografin (Bracco Diagnostics) was used to treat their bowel obstruction.
Those with previous abdominal surgery were more likely to be over age 65 years (48% vs. 36%), be female (50% vs. 25%), have a history of cancer (42.6% vs. 18.8%), and have a prior admission of SBO (41.2% vs 8.9%), according to Dr. Collom.
Among patients who previously had surgery, operative exploration was 50% less likely (odds ratio = .51, P = .04) than among those who had never had surgery. In a comparison of patients with and without previous surgery, introducing Gastrografin evened out the likelihood for an operation (OR = .17 and .21, respectively). Overall, those who received Gastrografin were 86% less likely to undergo bowel exploration(OR = .14, P less than .01).
Of the 36 NAS patients treated with Gastrografin, 33 underwent successful, nonoperative therapy, and 3 underwent a therapeutic laparotomy for a malignancy.
During a question-and-answer session, audience members called to attention the issue of the database used, which does not review complications or recurrences after 30 days or any missed abnormalities, indicating that some malignancies may have developed after the therapy.
Dr. Collom acknowledged the limitation and agreed that the next study would need to address this.
The investigators reported no relevant financial disclosures.
SOURCE: EAST Scientific Assembly abstract No. 24.
LAKE BUENA VISTA, FLA. – Gastrografin significantly decreased the need for an operation in small bowel obstruction (SBO) patients, even among patients who had never undergone abdominal surgery, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“Small bowel obstruction is a common clinical problem in the United States, with 15 out of 100 admissions for abdominal pain related to SBO,” said Morgan Collom, DO, surgical resident at Medical City Fort Worth (Tex.). “Many studies conclude that [operative exploration] is not needed and it is feasible to perform nonoperative conservative management, yet still argue that small obstruction in a virgin abdomen patient should undergo mandatory exploration to avoid missing a diagnosis of malignancy.”
Investigators studied 601 SBO patients admitted to one of 14 institutions included in an EAST database between February 2015 and December 2016 for this prospective study.
Of those included, 500 had previous abdominal surgery and the others had never had surgery. Gastrografin (Bracco Diagnostics) was used to treat their bowel obstruction.
Those with previous abdominal surgery were more likely to be over age 65 years (48% vs. 36%), be female (50% vs. 25%), have a history of cancer (42.6% vs. 18.8%), and have a prior admission of SBO (41.2% vs 8.9%), according to Dr. Collom.
Among patients who previously had surgery, operative exploration was 50% less likely (odds ratio = .51, P = .04) than among those who had never had surgery. In a comparison of patients with and without previous surgery, introducing Gastrografin evened out the likelihood for an operation (OR = .17 and .21, respectively). Overall, those who received Gastrografin were 86% less likely to undergo bowel exploration(OR = .14, P less than .01).
Of the 36 NAS patients treated with Gastrografin, 33 underwent successful, nonoperative therapy, and 3 underwent a therapeutic laparotomy for a malignancy.
During a question-and-answer session, audience members called to attention the issue of the database used, which does not review complications or recurrences after 30 days or any missed abnormalities, indicating that some malignancies may have developed after the therapy.
Dr. Collom acknowledged the limitation and agreed that the next study would need to address this.
The investigators reported no relevant financial disclosures.
SOURCE: EAST Scientific Assembly abstract No. 24.
LAKE BUENA VISTA, FLA. – Gastrografin significantly decreased the need for an operation in small bowel obstruction (SBO) patients, even among patients who had never undergone abdominal surgery, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“Small bowel obstruction is a common clinical problem in the United States, with 15 out of 100 admissions for abdominal pain related to SBO,” said Morgan Collom, DO, surgical resident at Medical City Fort Worth (Tex.). “Many studies conclude that [operative exploration] is not needed and it is feasible to perform nonoperative conservative management, yet still argue that small obstruction in a virgin abdomen patient should undergo mandatory exploration to avoid missing a diagnosis of malignancy.”
Investigators studied 601 SBO patients admitted to one of 14 institutions included in an EAST database between February 2015 and December 2016 for this prospective study.
Of those included, 500 had previous abdominal surgery and the others had never had surgery. Gastrografin (Bracco Diagnostics) was used to treat their bowel obstruction.
Those with previous abdominal surgery were more likely to be over age 65 years (48% vs. 36%), be female (50% vs. 25%), have a history of cancer (42.6% vs. 18.8%), and have a prior admission of SBO (41.2% vs 8.9%), according to Dr. Collom.
Among patients who previously had surgery, operative exploration was 50% less likely (odds ratio = .51, P = .04) than among those who had never had surgery. In a comparison of patients with and without previous surgery, introducing Gastrografin evened out the likelihood for an operation (OR = .17 and .21, respectively). Overall, those who received Gastrografin were 86% less likely to undergo bowel exploration(OR = .14, P less than .01).
Of the 36 NAS patients treated with Gastrografin, 33 underwent successful, nonoperative therapy, and 3 underwent a therapeutic laparotomy for a malignancy.
During a question-and-answer session, audience members called to attention the issue of the database used, which does not review complications or recurrences after 30 days or any missed abnormalities, indicating that some malignancies may have developed after the therapy.
Dr. Collom acknowledged the limitation and agreed that the next study would need to address this.
The investigators reported no relevant financial disclosures.
SOURCE: EAST Scientific Assembly abstract No. 24.
REPORTING FROM EAST 2018
Key clinical point: Gastrografin is an effective alternative to operative exploration in small bowel obstruction patients with or without a history of surgical intervention.
Major finding: Treatment with Gastrografin (Bracco Diagnostics) reduced the risk of operative exploration for patients with small bowel obstruction (OR = .14, P less than .01).
Data source: Prospective, observational study of 601 small bowel obstruction patients seen at 14 institutions between February 2015 and December 2016.
Disclosures: The investigators reported no relevant financial disclosures.
Source: Collom et al. EAST Scientific Assembly, abstract 24.
PPIs, certain antibiotics increase risk of hospital onset C. difficile infection
The use of proton pump inhibitors increased the odds of a patient having hospital-onset Clostridium difficile infection (HO CDI) as did the use of third- and fourth-generation cephalosporins, carbapenems, and piperacillin/tazobactam, according to the results of a retrospective database study of more than 1 million patients at 150 U.S. hospitals.
PPIs increased the odds of HO CDI by 44% (P less than .001), whereas the use of H2 antagonists increased the odds ratio for HO CDI to a lesser, but still significant, extent (13% increase, P less than .001), according to the report published online in Clinical Infectious Diseases.
Overall, the odds of HO CDI were significantly higher in patients taking carbapenems, third- and fourth-generation cephalosporins, metronidazole, and piperacillin/tazobactam, as well as patients on multiple antibiotics. However, treatment with tetracyclines, macrolides, or clindamycin significantly reduced the odds of HO CDI.
The combination of PPIs with fluoroquinolones, third-generation cephalosporins, fourth-generation cephalosporins, clindamycin, or carbapenems did not significantly alter the odds of HO CDI, which was in contrast with a previous meta-analysis (Am J Gastroenterol. 2012;107[7]:1011-9).
In addition to the drug associations, the odds of a patient having HO CDI increased by 0.5% for each year in age. The odds of CDI in women was 1.2 times as likely as in men, and admission from a long-term care facility, the presence of the comorbidities of diabetes, Crohn’s disease or ulcerative colitis, as well as days in the ICU and antibiotic days of therapy all significantly increased the odds of a patient having HO CDI. (Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112).
“The results support the need for stewardship practices around both high-risk antibiotics and medications that alter gastric acid regulation. Furthermore, the impact of deprescribing acid suppression therapy coupled with antibiotic stewardship could greatly reduce the incidence of HO CDI,” the researchers concluded.
The authors reported that they had no conflicts or funding source for this work.
SOURCE: Watson, T. et al. Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112.
The use of proton pump inhibitors increased the odds of a patient having hospital-onset Clostridium difficile infection (HO CDI) as did the use of third- and fourth-generation cephalosporins, carbapenems, and piperacillin/tazobactam, according to the results of a retrospective database study of more than 1 million patients at 150 U.S. hospitals.
PPIs increased the odds of HO CDI by 44% (P less than .001), whereas the use of H2 antagonists increased the odds ratio for HO CDI to a lesser, but still significant, extent (13% increase, P less than .001), according to the report published online in Clinical Infectious Diseases.
Overall, the odds of HO CDI were significantly higher in patients taking carbapenems, third- and fourth-generation cephalosporins, metronidazole, and piperacillin/tazobactam, as well as patients on multiple antibiotics. However, treatment with tetracyclines, macrolides, or clindamycin significantly reduced the odds of HO CDI.
The combination of PPIs with fluoroquinolones, third-generation cephalosporins, fourth-generation cephalosporins, clindamycin, or carbapenems did not significantly alter the odds of HO CDI, which was in contrast with a previous meta-analysis (Am J Gastroenterol. 2012;107[7]:1011-9).
In addition to the drug associations, the odds of a patient having HO CDI increased by 0.5% for each year in age. The odds of CDI in women was 1.2 times as likely as in men, and admission from a long-term care facility, the presence of the comorbidities of diabetes, Crohn’s disease or ulcerative colitis, as well as days in the ICU and antibiotic days of therapy all significantly increased the odds of a patient having HO CDI. (Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112).
“The results support the need for stewardship practices around both high-risk antibiotics and medications that alter gastric acid regulation. Furthermore, the impact of deprescribing acid suppression therapy coupled with antibiotic stewardship could greatly reduce the incidence of HO CDI,” the researchers concluded.
The authors reported that they had no conflicts or funding source for this work.
SOURCE: Watson, T. et al. Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112.
The use of proton pump inhibitors increased the odds of a patient having hospital-onset Clostridium difficile infection (HO CDI) as did the use of third- and fourth-generation cephalosporins, carbapenems, and piperacillin/tazobactam, according to the results of a retrospective database study of more than 1 million patients at 150 U.S. hospitals.
PPIs increased the odds of HO CDI by 44% (P less than .001), whereas the use of H2 antagonists increased the odds ratio for HO CDI to a lesser, but still significant, extent (13% increase, P less than .001), according to the report published online in Clinical Infectious Diseases.
Overall, the odds of HO CDI were significantly higher in patients taking carbapenems, third- and fourth-generation cephalosporins, metronidazole, and piperacillin/tazobactam, as well as patients on multiple antibiotics. However, treatment with tetracyclines, macrolides, or clindamycin significantly reduced the odds of HO CDI.
The combination of PPIs with fluoroquinolones, third-generation cephalosporins, fourth-generation cephalosporins, clindamycin, or carbapenems did not significantly alter the odds of HO CDI, which was in contrast with a previous meta-analysis (Am J Gastroenterol. 2012;107[7]:1011-9).
In addition to the drug associations, the odds of a patient having HO CDI increased by 0.5% for each year in age. The odds of CDI in women was 1.2 times as likely as in men, and admission from a long-term care facility, the presence of the comorbidities of diabetes, Crohn’s disease or ulcerative colitis, as well as days in the ICU and antibiotic days of therapy all significantly increased the odds of a patient having HO CDI. (Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112).
“The results support the need for stewardship practices around both high-risk antibiotics and medications that alter gastric acid regulation. Furthermore, the impact of deprescribing acid suppression therapy coupled with antibiotic stewardship could greatly reduce the incidence of HO CDI,” the researchers concluded.
The authors reported that they had no conflicts or funding source for this work.
SOURCE: Watson, T. et al. Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112.
FROM CLINICAL INFECTIOUS DISEASES
Key clinical point: Proper stewardship of PPIs, antibiotics might lower risk of hospital-onset C. difficile infection.
Major finding: Patients taking PPIs had a 44% increased risk of developing hospital-onset C. difficile infection.
Study details: Retrospective database study of more than 1 million patients at 150 U.S. hospitals.
Disclosures: The authors reported that they had no conflicts or funding source for this work.
Source: Watson, T. et al. Clin Infect Dis. 2017 Dec. 20. doi: 10.1093/cid/cix1112.
Shortened PTSD therapy still effective in active duty military personnel
A compressed 2-week version of prolonged exposure therapy for posttraumatic stress disorder in active duty military personnel delivers results similar to those seen in an 8-week course of treatment, new research suggested.
However, the four-arm clinical trial, published in JAMA, also found that the standard 8-week course of prolonged exposure therapy offered no significant benefits above present-centered therapy, prompting the suggestion that it may be less effective in military personnel.
The trial enrolled 366 military personnel – 12% female – on active duty and with PTSD who had returned from Iraq and/or Afghanistan. They were randomized to prolonged exposure therapy, which is a form of cognitive-behavioral therapy involving repeat exposure to traumatic memories and reminders, delivered in this study as either massed therapy over 2 weeks or spaced therapy over 8 weeks; to non–trauma-focused present-centered therapy over 8 weeks; or to a minimal-contact control consisting of once-weekly telephone calls from therapists for 4 weeks.
At 2 weeks after treatment, individuals who underwent massed exposure therapy showed a mean decrease in PTSD Symptom Scale–Interview (PSS-I) score from baseline of 7.13 points, compared with a mean decrease of 7.29 in the spaced-therapy group, thereby meeting the criteria for noninferiority.
At 12 weeks after treatment, the massed-therapy group showed a 6.32-point mean decrease and the spaced-therapy group had a 6.97-point mean decrease in PSS-I scores.
By comparison, individuals in the minimal-contact control group showed a mean decrease of 3.43 points at 2 weeks after treatment.
When the spaced version of the prolonged exposure therapy was compared with present-centered therapy, researchers saw no significant difference in changes in mean levels of PSS-I between the two groups at posttreatment follow-up.
Edna B. Foa, PhD, from the department of psychiatry at the University of Pennsylvania, Philadelphia, and her coauthors wrote that prolonged exposure therapy for PTSD has been shown to be effective in civilians and veterans, but its use in active duty military personnel has only been explored in case studies.
“One barrier to implementation of prolonged exposure therapy in the military is treatment length (8-15 weeks), which can conflict with military obligations,” they wrote. “A shorter course of therapy could hasten amelioration of PTSD, with the added benefit of facilitating military readiness.”
There had been concerns that the massed-therapy approach would be too emotionally taxing because it involved daily sessions on 10 consecutive weekdays, with patients participating in repeated recounting of the most disturbing traumatic memory followed by processing the thoughts and feelings associated with that memory.
“The noninferiority of massed therapy to spaced therapy is particularly important for the military because 2-week treatment not only is associated with more rapid symptom improvement but also may reduce interference with the demanding military schedule,” the authors wrote.
However, the researchers noted that the effect of both the massed and spaced therapy in this study population was less than that seen in previous studies.
“This suggests that well-established evidence-based treatments for PTSD may be less efficacious for active duty military personnel with PTSD and that modifications to these treatments, or alternative treatments, may be needed to achieve better outcomes.”
The study was conducted with the support of the Department of Defense. Eight authors declared funding from bodies including the Department of Defense, and one author received royalties from books on PTSD treatments.
SOURCE: Foa EB et al. JAMA. 2018 Jan 23. doi: 10.1001/jama.2017.21242.
Guidelines for the management of PTSD currently recommend trauma-focused psychotherapies, such as prolonged exposure therapy and cognitive processing therapy, as the first line of treatment for PTSD ahead of medications. However barriers to care, dropouts, and stigma remain challenges to uptake of these therapies.
The finding that trauma-focused and non–trauma-focused therapy achieve similar outcomes adds to a growing body of evidence that the differences between these approaches are small to negligible. But while current guidelines support present-centered therapy as a second-line approach, recommending it as a primary treatment is a perplexing evolution for a therapy originally developed as a therapy control condition for randomized controlled trials.
It is clear that more substantive evolution in PTSD treatments is needed and that individual variability in mechanisms of recovery and therapeutic preferences – as well as longer-term strategies – must be taken into account when deciding on a therapeutic approach
Charles W. Hoge, MD, is from the Walter Reed Army Institute of Research, Silver Spring, Md., and Kathleen M. Chard, PhD, is from the Trauma Recovery Center at Cincinnati VA Medical Center. These comments are taken from an accompanying editorial (JAMA. 2018 January 23;319:343-5). No conflicts of interest were declared.
Guidelines for the management of PTSD currently recommend trauma-focused psychotherapies, such as prolonged exposure therapy and cognitive processing therapy, as the first line of treatment for PTSD ahead of medications. However barriers to care, dropouts, and stigma remain challenges to uptake of these therapies.
The finding that trauma-focused and non–trauma-focused therapy achieve similar outcomes adds to a growing body of evidence that the differences between these approaches are small to negligible. But while current guidelines support present-centered therapy as a second-line approach, recommending it as a primary treatment is a perplexing evolution for a therapy originally developed as a therapy control condition for randomized controlled trials.
It is clear that more substantive evolution in PTSD treatments is needed and that individual variability in mechanisms of recovery and therapeutic preferences – as well as longer-term strategies – must be taken into account when deciding on a therapeutic approach
Charles W. Hoge, MD, is from the Walter Reed Army Institute of Research, Silver Spring, Md., and Kathleen M. Chard, PhD, is from the Trauma Recovery Center at Cincinnati VA Medical Center. These comments are taken from an accompanying editorial (JAMA. 2018 January 23;319:343-5). No conflicts of interest were declared.
Guidelines for the management of PTSD currently recommend trauma-focused psychotherapies, such as prolonged exposure therapy and cognitive processing therapy, as the first line of treatment for PTSD ahead of medications. However barriers to care, dropouts, and stigma remain challenges to uptake of these therapies.
The finding that trauma-focused and non–trauma-focused therapy achieve similar outcomes adds to a growing body of evidence that the differences between these approaches are small to negligible. But while current guidelines support present-centered therapy as a second-line approach, recommending it as a primary treatment is a perplexing evolution for a therapy originally developed as a therapy control condition for randomized controlled trials.
It is clear that more substantive evolution in PTSD treatments is needed and that individual variability in mechanisms of recovery and therapeutic preferences – as well as longer-term strategies – must be taken into account when deciding on a therapeutic approach
Charles W. Hoge, MD, is from the Walter Reed Army Institute of Research, Silver Spring, Md., and Kathleen M. Chard, PhD, is from the Trauma Recovery Center at Cincinnati VA Medical Center. These comments are taken from an accompanying editorial (JAMA. 2018 January 23;319:343-5). No conflicts of interest were declared.
A compressed 2-week version of prolonged exposure therapy for posttraumatic stress disorder in active duty military personnel delivers results similar to those seen in an 8-week course of treatment, new research suggested.
However, the four-arm clinical trial, published in JAMA, also found that the standard 8-week course of prolonged exposure therapy offered no significant benefits above present-centered therapy, prompting the suggestion that it may be less effective in military personnel.
The trial enrolled 366 military personnel – 12% female – on active duty and with PTSD who had returned from Iraq and/or Afghanistan. They were randomized to prolonged exposure therapy, which is a form of cognitive-behavioral therapy involving repeat exposure to traumatic memories and reminders, delivered in this study as either massed therapy over 2 weeks or spaced therapy over 8 weeks; to non–trauma-focused present-centered therapy over 8 weeks; or to a minimal-contact control consisting of once-weekly telephone calls from therapists for 4 weeks.
At 2 weeks after treatment, individuals who underwent massed exposure therapy showed a mean decrease in PTSD Symptom Scale–Interview (PSS-I) score from baseline of 7.13 points, compared with a mean decrease of 7.29 in the spaced-therapy group, thereby meeting the criteria for noninferiority.
At 12 weeks after treatment, the massed-therapy group showed a 6.32-point mean decrease and the spaced-therapy group had a 6.97-point mean decrease in PSS-I scores.
By comparison, individuals in the minimal-contact control group showed a mean decrease of 3.43 points at 2 weeks after treatment.
When the spaced version of the prolonged exposure therapy was compared with present-centered therapy, researchers saw no significant difference in changes in mean levels of PSS-I between the two groups at posttreatment follow-up.
Edna B. Foa, PhD, from the department of psychiatry at the University of Pennsylvania, Philadelphia, and her coauthors wrote that prolonged exposure therapy for PTSD has been shown to be effective in civilians and veterans, but its use in active duty military personnel has only been explored in case studies.
“One barrier to implementation of prolonged exposure therapy in the military is treatment length (8-15 weeks), which can conflict with military obligations,” they wrote. “A shorter course of therapy could hasten amelioration of PTSD, with the added benefit of facilitating military readiness.”
There had been concerns that the massed-therapy approach would be too emotionally taxing because it involved daily sessions on 10 consecutive weekdays, with patients participating in repeated recounting of the most disturbing traumatic memory followed by processing the thoughts and feelings associated with that memory.
“The noninferiority of massed therapy to spaced therapy is particularly important for the military because 2-week treatment not only is associated with more rapid symptom improvement but also may reduce interference with the demanding military schedule,” the authors wrote.
However, the researchers noted that the effect of both the massed and spaced therapy in this study population was less than that seen in previous studies.
“This suggests that well-established evidence-based treatments for PTSD may be less efficacious for active duty military personnel with PTSD and that modifications to these treatments, or alternative treatments, may be needed to achieve better outcomes.”
The study was conducted with the support of the Department of Defense. Eight authors declared funding from bodies including the Department of Defense, and one author received royalties from books on PTSD treatments.
SOURCE: Foa EB et al. JAMA. 2018 Jan 23. doi: 10.1001/jama.2017.21242.
A compressed 2-week version of prolonged exposure therapy for posttraumatic stress disorder in active duty military personnel delivers results similar to those seen in an 8-week course of treatment, new research suggested.
However, the four-arm clinical trial, published in JAMA, also found that the standard 8-week course of prolonged exposure therapy offered no significant benefits above present-centered therapy, prompting the suggestion that it may be less effective in military personnel.
The trial enrolled 366 military personnel – 12% female – on active duty and with PTSD who had returned from Iraq and/or Afghanistan. They were randomized to prolonged exposure therapy, which is a form of cognitive-behavioral therapy involving repeat exposure to traumatic memories and reminders, delivered in this study as either massed therapy over 2 weeks or spaced therapy over 8 weeks; to non–trauma-focused present-centered therapy over 8 weeks; or to a minimal-contact control consisting of once-weekly telephone calls from therapists for 4 weeks.
At 2 weeks after treatment, individuals who underwent massed exposure therapy showed a mean decrease in PTSD Symptom Scale–Interview (PSS-I) score from baseline of 7.13 points, compared with a mean decrease of 7.29 in the spaced-therapy group, thereby meeting the criteria for noninferiority.
At 12 weeks after treatment, the massed-therapy group showed a 6.32-point mean decrease and the spaced-therapy group had a 6.97-point mean decrease in PSS-I scores.
By comparison, individuals in the minimal-contact control group showed a mean decrease of 3.43 points at 2 weeks after treatment.
When the spaced version of the prolonged exposure therapy was compared with present-centered therapy, researchers saw no significant difference in changes in mean levels of PSS-I between the two groups at posttreatment follow-up.
Edna B. Foa, PhD, from the department of psychiatry at the University of Pennsylvania, Philadelphia, and her coauthors wrote that prolonged exposure therapy for PTSD has been shown to be effective in civilians and veterans, but its use in active duty military personnel has only been explored in case studies.
“One barrier to implementation of prolonged exposure therapy in the military is treatment length (8-15 weeks), which can conflict with military obligations,” they wrote. “A shorter course of therapy could hasten amelioration of PTSD, with the added benefit of facilitating military readiness.”
There had been concerns that the massed-therapy approach would be too emotionally taxing because it involved daily sessions on 10 consecutive weekdays, with patients participating in repeated recounting of the most disturbing traumatic memory followed by processing the thoughts and feelings associated with that memory.
“The noninferiority of massed therapy to spaced therapy is particularly important for the military because 2-week treatment not only is associated with more rapid symptom improvement but also may reduce interference with the demanding military schedule,” the authors wrote.
However, the researchers noted that the effect of both the massed and spaced therapy in this study population was less than that seen in previous studies.
“This suggests that well-established evidence-based treatments for PTSD may be less efficacious for active duty military personnel with PTSD and that modifications to these treatments, or alternative treatments, may be needed to achieve better outcomes.”
The study was conducted with the support of the Department of Defense. Eight authors declared funding from bodies including the Department of Defense, and one author received royalties from books on PTSD treatments.
SOURCE: Foa EB et al. JAMA. 2018 Jan 23. doi: 10.1001/jama.2017.21242.
FROM JAMA
CHIP gets a 6-year extension in stopgap budget
The legislation did not address two Affordable Care Act provisions that have been bandied about in this years’ budget debacle – delaying the “Cadillac tax” on high-valued employer health insurance plans and the medical device tax.
The short-term funding bill (H.R. 195) passed the Senate by an 81-18 vote and the House by a 266-150 vote after a 3-day shutdown of the federal government driven primarily by partisan disagreement over immigration policy.
CHIP funding had expired at the end of September 2017. The 6-year reauthorization period is the longest since the program was created in 1997. The Senate Finance Committee passed a bill reauthorizing CHIP for 5 years in October 2017, but the Senate did not take any action.
Although he voted for the 6-year extension, Sen. Ben Cardin (D-Md.) said that Congress was going only for a temporary extension rather than making CHIP a permanent program.
“I wish it were permanent,” Sen. Cardin said on the Senate floor. “Rather than putting another deadline on the program, we should try to make this permanent.”
Sen. Cardin also said the bill did nothing to extend funding to community health centers, where many children covered by CHIP get their medical treatments.
The legislation did not address two Affordable Care Act provisions that have been bandied about in this years’ budget debacle – delaying the “Cadillac tax” on high-valued employer health insurance plans and the medical device tax.
The short-term funding bill (H.R. 195) passed the Senate by an 81-18 vote and the House by a 266-150 vote after a 3-day shutdown of the federal government driven primarily by partisan disagreement over immigration policy.
CHIP funding had expired at the end of September 2017. The 6-year reauthorization period is the longest since the program was created in 1997. The Senate Finance Committee passed a bill reauthorizing CHIP for 5 years in October 2017, but the Senate did not take any action.
Although he voted for the 6-year extension, Sen. Ben Cardin (D-Md.) said that Congress was going only for a temporary extension rather than making CHIP a permanent program.
“I wish it were permanent,” Sen. Cardin said on the Senate floor. “Rather than putting another deadline on the program, we should try to make this permanent.”
Sen. Cardin also said the bill did nothing to extend funding to community health centers, where many children covered by CHIP get their medical treatments.
The legislation did not address two Affordable Care Act provisions that have been bandied about in this years’ budget debacle – delaying the “Cadillac tax” on high-valued employer health insurance plans and the medical device tax.
The short-term funding bill (H.R. 195) passed the Senate by an 81-18 vote and the House by a 266-150 vote after a 3-day shutdown of the federal government driven primarily by partisan disagreement over immigration policy.
CHIP funding had expired at the end of September 2017. The 6-year reauthorization period is the longest since the program was created in 1997. The Senate Finance Committee passed a bill reauthorizing CHIP for 5 years in October 2017, but the Senate did not take any action.
Although he voted for the 6-year extension, Sen. Ben Cardin (D-Md.) said that Congress was going only for a temporary extension rather than making CHIP a permanent program.
“I wish it were permanent,” Sen. Cardin said on the Senate floor. “Rather than putting another deadline on the program, we should try to make this permanent.”
Sen. Cardin also said the bill did nothing to extend funding to community health centers, where many children covered by CHIP get their medical treatments.
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The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Get your daily dose of medical news right here every weekday. MDEdge Medical News Briefing serves up the latest clinical research and socioeconomic news that impacts your practice, all in less than 3 minutes.
In today's news: Flu update, a blood test for cancer, malpractice premiums on the move, and more!
Check back again tomorrow for another quick infusion of medical news.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Get your daily dose of medical news right here every weekday. MDEdge Medical News Briefing serves up the latest clinical research and socioeconomic news that impacts your practice, all in less than 3 minutes.
In today's news: Flu update, a blood test for cancer, malpractice premiums on the move, and more!
Check back again tomorrow for another quick infusion of medical news.
Asymptomatic carotid in-stent restenosis? Think medical management
CHICAGO – with a carotid in-stent restenosis in excess of 70%, Jayer Chung, MD, asserted at a symposium on vascular surgery sponsored by Northwestern University.
That, in his view, makes medical management the clear preferred strategy.
A growing body of evidence, mainly from nested cohorts within randomized controlled trials, indicates that the late ipsilateral stroke rate associated with post–carotid endarterectomy restenosis (CEA) is much higher than that for carotid in-stent restenosis (C-ISR). In a recent meta-analysis of nine randomized trials, the difference in risk was more than 10-fold, with a 9.2% stroke rate at a mean of 37 months of follow-up in patients with post-CEA restenosis, compared with a 0.8% rate with 50 months of follow-up in patients with C-ISR (Eur J Vasc Endovasc Surg. 2017 Jun;53[6]:766-75).
“These pathologies behave very, very differently,” Dr. Chung observed. “The C-ISR lesions tend to be less embologenic.”
C-ISR is an uncommon event. Extrapolating from the landmark CREST (Carotid Revascularization Endarterectomy versus Stenting Trial) and other randomized trials, about 6% of patients who undergo percutaneous carotid stenting will be develop C-ISR within 2 years. But since the proportion of all carotid revascularizations that are done by carotid stent angioplasty has steadily increased over the past 15 years as the frequency of CEA has dropped, C-ISR is a problem that vascular specialists will continue to encounter on a regular basis.
Symptomatic C-ISR warrants reintervention; broad agreement exists on that. But there is a paucity of data to guide treatment decisions regarding asymptomatic yet angiographically severe C-ISR. Indeed, Dr. Chung was lead author of the only retrospective study of the natural history of untreated C-ISR, as opposed to carefully selected cohorts from randomized trials involving highly experienced operators. This study was a retrospective review of 59 patients with 75 C-ISRs of at least 50% seen at a single Veterans Affairs medical center over a 13-year period. Three-quarters of the ISRs were asymptomatic.
Forty of the 79 C-ISRs underwent percutaneous intervention at the physician’s discretion. Those patients did not differ from the observation-only group in age, comorbid conditions, type of original stent, or clopidogrel use. Reintervention was safe: There was one stent thrombosis resulting in stroke and death within 30 days in the reintervention group and no 30-day strokes in the observation-only group. During a mean 2.6 years of follow-up, the composite rate of death, stroke, or MI was low and not statistically significantly different between the two groups. Indeed, during up to 13 years of follow-up only one patient with untreated C-ISR experienced an ipsilateral stroke, as did two patients in the percutaneous intervention group (J Vasc Surg. 2016 Nov;64[5]:1286-94).
Dr. Chung does the math
According to data from the National Inpatient Sample, vascular surgeons do an average of 15 carotid angioplasty and stenting procedures per year. If 6% of those stents develop in-stent restenosis, and with a number needed to treat with revascularization of 25 to prevent 1 stroke, Dr. Chung estimated that hypothetically it would take the typical vascular surgeon 27 years to prevent one stroke due to C-ISR.
“That’s a very long time to prevent one stroke, in my opinion,” he said.
How his study has affected his own practice
Dr. Chung now intervenes only for symptomatic C-ISRs, and only after an affected patient is on optimal medical therapy, including a statin and dual-antiplatelet therapy.
“I try to do an open procedure if possible, especially if the restenosis is above C-2. The ones I tend to do percutaneously are the post-irradiation stenoses or those with excessive scarring, and I use a cerebral protection device,” the surgeon explained.
He emphasized, however, that the final word on the appropriate management of C-ISRs isn’t in yet. A standardized definition of C-ISR is needed, as are multicenter prospective registries of medically managed patients as well as those undergoing various forms of reintervention. And a pathologic study is warranted to confirm the hypothesis that the histopathology of post-CEA and post-stent restenosis – and hence the natural history – is markedly different.
Dr. Chung reported having no financial conflicts regarding his presentation.
CHICAGO – with a carotid in-stent restenosis in excess of 70%, Jayer Chung, MD, asserted at a symposium on vascular surgery sponsored by Northwestern University.
That, in his view, makes medical management the clear preferred strategy.
A growing body of evidence, mainly from nested cohorts within randomized controlled trials, indicates that the late ipsilateral stroke rate associated with post–carotid endarterectomy restenosis (CEA) is much higher than that for carotid in-stent restenosis (C-ISR). In a recent meta-analysis of nine randomized trials, the difference in risk was more than 10-fold, with a 9.2% stroke rate at a mean of 37 months of follow-up in patients with post-CEA restenosis, compared with a 0.8% rate with 50 months of follow-up in patients with C-ISR (Eur J Vasc Endovasc Surg. 2017 Jun;53[6]:766-75).
“These pathologies behave very, very differently,” Dr. Chung observed. “The C-ISR lesions tend to be less embologenic.”
C-ISR is an uncommon event. Extrapolating from the landmark CREST (Carotid Revascularization Endarterectomy versus Stenting Trial) and other randomized trials, about 6% of patients who undergo percutaneous carotid stenting will be develop C-ISR within 2 years. But since the proportion of all carotid revascularizations that are done by carotid stent angioplasty has steadily increased over the past 15 years as the frequency of CEA has dropped, C-ISR is a problem that vascular specialists will continue to encounter on a regular basis.
Symptomatic C-ISR warrants reintervention; broad agreement exists on that. But there is a paucity of data to guide treatment decisions regarding asymptomatic yet angiographically severe C-ISR. Indeed, Dr. Chung was lead author of the only retrospective study of the natural history of untreated C-ISR, as opposed to carefully selected cohorts from randomized trials involving highly experienced operators. This study was a retrospective review of 59 patients with 75 C-ISRs of at least 50% seen at a single Veterans Affairs medical center over a 13-year period. Three-quarters of the ISRs were asymptomatic.
Forty of the 79 C-ISRs underwent percutaneous intervention at the physician’s discretion. Those patients did not differ from the observation-only group in age, comorbid conditions, type of original stent, or clopidogrel use. Reintervention was safe: There was one stent thrombosis resulting in stroke and death within 30 days in the reintervention group and no 30-day strokes in the observation-only group. During a mean 2.6 years of follow-up, the composite rate of death, stroke, or MI was low and not statistically significantly different between the two groups. Indeed, during up to 13 years of follow-up only one patient with untreated C-ISR experienced an ipsilateral stroke, as did two patients in the percutaneous intervention group (J Vasc Surg. 2016 Nov;64[5]:1286-94).
Dr. Chung does the math
According to data from the National Inpatient Sample, vascular surgeons do an average of 15 carotid angioplasty and stenting procedures per year. If 6% of those stents develop in-stent restenosis, and with a number needed to treat with revascularization of 25 to prevent 1 stroke, Dr. Chung estimated that hypothetically it would take the typical vascular surgeon 27 years to prevent one stroke due to C-ISR.
“That’s a very long time to prevent one stroke, in my opinion,” he said.
How his study has affected his own practice
Dr. Chung now intervenes only for symptomatic C-ISRs, and only after an affected patient is on optimal medical therapy, including a statin and dual-antiplatelet therapy.
“I try to do an open procedure if possible, especially if the restenosis is above C-2. The ones I tend to do percutaneously are the post-irradiation stenoses or those with excessive scarring, and I use a cerebral protection device,” the surgeon explained.
He emphasized, however, that the final word on the appropriate management of C-ISRs isn’t in yet. A standardized definition of C-ISR is needed, as are multicenter prospective registries of medically managed patients as well as those undergoing various forms of reintervention. And a pathologic study is warranted to confirm the hypothesis that the histopathology of post-CEA and post-stent restenosis – and hence the natural history – is markedly different.
Dr. Chung reported having no financial conflicts regarding his presentation.
CHICAGO – with a carotid in-stent restenosis in excess of 70%, Jayer Chung, MD, asserted at a symposium on vascular surgery sponsored by Northwestern University.
That, in his view, makes medical management the clear preferred strategy.
A growing body of evidence, mainly from nested cohorts within randomized controlled trials, indicates that the late ipsilateral stroke rate associated with post–carotid endarterectomy restenosis (CEA) is much higher than that for carotid in-stent restenosis (C-ISR). In a recent meta-analysis of nine randomized trials, the difference in risk was more than 10-fold, with a 9.2% stroke rate at a mean of 37 months of follow-up in patients with post-CEA restenosis, compared with a 0.8% rate with 50 months of follow-up in patients with C-ISR (Eur J Vasc Endovasc Surg. 2017 Jun;53[6]:766-75).
“These pathologies behave very, very differently,” Dr. Chung observed. “The C-ISR lesions tend to be less embologenic.”
C-ISR is an uncommon event. Extrapolating from the landmark CREST (Carotid Revascularization Endarterectomy versus Stenting Trial) and other randomized trials, about 6% of patients who undergo percutaneous carotid stenting will be develop C-ISR within 2 years. But since the proportion of all carotid revascularizations that are done by carotid stent angioplasty has steadily increased over the past 15 years as the frequency of CEA has dropped, C-ISR is a problem that vascular specialists will continue to encounter on a regular basis.
Symptomatic C-ISR warrants reintervention; broad agreement exists on that. But there is a paucity of data to guide treatment decisions regarding asymptomatic yet angiographically severe C-ISR. Indeed, Dr. Chung was lead author of the only retrospective study of the natural history of untreated C-ISR, as opposed to carefully selected cohorts from randomized trials involving highly experienced operators. This study was a retrospective review of 59 patients with 75 C-ISRs of at least 50% seen at a single Veterans Affairs medical center over a 13-year period. Three-quarters of the ISRs were asymptomatic.
Forty of the 79 C-ISRs underwent percutaneous intervention at the physician’s discretion. Those patients did not differ from the observation-only group in age, comorbid conditions, type of original stent, or clopidogrel use. Reintervention was safe: There was one stent thrombosis resulting in stroke and death within 30 days in the reintervention group and no 30-day strokes in the observation-only group. During a mean 2.6 years of follow-up, the composite rate of death, stroke, or MI was low and not statistically significantly different between the two groups. Indeed, during up to 13 years of follow-up only one patient with untreated C-ISR experienced an ipsilateral stroke, as did two patients in the percutaneous intervention group (J Vasc Surg. 2016 Nov;64[5]:1286-94).
Dr. Chung does the math
According to data from the National Inpatient Sample, vascular surgeons do an average of 15 carotid angioplasty and stenting procedures per year. If 6% of those stents develop in-stent restenosis, and with a number needed to treat with revascularization of 25 to prevent 1 stroke, Dr. Chung estimated that hypothetically it would take the typical vascular surgeon 27 years to prevent one stroke due to C-ISR.
“That’s a very long time to prevent one stroke, in my opinion,” he said.
How his study has affected his own practice
Dr. Chung now intervenes only for symptomatic C-ISRs, and only after an affected patient is on optimal medical therapy, including a statin and dual-antiplatelet therapy.
“I try to do an open procedure if possible, especially if the restenosis is above C-2. The ones I tend to do percutaneously are the post-irradiation stenoses or those with excessive scarring, and I use a cerebral protection device,” the surgeon explained.
He emphasized, however, that the final word on the appropriate management of C-ISRs isn’t in yet. A standardized definition of C-ISR is needed, as are multicenter prospective registries of medically managed patients as well as those undergoing various forms of reintervention. And a pathologic study is warranted to confirm the hypothesis that the histopathology of post-CEA and post-stent restenosis – and hence the natural history – is markedly different.
Dr. Chung reported having no financial conflicts regarding his presentation.
EXPERT ANALYSIS FROM THE NORTHWESTERN VASCULAR SYMPOSIUM
Psychiatry Innovation Lab nurtures young businesses
The future of mental health is in our own hands. As psychiatrists, we have a wealth of experience to fuel transformation in our field and improve care for our patients. What we lack is the space in which to share our ideas and turn them into tangible solutions like sustainable businesses, diagnostic devices, mobile apps, or prevention campaigns.
The Psychiatry Innovation Lab provides just that – it is an incubator nurturing early-stage ideas and ventures by investing in them through mentorship, education, funding, and collaboration opportunities within a community of mental health innovators.
The lab’s main event is on Sunday, May 6, 2018, when leaders in psychiatry will gather alongside industry leaders at the Jacob Javits Convention Center in New York City during the American Psychiatric Association meeting for this fourth annual live event . At the event, finalists will pitch ideas “Shark Tank” style to a panel of expert judges. Finalists will work closely with industry leaders and audience members to fine-tune their ideas before pitching their revisions to the judges as well as to a live, voting audience, who together select the winners of cash awards and other prizes.
The Psychiatry Innovation Lab was founded in 2015 by Nina Vasan, MD, a Stanford (Calif.) University psychiatrist and author of Do Good Well: Your Guide to Leadership, Action, and Social Innovation (San Francisco: Jossey-Bass, 2013), with the purpose of catalyzing more entrepreneurship and innovation in mental health.
“The most meaningful part of the lab has been the impact that these ventures have had on the patients that we serve,” said Dr. Vasan, chair of the Psychiatry Innovation Lab and director of Brainstorm, the Stanford Laboratory for Brain Health Innovation and Entrepreneurship. “Year after year, psychiatrists come back and tell us that they are looking at their own patient care differently now. They’re looking for ways to be innovative, and we’re giving them the tools necessary to turn their clinical expertise into successful ventures.”
Applications are currently open online to pitch an idea in this year’s lab. Applications consist of brief answers to questions and a short YouTube video. The deadline for submissions is Friday, March 9, 2018. Anyone with innovative ideas, regardless of the stage, is invited to apply. The APA Workgroup on Psychiatry Innovation, which oversees the lab, welcomes ideas from people pitching for the first time to those working on their ideas full time. They noted that past finalists have come from all experience levels and a wide range of backgrounds, including students, CEOs, engineers, and psychiatrists.
Past winners and participants have come from a range of stages, from early start-ups to established companies, including NeuroLex Labs, which uses voice samples to detect behavioral health illness; Spring, which uses machine learning to determine the best depression treatment; Muse, which creates an EEG sensing headband to aid mindfulness practice; and Overdose Recovery Bracelet, which builds a wristband to deliver naloxone to people who have overdosed on opiates.
The diversity of ideas has been remarkable; ideas in the past have ranged from traditional for-profit businesses to nonprofits, educational and public health programs, and proposals for government reform. They address problems at all parts of the health care spectrum: prevention, diagnosis, treatment, systems, EMRs, and more.
“Many past ideas have revolved around technology such as artificial intelligence, social networking, or telemedicine,” Dr. Vasan said. “. Those ideas are especially important in solving the most pressing problems in our field today.”
In addition to those competing, anyone registered to attend the APA annual meeting can attend the event as an audience member or join a team and help as an innovation leader during the coaching portion of the program. Last year alone, more than 70% of the participants in the lab said that it was better than other educational events they have attended, 95% of participants found it useful, and participants made an average of six new contacts through the event.
“The Psychiatry Innovation Lab connected me to people who continue to inspire and educate me toward making a real impact with my own endeavors,” said Cody Rall, MD, founder of the YouTube channel Techforpsych and a 2016 semifinalist.
“The lab has grown dramatically. When we started we worked hard to find just one sponsor; last year we had 10 sponsors and over $25,000 in cash and prizes.” Dr. Vasan said. “We also had our first international finalist from Pakistan. The commitment to solving problems in mental health is taking off, and we want to ensure that psychiatrists are front and center in leading the change.”
For more information about joining the innovation lab or other ways to be involved, including sponsorship and judging, visit https://www.psychiatry.org/innovation or email Nina Taylor, APA deputy director of education, at [email protected].
This article was updated January 23, 2018.
Dr. Chaudhary is a board member of the APA Psychiatry Innovation Lab and the APA Workgroup on Psychiatry Innovation; chief resident in child and adolescent psychiatry at Massachusetts General Hospital/McLean and clinical fellow at Harvard Medical School, both in Boston; and founding partner of Brainstorm: Stanford Laboratory for Brain Health Innovation and Entrepreneurship. Dr. Ghomi is a board member of the APA Psychiatry Innovation Lab and the APA Workgroup on Psychiatry Innovation; resident in psychiatry at the University of Washington, Seattle; chief medical officer at NeuroLex; and founding partner of Brainstorm: Stanford Laboratory for Brain Health Innovation and Entrepreneurship.
The future of mental health is in our own hands. As psychiatrists, we have a wealth of experience to fuel transformation in our field and improve care for our patients. What we lack is the space in which to share our ideas and turn them into tangible solutions like sustainable businesses, diagnostic devices, mobile apps, or prevention campaigns.
The Psychiatry Innovation Lab provides just that – it is an incubator nurturing early-stage ideas and ventures by investing in them through mentorship, education, funding, and collaboration opportunities within a community of mental health innovators.
The lab’s main event is on Sunday, May 6, 2018, when leaders in psychiatry will gather alongside industry leaders at the Jacob Javits Convention Center in New York City during the American Psychiatric Association meeting for this fourth annual live event . At the event, finalists will pitch ideas “Shark Tank” style to a panel of expert judges. Finalists will work closely with industry leaders and audience members to fine-tune their ideas before pitching their revisions to the judges as well as to a live, voting audience, who together select the winners of cash awards and other prizes.
The Psychiatry Innovation Lab was founded in 2015 by Nina Vasan, MD, a Stanford (Calif.) University psychiatrist and author of Do Good Well: Your Guide to Leadership, Action, and Social Innovation (San Francisco: Jossey-Bass, 2013), with the purpose of catalyzing more entrepreneurship and innovation in mental health.
“The most meaningful part of the lab has been the impact that these ventures have had on the patients that we serve,” said Dr. Vasan, chair of the Psychiatry Innovation Lab and director of Brainstorm, the Stanford Laboratory for Brain Health Innovation and Entrepreneurship. “Year after year, psychiatrists come back and tell us that they are looking at their own patient care differently now. They’re looking for ways to be innovative, and we’re giving them the tools necessary to turn their clinical expertise into successful ventures.”
Applications are currently open online to pitch an idea in this year’s lab. Applications consist of brief answers to questions and a short YouTube video. The deadline for submissions is Friday, March 9, 2018. Anyone with innovative ideas, regardless of the stage, is invited to apply. The APA Workgroup on Psychiatry Innovation, which oversees the lab, welcomes ideas from people pitching for the first time to those working on their ideas full time. They noted that past finalists have come from all experience levels and a wide range of backgrounds, including students, CEOs, engineers, and psychiatrists.
Past winners and participants have come from a range of stages, from early start-ups to established companies, including NeuroLex Labs, which uses voice samples to detect behavioral health illness; Spring, which uses machine learning to determine the best depression treatment; Muse, which creates an EEG sensing headband to aid mindfulness practice; and Overdose Recovery Bracelet, which builds a wristband to deliver naloxone to people who have overdosed on opiates.
The diversity of ideas has been remarkable; ideas in the past have ranged from traditional for-profit businesses to nonprofits, educational and public health programs, and proposals for government reform. They address problems at all parts of the health care spectrum: prevention, diagnosis, treatment, systems, EMRs, and more.
“Many past ideas have revolved around technology such as artificial intelligence, social networking, or telemedicine,” Dr. Vasan said. “. Those ideas are especially important in solving the most pressing problems in our field today.”
In addition to those competing, anyone registered to attend the APA annual meeting can attend the event as an audience member or join a team and help as an innovation leader during the coaching portion of the program. Last year alone, more than 70% of the participants in the lab said that it was better than other educational events they have attended, 95% of participants found it useful, and participants made an average of six new contacts through the event.
“The Psychiatry Innovation Lab connected me to people who continue to inspire and educate me toward making a real impact with my own endeavors,” said Cody Rall, MD, founder of the YouTube channel Techforpsych and a 2016 semifinalist.
“The lab has grown dramatically. When we started we worked hard to find just one sponsor; last year we had 10 sponsors and over $25,000 in cash and prizes.” Dr. Vasan said. “We also had our first international finalist from Pakistan. The commitment to solving problems in mental health is taking off, and we want to ensure that psychiatrists are front and center in leading the change.”
For more information about joining the innovation lab or other ways to be involved, including sponsorship and judging, visit https://www.psychiatry.org/innovation or email Nina Taylor, APA deputy director of education, at [email protected].
This article was updated January 23, 2018.
Dr. Chaudhary is a board member of the APA Psychiatry Innovation Lab and the APA Workgroup on Psychiatry Innovation; chief resident in child and adolescent psychiatry at Massachusetts General Hospital/McLean and clinical fellow at Harvard Medical School, both in Boston; and founding partner of Brainstorm: Stanford Laboratory for Brain Health Innovation and Entrepreneurship. Dr. Ghomi is a board member of the APA Psychiatry Innovation Lab and the APA Workgroup on Psychiatry Innovation; resident in psychiatry at the University of Washington, Seattle; chief medical officer at NeuroLex; and founding partner of Brainstorm: Stanford Laboratory for Brain Health Innovation and Entrepreneurship.
The future of mental health is in our own hands. As psychiatrists, we have a wealth of experience to fuel transformation in our field and improve care for our patients. What we lack is the space in which to share our ideas and turn them into tangible solutions like sustainable businesses, diagnostic devices, mobile apps, or prevention campaigns.
The Psychiatry Innovation Lab provides just that – it is an incubator nurturing early-stage ideas and ventures by investing in them through mentorship, education, funding, and collaboration opportunities within a community of mental health innovators.
The lab’s main event is on Sunday, May 6, 2018, when leaders in psychiatry will gather alongside industry leaders at the Jacob Javits Convention Center in New York City during the American Psychiatric Association meeting for this fourth annual live event . At the event, finalists will pitch ideas “Shark Tank” style to a panel of expert judges. Finalists will work closely with industry leaders and audience members to fine-tune their ideas before pitching their revisions to the judges as well as to a live, voting audience, who together select the winners of cash awards and other prizes.
The Psychiatry Innovation Lab was founded in 2015 by Nina Vasan, MD, a Stanford (Calif.) University psychiatrist and author of Do Good Well: Your Guide to Leadership, Action, and Social Innovation (San Francisco: Jossey-Bass, 2013), with the purpose of catalyzing more entrepreneurship and innovation in mental health.
“The most meaningful part of the lab has been the impact that these ventures have had on the patients that we serve,” said Dr. Vasan, chair of the Psychiatry Innovation Lab and director of Brainstorm, the Stanford Laboratory for Brain Health Innovation and Entrepreneurship. “Year after year, psychiatrists come back and tell us that they are looking at their own patient care differently now. They’re looking for ways to be innovative, and we’re giving them the tools necessary to turn their clinical expertise into successful ventures.”
Applications are currently open online to pitch an idea in this year’s lab. Applications consist of brief answers to questions and a short YouTube video. The deadline for submissions is Friday, March 9, 2018. Anyone with innovative ideas, regardless of the stage, is invited to apply. The APA Workgroup on Psychiatry Innovation, which oversees the lab, welcomes ideas from people pitching for the first time to those working on their ideas full time. They noted that past finalists have come from all experience levels and a wide range of backgrounds, including students, CEOs, engineers, and psychiatrists.
Past winners and participants have come from a range of stages, from early start-ups to established companies, including NeuroLex Labs, which uses voice samples to detect behavioral health illness; Spring, which uses machine learning to determine the best depression treatment; Muse, which creates an EEG sensing headband to aid mindfulness practice; and Overdose Recovery Bracelet, which builds a wristband to deliver naloxone to people who have overdosed on opiates.
The diversity of ideas has been remarkable; ideas in the past have ranged from traditional for-profit businesses to nonprofits, educational and public health programs, and proposals for government reform. They address problems at all parts of the health care spectrum: prevention, diagnosis, treatment, systems, EMRs, and more.
“Many past ideas have revolved around technology such as artificial intelligence, social networking, or telemedicine,” Dr. Vasan said. “. Those ideas are especially important in solving the most pressing problems in our field today.”
In addition to those competing, anyone registered to attend the APA annual meeting can attend the event as an audience member or join a team and help as an innovation leader during the coaching portion of the program. Last year alone, more than 70% of the participants in the lab said that it was better than other educational events they have attended, 95% of participants found it useful, and participants made an average of six new contacts through the event.
“The Psychiatry Innovation Lab connected me to people who continue to inspire and educate me toward making a real impact with my own endeavors,” said Cody Rall, MD, founder of the YouTube channel Techforpsych and a 2016 semifinalist.
“The lab has grown dramatically. When we started we worked hard to find just one sponsor; last year we had 10 sponsors and over $25,000 in cash and prizes.” Dr. Vasan said. “We also had our first international finalist from Pakistan. The commitment to solving problems in mental health is taking off, and we want to ensure that psychiatrists are front and center in leading the change.”
For more information about joining the innovation lab or other ways to be involved, including sponsorship and judging, visit https://www.psychiatry.org/innovation or email Nina Taylor, APA deputy director of education, at [email protected].
This article was updated January 23, 2018.
Dr. Chaudhary is a board member of the APA Psychiatry Innovation Lab and the APA Workgroup on Psychiatry Innovation; chief resident in child and adolescent psychiatry at Massachusetts General Hospital/McLean and clinical fellow at Harvard Medical School, both in Boston; and founding partner of Brainstorm: Stanford Laboratory for Brain Health Innovation and Entrepreneurship. Dr. Ghomi is a board member of the APA Psychiatry Innovation Lab and the APA Workgroup on Psychiatry Innovation; resident in psychiatry at the University of Washington, Seattle; chief medical officer at NeuroLex; and founding partner of Brainstorm: Stanford Laboratory for Brain Health Innovation and Entrepreneurship.
Isolated severe tricuspid regurgitation: An emerging disease
SNOWMASS, COLO. – that’s treatable, provided affected patients are referred for surgery before the clinical course progresses to intractable right heart disease with cirrhosis and liver failure, Rick A. Nishimura, MD, said at the Annual Cardiovascular Conference at Snowmass.
“This is an emerging disease that you’re all going to see in your practices this year. You’ve got to know what to do with these patients. Get to them early,” urged Dr. Nishimura, professor of cardiovascular sciences and hypertension at the Mayo Clinic in Rochester, Minn.
The medical textbooks don’t discuss isolated severe tricuspid regurgitation (ISTR) or its etiology. ISTR is a disorder of progressive right ventricular dilation and dysfunction whose etiology involves either longstanding atrial fibrillation or valvular disruption due to interference from a crossing lead of a permanent pacemaker or implantable cardioverter defibrillator.
“This is something different. These patients have a normal left heart and left heart valves and normal pressures, with no pulmonary hypertension. So it doesn’t fit into any of the textbook categories of tricuspid regurgitation,” the cardiologist said.
Moreover, the current American College of Cardiology/American Heart Association guidelines on valvular heart disease don’t address ISTR, either. Physicians who attempt to apply the guidelines in deciding when to refer a patient with ISTR for surgery will oftentimes find they’ve waited too long and the patient has started to develop end-stage disease, according to Dr. Nishimura.
And he should know: He was lead author of the current ACC/AHA guidelines (J Am Coll Cardiol. 2014 Jun 10;63[22]:2438-88).
Decades ago, Eugene Braunwald, MD, of Harvard Medical School, Boston, famously called the tricuspid valve “the forgotten valve.” The history of the Snowmass winter cardiology conference bears that out. During 2007-2017, the conference featured an average of 5.4 sessions per year on aortic valve disease, 4.5 sessions per year on mitral valve disease, and not a single session on tricuspid valve disease. But the tricuspid valve is forgotten no longer, Dr. Nishimura emphasized.
How ISTR presents
The affected patient has a history of either longstanding atrial fibrillation or a permanent pacemaker or ICD.
“This is something that 4 or 5 years ago people said didn’t exist. Our pacemaker people told me, ‘Nah, you can never get tricuspid regurgitation from our leads.’ Now it’s one of the leading causes of tricuspid regurgitation going to operation,” said Dr. Nishimura.
The presenting symptoms of ISTR are typically ascites, edema, and shortness of breath.
“Why should patients with a right heart problem get dyspnea? It turns out that when the right ventricle dilates it pushes the septum in, so the effective operative compliance of the left ventricle decreases and you actually see the pulmonary artery wedge pressure go up,” he explained.
On physical examination, the patient will have elevated jugular venous pressure with large V waves.
“This is a clue that something is going on. The patient will have neck veins jumping up to her ear lobes. The ear lobes are going to wiggle with every heart beat – boom, boom, boom. If you see that, you start to figure out what’s going on. You need nothing else,” Dr. Nishimura said.
The patient will likely also have a pulsatile enlarged liver and, even though this is valve disease, a murmur that’s either soft or inaudible.
Echocardiographic diagnosis
Echocardiography will show a dilated right ventricle and right atrium, a dilated inferior vena cava, and a normal left ventricle with no pulmonary hypertension. The classic sign of ISTR on continuous wave Doppler echocardiography is a dagger-shaped tricuspid regurgitation peak velocity signal of less than 2.5 meters/sec, which indicates the absence of pulmonary hypertension. This dagger shape occurs because the right atrial pressure equalizes the right ventricular pressure.
It’s also important to point the echo probe at the hepatic veins to spot another echocardiographic hallmark of ISTR: systolic reversal.
A thorough echo exam makes hemodynamic catheterization unnecessary in these patients, Dr. Nishimura added.
When to refer for tricuspid valve repair or replacement
The clinical course of ISTR is progressive, often rapidly so. It starts with elevated jugular venous pressure, then comes fatigue and shortness of breath, moving on to ascites and edema, then finally cirrhosis and renal failure. It’s a vicious cycle in which tricuspid regurgitation begets annular dilation, which causes chordal stretching and worsening tricuspid regurgitation, leading to further annular dilation.
Patients typically aren’t referred for surgery – and may not even present to a physician – until they’ve already developed end-stage disease. That’s probably why the outcomes of surgery for ISTR are so poor. Dr. Nishimura was senior investigator of a recent retrospective study of national trends and outcomes for ISTR surgery based on the National Inpatient Sample. The number of operations increased by 250% during a recent 10-year period, but the surgery is still rare: 290 operations in 2004, climbing to 780 nationwide in 2013.
In-hospital mortality remained steady over time at 8.8%, far higher than rates of in-hospital mortality for surgery for aortic and mitral valve disease, which today stand at 1%-2% or less. The adjusted risk of in-hospital mortality for tricuspid valve replacement in patients with ISTR was 1.9-fold greater than for valve repair (J Am Coll Cardiol. 2017 Dec 19;70[24]:2953-60).
“I think the reason the operative risk of valve surgery for ISTR is so high is that we’re waiting until patients have end-stage disease,” Dr. Nishimura said.
Indeed, he recommends referral for surgery as soon as the echocardiographic diagnosis of ISTR is made in a patient with huge neck veins.
“This will probably take the operative risk down by going to a time when the right ventricle can still recover,” he added.
In a patient with ISTR and pacemaker or defibrillator leads crossing the valve, tricuspid valve repair or replacement should be accompanied by exteriorization of the leads.
Dr. Nishimura reported having no financial conflicts of interest regarding his presentation.
SNOWMASS, COLO. – that’s treatable, provided affected patients are referred for surgery before the clinical course progresses to intractable right heart disease with cirrhosis and liver failure, Rick A. Nishimura, MD, said at the Annual Cardiovascular Conference at Snowmass.
“This is an emerging disease that you’re all going to see in your practices this year. You’ve got to know what to do with these patients. Get to them early,” urged Dr. Nishimura, professor of cardiovascular sciences and hypertension at the Mayo Clinic in Rochester, Minn.
The medical textbooks don’t discuss isolated severe tricuspid regurgitation (ISTR) or its etiology. ISTR is a disorder of progressive right ventricular dilation and dysfunction whose etiology involves either longstanding atrial fibrillation or valvular disruption due to interference from a crossing lead of a permanent pacemaker or implantable cardioverter defibrillator.
“This is something different. These patients have a normal left heart and left heart valves and normal pressures, with no pulmonary hypertension. So it doesn’t fit into any of the textbook categories of tricuspid regurgitation,” the cardiologist said.
Moreover, the current American College of Cardiology/American Heart Association guidelines on valvular heart disease don’t address ISTR, either. Physicians who attempt to apply the guidelines in deciding when to refer a patient with ISTR for surgery will oftentimes find they’ve waited too long and the patient has started to develop end-stage disease, according to Dr. Nishimura.
And he should know: He was lead author of the current ACC/AHA guidelines (J Am Coll Cardiol. 2014 Jun 10;63[22]:2438-88).
Decades ago, Eugene Braunwald, MD, of Harvard Medical School, Boston, famously called the tricuspid valve “the forgotten valve.” The history of the Snowmass winter cardiology conference bears that out. During 2007-2017, the conference featured an average of 5.4 sessions per year on aortic valve disease, 4.5 sessions per year on mitral valve disease, and not a single session on tricuspid valve disease. But the tricuspid valve is forgotten no longer, Dr. Nishimura emphasized.
How ISTR presents
The affected patient has a history of either longstanding atrial fibrillation or a permanent pacemaker or ICD.
“This is something that 4 or 5 years ago people said didn’t exist. Our pacemaker people told me, ‘Nah, you can never get tricuspid regurgitation from our leads.’ Now it’s one of the leading causes of tricuspid regurgitation going to operation,” said Dr. Nishimura.
The presenting symptoms of ISTR are typically ascites, edema, and shortness of breath.
“Why should patients with a right heart problem get dyspnea? It turns out that when the right ventricle dilates it pushes the septum in, so the effective operative compliance of the left ventricle decreases and you actually see the pulmonary artery wedge pressure go up,” he explained.
On physical examination, the patient will have elevated jugular venous pressure with large V waves.
“This is a clue that something is going on. The patient will have neck veins jumping up to her ear lobes. The ear lobes are going to wiggle with every heart beat – boom, boom, boom. If you see that, you start to figure out what’s going on. You need nothing else,” Dr. Nishimura said.
The patient will likely also have a pulsatile enlarged liver and, even though this is valve disease, a murmur that’s either soft or inaudible.
Echocardiographic diagnosis
Echocardiography will show a dilated right ventricle and right atrium, a dilated inferior vena cava, and a normal left ventricle with no pulmonary hypertension. The classic sign of ISTR on continuous wave Doppler echocardiography is a dagger-shaped tricuspid regurgitation peak velocity signal of less than 2.5 meters/sec, which indicates the absence of pulmonary hypertension. This dagger shape occurs because the right atrial pressure equalizes the right ventricular pressure.
It’s also important to point the echo probe at the hepatic veins to spot another echocardiographic hallmark of ISTR: systolic reversal.
A thorough echo exam makes hemodynamic catheterization unnecessary in these patients, Dr. Nishimura added.
When to refer for tricuspid valve repair or replacement
The clinical course of ISTR is progressive, often rapidly so. It starts with elevated jugular venous pressure, then comes fatigue and shortness of breath, moving on to ascites and edema, then finally cirrhosis and renal failure. It’s a vicious cycle in which tricuspid regurgitation begets annular dilation, which causes chordal stretching and worsening tricuspid regurgitation, leading to further annular dilation.
Patients typically aren’t referred for surgery – and may not even present to a physician – until they’ve already developed end-stage disease. That’s probably why the outcomes of surgery for ISTR are so poor. Dr. Nishimura was senior investigator of a recent retrospective study of national trends and outcomes for ISTR surgery based on the National Inpatient Sample. The number of operations increased by 250% during a recent 10-year period, but the surgery is still rare: 290 operations in 2004, climbing to 780 nationwide in 2013.
In-hospital mortality remained steady over time at 8.8%, far higher than rates of in-hospital mortality for surgery for aortic and mitral valve disease, which today stand at 1%-2% or less. The adjusted risk of in-hospital mortality for tricuspid valve replacement in patients with ISTR was 1.9-fold greater than for valve repair (J Am Coll Cardiol. 2017 Dec 19;70[24]:2953-60).
“I think the reason the operative risk of valve surgery for ISTR is so high is that we’re waiting until patients have end-stage disease,” Dr. Nishimura said.
Indeed, he recommends referral for surgery as soon as the echocardiographic diagnosis of ISTR is made in a patient with huge neck veins.
“This will probably take the operative risk down by going to a time when the right ventricle can still recover,” he added.
In a patient with ISTR and pacemaker or defibrillator leads crossing the valve, tricuspid valve repair or replacement should be accompanied by exteriorization of the leads.
Dr. Nishimura reported having no financial conflicts of interest regarding his presentation.
SNOWMASS, COLO. – that’s treatable, provided affected patients are referred for surgery before the clinical course progresses to intractable right heart disease with cirrhosis and liver failure, Rick A. Nishimura, MD, said at the Annual Cardiovascular Conference at Snowmass.
“This is an emerging disease that you’re all going to see in your practices this year. You’ve got to know what to do with these patients. Get to them early,” urged Dr. Nishimura, professor of cardiovascular sciences and hypertension at the Mayo Clinic in Rochester, Minn.
The medical textbooks don’t discuss isolated severe tricuspid regurgitation (ISTR) or its etiology. ISTR is a disorder of progressive right ventricular dilation and dysfunction whose etiology involves either longstanding atrial fibrillation or valvular disruption due to interference from a crossing lead of a permanent pacemaker or implantable cardioverter defibrillator.
“This is something different. These patients have a normal left heart and left heart valves and normal pressures, with no pulmonary hypertension. So it doesn’t fit into any of the textbook categories of tricuspid regurgitation,” the cardiologist said.
Moreover, the current American College of Cardiology/American Heart Association guidelines on valvular heart disease don’t address ISTR, either. Physicians who attempt to apply the guidelines in deciding when to refer a patient with ISTR for surgery will oftentimes find they’ve waited too long and the patient has started to develop end-stage disease, according to Dr. Nishimura.
And he should know: He was lead author of the current ACC/AHA guidelines (J Am Coll Cardiol. 2014 Jun 10;63[22]:2438-88).
Decades ago, Eugene Braunwald, MD, of Harvard Medical School, Boston, famously called the tricuspid valve “the forgotten valve.” The history of the Snowmass winter cardiology conference bears that out. During 2007-2017, the conference featured an average of 5.4 sessions per year on aortic valve disease, 4.5 sessions per year on mitral valve disease, and not a single session on tricuspid valve disease. But the tricuspid valve is forgotten no longer, Dr. Nishimura emphasized.
How ISTR presents
The affected patient has a history of either longstanding atrial fibrillation or a permanent pacemaker or ICD.
“This is something that 4 or 5 years ago people said didn’t exist. Our pacemaker people told me, ‘Nah, you can never get tricuspid regurgitation from our leads.’ Now it’s one of the leading causes of tricuspid regurgitation going to operation,” said Dr. Nishimura.
The presenting symptoms of ISTR are typically ascites, edema, and shortness of breath.
“Why should patients with a right heart problem get dyspnea? It turns out that when the right ventricle dilates it pushes the septum in, so the effective operative compliance of the left ventricle decreases and you actually see the pulmonary artery wedge pressure go up,” he explained.
On physical examination, the patient will have elevated jugular venous pressure with large V waves.
“This is a clue that something is going on. The patient will have neck veins jumping up to her ear lobes. The ear lobes are going to wiggle with every heart beat – boom, boom, boom. If you see that, you start to figure out what’s going on. You need nothing else,” Dr. Nishimura said.
The patient will likely also have a pulsatile enlarged liver and, even though this is valve disease, a murmur that’s either soft or inaudible.
Echocardiographic diagnosis
Echocardiography will show a dilated right ventricle and right atrium, a dilated inferior vena cava, and a normal left ventricle with no pulmonary hypertension. The classic sign of ISTR on continuous wave Doppler echocardiography is a dagger-shaped tricuspid regurgitation peak velocity signal of less than 2.5 meters/sec, which indicates the absence of pulmonary hypertension. This dagger shape occurs because the right atrial pressure equalizes the right ventricular pressure.
It’s also important to point the echo probe at the hepatic veins to spot another echocardiographic hallmark of ISTR: systolic reversal.
A thorough echo exam makes hemodynamic catheterization unnecessary in these patients, Dr. Nishimura added.
When to refer for tricuspid valve repair or replacement
The clinical course of ISTR is progressive, often rapidly so. It starts with elevated jugular venous pressure, then comes fatigue and shortness of breath, moving on to ascites and edema, then finally cirrhosis and renal failure. It’s a vicious cycle in which tricuspid regurgitation begets annular dilation, which causes chordal stretching and worsening tricuspid regurgitation, leading to further annular dilation.
Patients typically aren’t referred for surgery – and may not even present to a physician – until they’ve already developed end-stage disease. That’s probably why the outcomes of surgery for ISTR are so poor. Dr. Nishimura was senior investigator of a recent retrospective study of national trends and outcomes for ISTR surgery based on the National Inpatient Sample. The number of operations increased by 250% during a recent 10-year period, but the surgery is still rare: 290 operations in 2004, climbing to 780 nationwide in 2013.
In-hospital mortality remained steady over time at 8.8%, far higher than rates of in-hospital mortality for surgery for aortic and mitral valve disease, which today stand at 1%-2% or less. The adjusted risk of in-hospital mortality for tricuspid valve replacement in patients with ISTR was 1.9-fold greater than for valve repair (J Am Coll Cardiol. 2017 Dec 19;70[24]:2953-60).
“I think the reason the operative risk of valve surgery for ISTR is so high is that we’re waiting until patients have end-stage disease,” Dr. Nishimura said.
Indeed, he recommends referral for surgery as soon as the echocardiographic diagnosis of ISTR is made in a patient with huge neck veins.
“This will probably take the operative risk down by going to a time when the right ventricle can still recover,” he added.
In a patient with ISTR and pacemaker or defibrillator leads crossing the valve, tricuspid valve repair or replacement should be accompanied by exteriorization of the leads.
Dr. Nishimura reported having no financial conflicts of interest regarding his presentation.
EXPERT ANALYSIS FROM THE CARDIOVASCULAR CONFERENCE AT SNOWMASS
Pilot Inpatient Pain Pharmacist Consult Service at the West Palm Beach VA Medical Center
The term pain refers to unpleasant sensory, emotional experiences associated with actual or potential tissue damage and is described in terms of such damage.1 Acute pain from neurophysiologic responses to noxious stimuli resolves upon tissue healing or stimuli removal (eg, 3-6 months); however, chronic pain lingers beyond the expected time course of the acute injury and repair process.1,2 Despite pain management advances, the under- or overtreatment of pain for different patient populations (eg, cancer and noncancer) remains an important concern.3,4
Hospitals have focused on optimizing inpatient pain management, because uncontrolled pain remains the most common reason for readmissions the first week postsurgery.5 The safe use of opioids (prescription, illicit synthetic, or heroin) poses major challenges and raises significant concerns. Rates of opioid-related hospital admissions have increased by 42% since 2009, and total overdose deaths reached a new high of 47,055 in 2014, including 28,647 (61%) from opioids.6
Opioids rank among the medications most often associated with serious adverse events (AEs), including respiratory depression and death.7 In response, the Joint Commission recommends patient assessments for opioid-related AEs, technology to monitor opioid prescribing, pharmacist consultation for opioid conversions and route of administration changes, provider education about risks of opioids, and risk screening tools for opioid-related oversedation and respiratory depression.7 Treatment guidelines strive to minimize the impact of acute pain by offering a scientific basis for practice, but evidence suggests a lack of suitable pain programs.7 Increases in opioid prescribing along with clinical guidelines and state laws recommending specialty pain service referrals for patients on high-dose opioids, have increased demand for competent pain clinicians.8
The expertise of a clinical pharmacy specialists (CPS) can help refine ineffective and potentially harmful pain medication therapy in complex patient cases. Existing literature outlines the various benefits of pharmacist participation in collaborative pain services for cancer and noncancer pain, as well as cases involving substance abuse.9-13 Various articles support pharmacists’ role as an educator and team member who can add valuable, trustworthy clinical knowledge that enhances clinical encounters and guides protocol/policy development.12,13 These efforts have improved patient satisfaction and encouraged physicians and nurses to proactively seek pharmacists’ advice for difficult cases.9
Frequent communication with interdisciplinary teams have helped considerably in establishing clinical pharmacy services that benefit patient care and offer sources of professional accomplishment.10,11 For example, pharmacists at Kaweah Delta Medical Center in Visalia, CA launched an innovative pain program that encompassed consultations and opioid stewardship, which demonstrated that pharmacists can improve patient outcomes in the front lines of pain management.14 Pain CPSs have advanced knowledge of pharmacokinetics, pharmacodynamics, and therapeutics to promote safe and effective analgesic use, as well as to identify opioid use disorders. Evidence suggests that pharmacists’ presence on interdisciplinary pain teams improves outcomes by optimizing medication selection, improving adherence, and preventing AEs.8
Following the plan-do-study-act model for quality improvement (QI), this project hoped to expand current pain programs at the West Palm Beach VAMC (WPBVAMC) by evaluating the feasibility of an inpatient pain pharmacist consult service (IPPCS) at the 301-bed teaching facility, which includes 130 acute/intensive care and 120 nursing/domiciliary beds.15 Staff provide primary- and secondary-level care to veterans in 7 counties along Florida’s southeastern coast.
In 2009, the WPBVAMC PGY-2 Pain Management and Palliative Care Program became the VA’s first accredited pain pharmacy residency. Residents train with the Physical Medicine & Rehabilitation (PMR) and Chronic Pain Management departments, which provide outpatient services from 7 pain physicians, a pain psychologist, registered nurse, chiropractor, acupuncturist, physical/occupational therapy (PT/OT), and 3 pain/palliative care CPSs.
The WPBVAMC had established interdisciplinary outpatient chronic pain clinic (OCPC) physician- and pharmacist-run services along with a pain CPS electronic consult (e-consult) program. However, no formal mechanisms for inpatient pain consultations existed. Prior to the IPPCS outlined in this study, OCPC practitioners, including 2 pain CPSs, managed impromptu inpatient pain issues as “curbside consultations” along with usual day-to-day clinic duties.
The OCPC, PMR, and Clinical Pharmacy administration recognized the need for more clinical support to manage complex analgesic issues in inpatient veterans, as these patients often have acute pain with underlying chronic pain syndromes. In a national survey, veterans were significantly more likely than were nonveterans to report painful health conditions (65.5% vs 56.4%) and to classify their pain as severe (9.1% vs 6.3%).16 The WPBVAMC administration concluded that an IPPCS would offer a more efficient means of handling such cases. The IPPCS would formally streamline inpatient pain consults, enabling CPSs to thoroughly evaluate pain-related issues to propose evidence-based recommendations.
The primary objective of this QI project was to assess the IPPCS implementation as part of multimodal care to satisfy unmet patient care needs at the WPBVAMC. Secondary objectives for program feasibility included identifying the volume and type of pain consults, categorizing pharmacist interventions, classifying providers’ satisfaction, and determining types of responses to pharmacists’ medication recommendations.
Methods
This QI project ascertained the feasibility of the IPPCS by evaluating all consults obtained during the pilot period from November 2, 2015 through May 6, 2016. The IPPCS was accessible Monday through Friday during normal business hours. Goal turnaround time for consult completion was 24 to 72 hours, given the lack of coverage on holidays and weekends. The target population included veterans hospitalized at the WPBVAMC inpatient ward or nursing home with uncontrolled pain on IV and/or oral analgesic medications. All IPPCS consults submitted during the pilot period were included in the sample.
The WPBVAMC Scientific Advisory Committee (SAC) approved this QI program prior to initiation. Following supervisory support from the OCPC, PMR, and Clinical Pharmacy departments, hospital technologists assisted in creating a consult link in the Computerized Patient Record System (CPRS), which allowed providers to submit IPPCS requests for specific patients efficiently. Consults were categorized as postoperative pain, acute or chronic pain, malignant pain, or end-of-life pain. Inpatient providers could enter requests for assistance with 1 or more of the following: opioid dose conversions, opioid taper/titration schedules, general opioid treatment recommendations, or nonopioid/adjuvant recommendations.
The Medical Records Committee approved a customized CPRS subjective-objective-assessment-recommendations (SOAR) note template, which helped standardize the pain CPS documentation. To promote consult requests and interdisciplinary collaboration, inpatient clinicians received education about the IPPCS at respective meetings (eg, General Medicine staff and Clinical Pharmacy meetings).
All CPSs involved in this project were residency-trained in direct patient care, including pain and palliative care, and maintained national board certification as pharmacotherapy specialists. Their role included reviewing patients’ electronic medical records, conducting face-to-face pain assessments, completing opioid risk assessments, evaluating analgesic regimen appropriateness, reviewing medication adherence, completing pain medication reconciliation, querying the Florida Prescription Drug Monitoring Program (PDMP), interpreting urine drug testing (UDT), and delivering provider/patient/caregiver education. Parameters used to determine the appropriateness of analgesic regimens included, but were not limited to:
- Use of oral instead of IV medications if oral dosing was feasible/possible/appropriate;
- Dose and adjustments per renal/hepatic function;
- Adequate treatment duration and titration;
- No therapeutic drug class duplications;
- Medication tolerability (eg, allergies, AEs, drug interactions); and
- Opioid risk assessment per Opioid Risk Tool (ORT) score and medical history.
Consulting providers clarified patients’ pain diagnoses prior to pharmacy consultations.
After face-to-face patient interviews, the inpatient pain CPS prepared pain management recommendations, including nonopioid/adjuvant pain medications and/or opioid dose adjustments. The IPPCS also collaborated with pain physicians for intervention procedures, nonpharmacologic recommendations, and for more complex patients who may have required additional imaging or detailed physical evaluations. Pain CPSs documented CPRS notes with the SOAR template and discussed all recommendations with appropriate inpatient teams.
Respective providers received questionnaires hosted on SurveyMonkey.com (San Mateo, CA) to gauge their satisfaction with the IPPCS at the end of the pilot period, which helped determine program utility. Data collected for the pilot included patient demographics; patient admission diagnosis; consulting inpatient service; type of pain and reason for IPPCS request; total morphine equivalent daily dose (MEDD); pertinent past medical history (ie, sleep apnea, psychiatric comorbidities, or substance use disorder [SUD]); ORT score; patients’ reported average pain severity on the 10-point Numeric Pain Rating Scale (NPRS); number of requests submitted; medications discontinued, initiated, or dose increased/decreased; and number of pharmacist recommendations, including number accepted by providers. The ORT is a 5-item questionnaire used to determine risk of opioid-related aberrant behaviors in adults to help discriminate between low-risk and high-risk individuals (Table 1).17 
Descriptive statistics were used to evaluate the results, and a Likert scale was used to evaluate responses the from provider satisfaction questionnaires. The IPPCS collected and organized the data using Microsoft Excel (Redmond, WA).
Results
By the end of the pilot period in May 2016, the IPPCS had received 100 consult requests and completed 81% (Figure). The remaining consults included 11% forwarded to other disciplines. The service discontinued 8% of the requests, given patients’ hospital discharge prior to IPPCS review. 
Baseline patient data are outlined in Tables 2, 3, 4, and 5. For each of the 100 consults, providers could select more than 1 reason for the request. The nonopioid/adjuvant treatment recommendations were the most common at 49% (62/128). Patients could have more than 1 pertinent medical comorbidity, with psychiatric illnesses the most prevalent at 68% (133/197). A mean ORT score of 8.1 indicated a high risk for opioid-related aberrant behavior. Overall, half the patients (37/73) were high risk, 25% (18/73) were medium risk (ORT 4-7), and 25% (18/73) were low risk (ORT 0-3). Patients’ reported average pain was often severe (NPRS 7-10) at 54% (40/74) or moderate (NPRS 4-6) at 39% (29/74). 
The IPPCS recommended various medications for initiation, discontinuation, or dosage changes (Table 6). For example, the IPPCS recommended initiation of topical agents in 38% (48/128) of cases. The inpatient pain CPS offered opioid initiation in 17% (22/128) of cases, with immediate-release oral morphine as the most predominant. Notably, opioids remained the most common medications suggested for discontinuation at 74% (38/51), including 47% (18/38) for IV hydromorphone. Dose titration recommendations mainly included anticonvulsants at 33% (16/48), and most dose reductions involved opioids at 78% (7/9), namely, oxycodone/acetaminophen and IV hydromorphone. 
Providers accepted 76% (179/234) of IPPCS pharmacist medication recommendations. The most common included initiation/optimization of adjuvant therapy (eg, anticonvulsants, serotonin-norepinephrine reuptake inhibitors [SNRIs], and topical agents) at 46% (83/179), followed by opioid discontinuation (eg, IV hydromorphone) at 22% (40/179). Although this project primarily tracked medication interventions, examples of accepted nonpharmacologic recommendations included UDT and referrals to other programs (eg, pain psychology, substance abuse, mental health, acupuncture, chiropractor, PT/OT/PMR, and interventional pain management), which received support from each respective discipline. Declined pharmacologic recommendations mostly included topicals (eg, lidocaine, trolamine, and capsaicin cream) at 35% (19/55). However, findings also show that providers implemented 100% of medication recommendations in whole for 58% (47/81) of consults.
Likert scale satisfaction questionnaires offered insight into providers’ perception of the IPPCS (Table 7). One provider felt “neutral” about the consult submission process, given the time needed to complete the CPRS requests, but all other providers “agreed” or “strongly agreed” that the IPPCS was user-friendly. More importantly, 100% (15/15) “agreed” or “strongly agreed” that the inpatient pain CPS answered consults promptly with reasonable, evidence-based recommendations. All respondents declared that they would recommend the IPPCS to other practitioners and felt comfortable entering requests for future patients. 
Discussion
The IPPCS achieved a total of 100 consults, which served as the sample for the pilot program. With support from the OCPC, PMR, and Clinical Pharmacy Department Administration, the IPPCS operated from November 2, 2015 through May 6, 2016. Results suggested that this new service could assist in managing inpatient pain issues in collaboration with inpatient multidisciplinary teams.
The most popular reason for IPPCS consults was acute on chronic pain. Given national efforts to improve opioid prescribing through the VA Opioid Safety Initiative (OSI) and the 2016 CDC Guideline for Opioid Prescribing, most pain consults requested nonopioid/adjuvant recommendations.18,19 Despite the wide MEDD range in this sample, the median/mean generally remained below recommended limits per current guidelines.18,19 However, the small sample size and lack of patient diversity (mostly white male veterans) limited the generalizability to non-VA medical facilities. Veterans often experienced both chronic pain and psychiatric disturbances, which explained the significant number of underlying mental health comorbidities observed. This affirmed the close interrelationship between pain and psychiatric issues described in the literature.20
Providers’ acceptance of pharmacologic and nonpharmacologic treatment modalities supported a comprehensive, multidisciplinary, and biopsychosocial approach to effective analgesic management. During this pilot, the most common pharmacy medication recommendations, namely, discontinuation of inappropriate opioids (eg, IV hydromorphone in patients who are controlled on and/or able to tolerate oral medications) and dose titration of adjuvant medications (eg, anticonvulsants for neuropathic pain), revealed that the IPPCS provided needed expertise and alternatives for complex pain patients. The IPPCS was well received, as inpatient providers accepted and implemented a large proportion of pharmacist recommendations. Despite risks of bias with a nonvalidated questionnaire, providers offered positive feedback. In the future, distributing satisfaction evaluations to patients also would provide more insight into how others perceived the IPPCS.
Limitations
Reasons for unaccepted recommendations included perceived limited effectiveness and/or feasibility of topical agents for acute pain, as providers seemed to favor systemic therapy for supposedly more immediate analgesia. Prescriber preference may explain why inpatient teams sometimes declined adjuvant therapy recommendations. However, the 2016 American Pain Society Guidelines on the Management of Postoperative Pain support a multimodal approach and confirm that adjuvants can reduce patients’ opioid requirements.21
Consulting teams did not execute some opioid recommendations, which may be due to various factors, including patient-related or provider-related factors in the inpatient vs outpatient setting. Lack of retrospective analysis for comparison of results pre- and post-IPPCS implementation also limited the outcomes. However, this project was piloted as a QI initiative after providers identified significant needs for inpatient pain management at the WPBVAMC. No retrospective analysis was undertaken, as this project analyzed only responses during the pilot program.
Other obstacles of the IPPCS included request appropriateness and triaging. The inpatient pain CPS deferred management of some consults to other disciplines (eg, gastroenterology) for more appropriate care. The IPPCS deferred certain cases of acute pancreatic pain or generalized abdominal pain for further workup to address patients’ underlying issues. The inpatient pain CPS relayed pertinent information regarding appropriate consults to inpatient teams. In the future, developing more specific inclusion/exclusion criteria and delivering provider education about proper IPPCS requests may resolve this issue.
Challenges with pain consults from inpatient psychiatry stemmed from patients’ skepticism and unwillingness to accept nonopioid/adjuvant therapies. Additionally, comorbid psychiatric disorders are often associated with SUDs and potentially opioid-related aberrant behavior. More than 40% of opioid-dependent individuals have comorbid psychiatric disorders, especially depression, anxiety, and bipolar disorder.22 Poorly-managed pain also drives SUD, as 80% of these patients illegally obtain prescription opioids. Thus, undertreatment of pain may push individuals to secure pain medications from illegal/illicit sources to achieve analgesia.23 Following pain physician consultation, the IPPCS continued inpatient opioids for 12% (10/81) of patients with a SUD history, including 5 with postoperative pain or other acute processes, since patients were kept in a monitored health care environment. The remaining included 4 with malignant pain and 1 with end-of-life pain. Overall, the IPPCS recommended that inpatient teams discharge these patients on as little opioids as possible, as well as to make referrals to substance abuse programs when necessary. Effective pain management of patients with aberrant behavior requires a comprehensive interdisciplinary team approach. To mitigate risk, effectively treat pain, and maintain patient safety, clinicians must recognize biologic, chemical, social, and psychiatric aspects of substance abuse.21
Another limitation during this pilot was an inability to promptly assess the impact of recommendations, given limited opportunities to reevaluate patients. In the future, more dedicated time for the inpatient pain CPSs to respond to consults may allow for better follow-up rather than initial consults only. Providers sometimes discharged patients within 24 hours of submitting consults as well, which left no time for the inpatient pain CPS consultation. However, the IPPCS forwarded appropriate requests to pain CPS e-consult services for chart review recommendations. Encouraging providers to submit consults earlier in patients’ hospital admissions may help reduce the number of incomplete IPPCS requests. Although expanding service hours would require more dedicated CPS staffing resources, it is another option for quicker consult completion and prompt follow-up.
Future Directions
Future efforts to expand this project include ensuring patient safety through judicious opioid use. Smooth transitions of care will particularly help to improve the quality of pain management. Current WPBVAMC policies stated that the primary care provider (PCP) alone must agree to continue prescribing outpatient analgesic medications, including opioids, prescribed from the OCPC once patients return to Primary Care. Continued provider education would ideally promote efficient utilization of the IPPCS and OCPC.
The pain pharmacy SOAR note template also could undergo additional edits/revisions, including the addition of opioid overdose risk assessments. For improved documentation and standardization, the template could autopopulate patient-specific information when the inpatient pain CPS chooses the designated note title. The IPPCS also hoped to streamline the CPRS consult link for more convenience and ease of use. Ultimately, the IPPCS wished to provide ongoing provider education, inpatient opioid therapy, and other topics upon request.
Conclusion
The IPPCS received positive provider feedback and collected 100 consults (averaging 4 per week) during the 6-month pilot QI project. Most consults were for acute or chronic pain and requested nonopioid/adjuvant recommendations. The new service intended to fulfill unmet needs at the WPBVAMC by expanding the facility’s current pain programs. Prescribers reported a high level of satisfaction and a willingness to not only refer other clinicians to the program, but also continue using the consult. Providers unanimously agreed that the pain CPS provided reasonable, evidence-based recommendations. This project demonstrated that the IPPCS can aid in meeting new demands amid the challenging landscape of pain practice.
1. D’Arcy Y. Treating acute pain in the hospitalized patient. Nurse Pract. 2012;37(8):22-30.
2. Marks AD, Rodgers PE. Diagnosis and management of acute pain in the hospitalized patient. Am J Med. 2014;3(3):e396-e408.
3. Paice JA, Von Roenn JH. Under- or overtreatment of pain in the patient with cancer: how to achieve proper balance. J Clin Oncol. 2014;32(16):1721-1726.
4. Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening trends in the management and treatment of back pain. JAMA Intern Med. 2013;173(17):1573-1581.
5. Palomano RC, Rathmell JP, Krenzischek DA, Dunwoody CJ. Emerging trends and new approaches to acute pain management. J Perianesth Nurs. 2008;23(suppl 1):S43-S53.
6. U.S. Department of Health & Human Services, Office of the Surgeon General. Facing addiction in America: the surgeon general’s report on alcohol, drugs, and health, executive summary. https://addiction.surgeongeneral.gov/executive-summary.pdf. Published November 2016. Accessed November 1, 2017.
7. Bagian JP, Cohen M, Barnsteiner JH, et al. Safe use of opioids in hospitals. Sentinel Event Alert. 2012;49:1-5.
8. Atkinson TJ, Gulum AH, Forkum WG. The future of pain pharmacy: directed by need. Integrated Pharm Res Pract. 2016;2016(5):33-42.
9. Lothian ST, Fotis MA, Von Gutten CF, et al. Cancer pain management through a pharmacist-based analgesic dosing service. Am J Health Syst Pharm. 1999;56:1119-1125.
10. Lynn MA. Pharmacist interventions in pain management. Am J Health Syst Pharm. 2004;61(14):1487-1489.
11. Strickland JM, Huskey A, Brushwood DB. Pharmacist-physician collaboration in pain management practice. J Opioid Manag. 2007;3(6):295-301.
12. Fan T and Elgourt T. Pain management pharmacy service in a community hospital. Am J Health Syst Pharm. 2008;65(16):1560-1565.
13. Andrews LB, Bridgeman MB, Dalal KS, et al. Implementation of a pharmacist-directed pain management consultation service for hospitalised adults with a history of substance abuse. Int J Clin Pract. 2013;67(12):1342-1349.
14. Poirier RH, Brown CS, Garcia YT, Gann NY, Sandoval RA, McNulty JR. Implementation of a pharmacist directed pain management service in the inpatient setting. http://www.ashpadvantage.com/bestpractices/2014_papers/Kaweah-Delta.htm. Published 2014. Accessed November 1, 2017.
15. Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nded. San Francisco, CA: Jossey-Bass; 2009.
16. Nahin, RL. Severe pain in veterans: the effect of age and sex, and comparisons with the general population. J Pain. 2017;18(3):247-254.
17. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the opioid risk tool. Pain Med. 2005;6(6):432-442.
18. Nazario M. Opioid therapy risk management: the VA opioid safety and naloxone distribution initiatives. http://jfpsmeeting.pharmacist.com/sites/default/files/slides/Opioid%20Therapy%20Risk%20Management.pdf. Published October 15, 2015. Accessed November 1, 2017.
19. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. MMWR Rep. 2016;65(1):1-49.
20. Outcalt SD, Kroenke K, Krebs EE, et al. Chronic pain and comorbid mental health conditions: independent associations of posttraumatic stress disorder and depression with pain, disability, and quality of life. J Behav Med. 2015;38:535.
21. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131-157.
22. NIDA/SAMHSA Blending Initiative. https://www.drugabuse.gov/nidasamhsa-blending-initiative. Updated November 2015. Accessed November 1, 2017.
23. Alford DP, German JS, Samet JH, Cheng DM, Lloyd-Travaglini CA, Saitz R. Primary care patients with drug use report chronic pain and self-medicate with alcohol and other drugs. J Gen Intern Med. 2016;31(5):486-491.
The term pain refers to unpleasant sensory, emotional experiences associated with actual or potential tissue damage and is described in terms of such damage.1 Acute pain from neurophysiologic responses to noxious stimuli resolves upon tissue healing or stimuli removal (eg, 3-6 months); however, chronic pain lingers beyond the expected time course of the acute injury and repair process.1,2 Despite pain management advances, the under- or overtreatment of pain for different patient populations (eg, cancer and noncancer) remains an important concern.3,4
Hospitals have focused on optimizing inpatient pain management, because uncontrolled pain remains the most common reason for readmissions the first week postsurgery.5 The safe use of opioids (prescription, illicit synthetic, or heroin) poses major challenges and raises significant concerns. Rates of opioid-related hospital admissions have increased by 42% since 2009, and total overdose deaths reached a new high of 47,055 in 2014, including 28,647 (61%) from opioids.6
Opioids rank among the medications most often associated with serious adverse events (AEs), including respiratory depression and death.7 In response, the Joint Commission recommends patient assessments for opioid-related AEs, technology to monitor opioid prescribing, pharmacist consultation for opioid conversions and route of administration changes, provider education about risks of opioids, and risk screening tools for opioid-related oversedation and respiratory depression.7 Treatment guidelines strive to minimize the impact of acute pain by offering a scientific basis for practice, but evidence suggests a lack of suitable pain programs.7 Increases in opioid prescribing along with clinical guidelines and state laws recommending specialty pain service referrals for patients on high-dose opioids, have increased demand for competent pain clinicians.8
The expertise of a clinical pharmacy specialists (CPS) can help refine ineffective and potentially harmful pain medication therapy in complex patient cases. Existing literature outlines the various benefits of pharmacist participation in collaborative pain services for cancer and noncancer pain, as well as cases involving substance abuse.9-13 Various articles support pharmacists’ role as an educator and team member who can add valuable, trustworthy clinical knowledge that enhances clinical encounters and guides protocol/policy development.12,13 These efforts have improved patient satisfaction and encouraged physicians and nurses to proactively seek pharmacists’ advice for difficult cases.9
Frequent communication with interdisciplinary teams have helped considerably in establishing clinical pharmacy services that benefit patient care and offer sources of professional accomplishment.10,11 For example, pharmacists at Kaweah Delta Medical Center in Visalia, CA launched an innovative pain program that encompassed consultations and opioid stewardship, which demonstrated that pharmacists can improve patient outcomes in the front lines of pain management.14 Pain CPSs have advanced knowledge of pharmacokinetics, pharmacodynamics, and therapeutics to promote safe and effective analgesic use, as well as to identify opioid use disorders. Evidence suggests that pharmacists’ presence on interdisciplinary pain teams improves outcomes by optimizing medication selection, improving adherence, and preventing AEs.8
Following the plan-do-study-act model for quality improvement (QI), this project hoped to expand current pain programs at the West Palm Beach VAMC (WPBVAMC) by evaluating the feasibility of an inpatient pain pharmacist consult service (IPPCS) at the 301-bed teaching facility, which includes 130 acute/intensive care and 120 nursing/domiciliary beds.15 Staff provide primary- and secondary-level care to veterans in 7 counties along Florida’s southeastern coast.
In 2009, the WPBVAMC PGY-2 Pain Management and Palliative Care Program became the VA’s first accredited pain pharmacy residency. Residents train with the Physical Medicine & Rehabilitation (PMR) and Chronic Pain Management departments, which provide outpatient services from 7 pain physicians, a pain psychologist, registered nurse, chiropractor, acupuncturist, physical/occupational therapy (PT/OT), and 3 pain/palliative care CPSs.
The WPBVAMC had established interdisciplinary outpatient chronic pain clinic (OCPC) physician- and pharmacist-run services along with a pain CPS electronic consult (e-consult) program. However, no formal mechanisms for inpatient pain consultations existed. Prior to the IPPCS outlined in this study, OCPC practitioners, including 2 pain CPSs, managed impromptu inpatient pain issues as “curbside consultations” along with usual day-to-day clinic duties.
The OCPC, PMR, and Clinical Pharmacy administration recognized the need for more clinical support to manage complex analgesic issues in inpatient veterans, as these patients often have acute pain with underlying chronic pain syndromes. In a national survey, veterans were significantly more likely than were nonveterans to report painful health conditions (65.5% vs 56.4%) and to classify their pain as severe (9.1% vs 6.3%).16 The WPBVAMC administration concluded that an IPPCS would offer a more efficient means of handling such cases. The IPPCS would formally streamline inpatient pain consults, enabling CPSs to thoroughly evaluate pain-related issues to propose evidence-based recommendations.
The primary objective of this QI project was to assess the IPPCS implementation as part of multimodal care to satisfy unmet patient care needs at the WPBVAMC. Secondary objectives for program feasibility included identifying the volume and type of pain consults, categorizing pharmacist interventions, classifying providers’ satisfaction, and determining types of responses to pharmacists’ medication recommendations.
Methods
This QI project ascertained the feasibility of the IPPCS by evaluating all consults obtained during the pilot period from November 2, 2015 through May 6, 2016. The IPPCS was accessible Monday through Friday during normal business hours. Goal turnaround time for consult completion was 24 to 72 hours, given the lack of coverage on holidays and weekends. The target population included veterans hospitalized at the WPBVAMC inpatient ward or nursing home with uncontrolled pain on IV and/or oral analgesic medications. All IPPCS consults submitted during the pilot period were included in the sample.
The WPBVAMC Scientific Advisory Committee (SAC) approved this QI program prior to initiation. Following supervisory support from the OCPC, PMR, and Clinical Pharmacy departments, hospital technologists assisted in creating a consult link in the Computerized Patient Record System (CPRS), which allowed providers to submit IPPCS requests for specific patients efficiently. Consults were categorized as postoperative pain, acute or chronic pain, malignant pain, or end-of-life pain. Inpatient providers could enter requests for assistance with 1 or more of the following: opioid dose conversions, opioid taper/titration schedules, general opioid treatment recommendations, or nonopioid/adjuvant recommendations.
The Medical Records Committee approved a customized CPRS subjective-objective-assessment-recommendations (SOAR) note template, which helped standardize the pain CPS documentation. To promote consult requests and interdisciplinary collaboration, inpatient clinicians received education about the IPPCS at respective meetings (eg, General Medicine staff and Clinical Pharmacy meetings).
All CPSs involved in this project were residency-trained in direct patient care, including pain and palliative care, and maintained national board certification as pharmacotherapy specialists. Their role included reviewing patients’ electronic medical records, conducting face-to-face pain assessments, completing opioid risk assessments, evaluating analgesic regimen appropriateness, reviewing medication adherence, completing pain medication reconciliation, querying the Florida Prescription Drug Monitoring Program (PDMP), interpreting urine drug testing (UDT), and delivering provider/patient/caregiver education. Parameters used to determine the appropriateness of analgesic regimens included, but were not limited to:
- Use of oral instead of IV medications if oral dosing was feasible/possible/appropriate;
- Dose and adjustments per renal/hepatic function;
- Adequate treatment duration and titration;
- No therapeutic drug class duplications;
- Medication tolerability (eg, allergies, AEs, drug interactions); and
- Opioid risk assessment per Opioid Risk Tool (ORT) score and medical history.
Consulting providers clarified patients’ pain diagnoses prior to pharmacy consultations.
After face-to-face patient interviews, the inpatient pain CPS prepared pain management recommendations, including nonopioid/adjuvant pain medications and/or opioid dose adjustments. The IPPCS also collaborated with pain physicians for intervention procedures, nonpharmacologic recommendations, and for more complex patients who may have required additional imaging or detailed physical evaluations. Pain CPSs documented CPRS notes with the SOAR template and discussed all recommendations with appropriate inpatient teams.
Respective providers received questionnaires hosted on SurveyMonkey.com (San Mateo, CA) to gauge their satisfaction with the IPPCS at the end of the pilot period, which helped determine program utility. Data collected for the pilot included patient demographics; patient admission diagnosis; consulting inpatient service; type of pain and reason for IPPCS request; total morphine equivalent daily dose (MEDD); pertinent past medical history (ie, sleep apnea, psychiatric comorbidities, or substance use disorder [SUD]); ORT score; patients’ reported average pain severity on the 10-point Numeric Pain Rating Scale (NPRS); number of requests submitted; medications discontinued, initiated, or dose increased/decreased; and number of pharmacist recommendations, including number accepted by providers. The ORT is a 5-item questionnaire used to determine risk of opioid-related aberrant behaviors in adults to help discriminate between low-risk and high-risk individuals (Table 1).17
Descriptive statistics were used to evaluate the results, and a Likert scale was used to evaluate responses the from provider satisfaction questionnaires. The IPPCS collected and organized the data using Microsoft Excel (Redmond, WA).
Results
By the end of the pilot period in May 2016, the IPPCS had received 100 consult requests and completed 81% (Figure). The remaining consults included 11% forwarded to other disciplines. The service discontinued 8% of the requests, given patients’ hospital discharge prior to IPPCS review.
Baseline patient data are outlined in Tables 2, 3, 4, and 5. For each of the 100 consults, providers could select more than 1 reason for the request. The nonopioid/adjuvant treatment recommendations were the most common at 49% (62/128). Patients could have more than 1 pertinent medical comorbidity, with psychiatric illnesses the most prevalent at 68% (133/197). A mean ORT score of 8.1 indicated a high risk for opioid-related aberrant behavior. Overall, half the patients (37/73) were high risk, 25% (18/73) were medium risk (ORT 4-7), and 25% (18/73) were low risk (ORT 0-3). Patients’ reported average pain was often severe (NPRS 7-10) at 54% (40/74) or moderate (NPRS 4-6) at 39% (29/74).
The IPPCS recommended various medications for initiation, discontinuation, or dosage changes (Table 6). For example, the IPPCS recommended initiation of topical agents in 38% (48/128) of cases. The inpatient pain CPS offered opioid initiation in 17% (22/128) of cases, with immediate-release oral morphine as the most predominant. Notably, opioids remained the most common medications suggested for discontinuation at 74% (38/51), including 47% (18/38) for IV hydromorphone. Dose titration recommendations mainly included anticonvulsants at 33% (16/48), and most dose reductions involved opioids at 78% (7/9), namely, oxycodone/acetaminophen and IV hydromorphone.
Providers accepted 76% (179/234) of IPPCS pharmacist medication recommendations. The most common included initiation/optimization of adjuvant therapy (eg, anticonvulsants, serotonin-norepinephrine reuptake inhibitors [SNRIs], and topical agents) at 46% (83/179), followed by opioid discontinuation (eg, IV hydromorphone) at 22% (40/179). Although this project primarily tracked medication interventions, examples of accepted nonpharmacologic recommendations included UDT and referrals to other programs (eg, pain psychology, substance abuse, mental health, acupuncture, chiropractor, PT/OT/PMR, and interventional pain management), which received support from each respective discipline. Declined pharmacologic recommendations mostly included topicals (eg, lidocaine, trolamine, and capsaicin cream) at 35% (19/55). However, findings also show that providers implemented 100% of medication recommendations in whole for 58% (47/81) of consults.
Likert scale satisfaction questionnaires offered insight into providers’ perception of the IPPCS (Table 7). One provider felt “neutral” about the consult submission process, given the time needed to complete the CPRS requests, but all other providers “agreed” or “strongly agreed” that the IPPCS was user-friendly. More importantly, 100% (15/15) “agreed” or “strongly agreed” that the inpatient pain CPS answered consults promptly with reasonable, evidence-based recommendations. All respondents declared that they would recommend the IPPCS to other practitioners and felt comfortable entering requests for future patients.
Discussion
The IPPCS achieved a total of 100 consults, which served as the sample for the pilot program. With support from the OCPC, PMR, and Clinical Pharmacy Department Administration, the IPPCS operated from November 2, 2015 through May 6, 2016. Results suggested that this new service could assist in managing inpatient pain issues in collaboration with inpatient multidisciplinary teams.
The most popular reason for IPPCS consults was acute on chronic pain. Given national efforts to improve opioid prescribing through the VA Opioid Safety Initiative (OSI) and the 2016 CDC Guideline for Opioid Prescribing, most pain consults requested nonopioid/adjuvant recommendations.18,19 Despite the wide MEDD range in this sample, the median/mean generally remained below recommended limits per current guidelines.18,19 However, the small sample size and lack of patient diversity (mostly white male veterans) limited the generalizability to non-VA medical facilities. Veterans often experienced both chronic pain and psychiatric disturbances, which explained the significant number of underlying mental health comorbidities observed. This affirmed the close interrelationship between pain and psychiatric issues described in the literature.20
Providers’ acceptance of pharmacologic and nonpharmacologic treatment modalities supported a comprehensive, multidisciplinary, and biopsychosocial approach to effective analgesic management. During this pilot, the most common pharmacy medication recommendations, namely, discontinuation of inappropriate opioids (eg, IV hydromorphone in patients who are controlled on and/or able to tolerate oral medications) and dose titration of adjuvant medications (eg, anticonvulsants for neuropathic pain), revealed that the IPPCS provided needed expertise and alternatives for complex pain patients. The IPPCS was well received, as inpatient providers accepted and implemented a large proportion of pharmacist recommendations. Despite risks of bias with a nonvalidated questionnaire, providers offered positive feedback. In the future, distributing satisfaction evaluations to patients also would provide more insight into how others perceived the IPPCS.
Limitations
Reasons for unaccepted recommendations included perceived limited effectiveness and/or feasibility of topical agents for acute pain, as providers seemed to favor systemic therapy for supposedly more immediate analgesia. Prescriber preference may explain why inpatient teams sometimes declined adjuvant therapy recommendations. However, the 2016 American Pain Society Guidelines on the Management of Postoperative Pain support a multimodal approach and confirm that adjuvants can reduce patients’ opioid requirements.21
Consulting teams did not execute some opioid recommendations, which may be due to various factors, including patient-related or provider-related factors in the inpatient vs outpatient setting. Lack of retrospective analysis for comparison of results pre- and post-IPPCS implementation also limited the outcomes. However, this project was piloted as a QI initiative after providers identified significant needs for inpatient pain management at the WPBVAMC. No retrospective analysis was undertaken, as this project analyzed only responses during the pilot program.
Other obstacles of the IPPCS included request appropriateness and triaging. The inpatient pain CPS deferred management of some consults to other disciplines (eg, gastroenterology) for more appropriate care. The IPPCS deferred certain cases of acute pancreatic pain or generalized abdominal pain for further workup to address patients’ underlying issues. The inpatient pain CPS relayed pertinent information regarding appropriate consults to inpatient teams. In the future, developing more specific inclusion/exclusion criteria and delivering provider education about proper IPPCS requests may resolve this issue.
Challenges with pain consults from inpatient psychiatry stemmed from patients’ skepticism and unwillingness to accept nonopioid/adjuvant therapies. Additionally, comorbid psychiatric disorders are often associated with SUDs and potentially opioid-related aberrant behavior. More than 40% of opioid-dependent individuals have comorbid psychiatric disorders, especially depression, anxiety, and bipolar disorder.22 Poorly-managed pain also drives SUD, as 80% of these patients illegally obtain prescription opioids. Thus, undertreatment of pain may push individuals to secure pain medications from illegal/illicit sources to achieve analgesia.23 Following pain physician consultation, the IPPCS continued inpatient opioids for 12% (10/81) of patients with a SUD history, including 5 with postoperative pain or other acute processes, since patients were kept in a monitored health care environment. The remaining included 4 with malignant pain and 1 with end-of-life pain. Overall, the IPPCS recommended that inpatient teams discharge these patients on as little opioids as possible, as well as to make referrals to substance abuse programs when necessary. Effective pain management of patients with aberrant behavior requires a comprehensive interdisciplinary team approach. To mitigate risk, effectively treat pain, and maintain patient safety, clinicians must recognize biologic, chemical, social, and psychiatric aspects of substance abuse.21
Another limitation during this pilot was an inability to promptly assess the impact of recommendations, given limited opportunities to reevaluate patients. In the future, more dedicated time for the inpatient pain CPSs to respond to consults may allow for better follow-up rather than initial consults only. Providers sometimes discharged patients within 24 hours of submitting consults as well, which left no time for the inpatient pain CPS consultation. However, the IPPCS forwarded appropriate requests to pain CPS e-consult services for chart review recommendations. Encouraging providers to submit consults earlier in patients’ hospital admissions may help reduce the number of incomplete IPPCS requests. Although expanding service hours would require more dedicated CPS staffing resources, it is another option for quicker consult completion and prompt follow-up.
Future Directions
Future efforts to expand this project include ensuring patient safety through judicious opioid use. Smooth transitions of care will particularly help to improve the quality of pain management. Current WPBVAMC policies stated that the primary care provider (PCP) alone must agree to continue prescribing outpatient analgesic medications, including opioids, prescribed from the OCPC once patients return to Primary Care. Continued provider education would ideally promote efficient utilization of the IPPCS and OCPC.
The pain pharmacy SOAR note template also could undergo additional edits/revisions, including the addition of opioid overdose risk assessments. For improved documentation and standardization, the template could autopopulate patient-specific information when the inpatient pain CPS chooses the designated note title. The IPPCS also hoped to streamline the CPRS consult link for more convenience and ease of use. Ultimately, the IPPCS wished to provide ongoing provider education, inpatient opioid therapy, and other topics upon request.
Conclusion
The IPPCS received positive provider feedback and collected 100 consults (averaging 4 per week) during the 6-month pilot QI project. Most consults were for acute or chronic pain and requested nonopioid/adjuvant recommendations. The new service intended to fulfill unmet needs at the WPBVAMC by expanding the facility’s current pain programs. Prescribers reported a high level of satisfaction and a willingness to not only refer other clinicians to the program, but also continue using the consult. Providers unanimously agreed that the pain CPS provided reasonable, evidence-based recommendations. This project demonstrated that the IPPCS can aid in meeting new demands amid the challenging landscape of pain practice.
The term pain refers to unpleasant sensory, emotional experiences associated with actual or potential tissue damage and is described in terms of such damage.1 Acute pain from neurophysiologic responses to noxious stimuli resolves upon tissue healing or stimuli removal (eg, 3-6 months); however, chronic pain lingers beyond the expected time course of the acute injury and repair process.1,2 Despite pain management advances, the under- or overtreatment of pain for different patient populations (eg, cancer and noncancer) remains an important concern.3,4
Hospitals have focused on optimizing inpatient pain management, because uncontrolled pain remains the most common reason for readmissions the first week postsurgery.5 The safe use of opioids (prescription, illicit synthetic, or heroin) poses major challenges and raises significant concerns. Rates of opioid-related hospital admissions have increased by 42% since 2009, and total overdose deaths reached a new high of 47,055 in 2014, including 28,647 (61%) from opioids.6
Opioids rank among the medications most often associated with serious adverse events (AEs), including respiratory depression and death.7 In response, the Joint Commission recommends patient assessments for opioid-related AEs, technology to monitor opioid prescribing, pharmacist consultation for opioid conversions and route of administration changes, provider education about risks of opioids, and risk screening tools for opioid-related oversedation and respiratory depression.7 Treatment guidelines strive to minimize the impact of acute pain by offering a scientific basis for practice, but evidence suggests a lack of suitable pain programs.7 Increases in opioid prescribing along with clinical guidelines and state laws recommending specialty pain service referrals for patients on high-dose opioids, have increased demand for competent pain clinicians.8
The expertise of a clinical pharmacy specialists (CPS) can help refine ineffective and potentially harmful pain medication therapy in complex patient cases. Existing literature outlines the various benefits of pharmacist participation in collaborative pain services for cancer and noncancer pain, as well as cases involving substance abuse.9-13 Various articles support pharmacists’ role as an educator and team member who can add valuable, trustworthy clinical knowledge that enhances clinical encounters and guides protocol/policy development.12,13 These efforts have improved patient satisfaction and encouraged physicians and nurses to proactively seek pharmacists’ advice for difficult cases.9
Frequent communication with interdisciplinary teams have helped considerably in establishing clinical pharmacy services that benefit patient care and offer sources of professional accomplishment.10,11 For example, pharmacists at Kaweah Delta Medical Center in Visalia, CA launched an innovative pain program that encompassed consultations and opioid stewardship, which demonstrated that pharmacists can improve patient outcomes in the front lines of pain management.14 Pain CPSs have advanced knowledge of pharmacokinetics, pharmacodynamics, and therapeutics to promote safe and effective analgesic use, as well as to identify opioid use disorders. Evidence suggests that pharmacists’ presence on interdisciplinary pain teams improves outcomes by optimizing medication selection, improving adherence, and preventing AEs.8
Following the plan-do-study-act model for quality improvement (QI), this project hoped to expand current pain programs at the West Palm Beach VAMC (WPBVAMC) by evaluating the feasibility of an inpatient pain pharmacist consult service (IPPCS) at the 301-bed teaching facility, which includes 130 acute/intensive care and 120 nursing/domiciliary beds.15 Staff provide primary- and secondary-level care to veterans in 7 counties along Florida’s southeastern coast.
In 2009, the WPBVAMC PGY-2 Pain Management and Palliative Care Program became the VA’s first accredited pain pharmacy residency. Residents train with the Physical Medicine & Rehabilitation (PMR) and Chronic Pain Management departments, which provide outpatient services from 7 pain physicians, a pain psychologist, registered nurse, chiropractor, acupuncturist, physical/occupational therapy (PT/OT), and 3 pain/palliative care CPSs.
The WPBVAMC had established interdisciplinary outpatient chronic pain clinic (OCPC) physician- and pharmacist-run services along with a pain CPS electronic consult (e-consult) program. However, no formal mechanisms for inpatient pain consultations existed. Prior to the IPPCS outlined in this study, OCPC practitioners, including 2 pain CPSs, managed impromptu inpatient pain issues as “curbside consultations” along with usual day-to-day clinic duties.
The OCPC, PMR, and Clinical Pharmacy administration recognized the need for more clinical support to manage complex analgesic issues in inpatient veterans, as these patients often have acute pain with underlying chronic pain syndromes. In a national survey, veterans were significantly more likely than were nonveterans to report painful health conditions (65.5% vs 56.4%) and to classify their pain as severe (9.1% vs 6.3%).16 The WPBVAMC administration concluded that an IPPCS would offer a more efficient means of handling such cases. The IPPCS would formally streamline inpatient pain consults, enabling CPSs to thoroughly evaluate pain-related issues to propose evidence-based recommendations.
The primary objective of this QI project was to assess the IPPCS implementation as part of multimodal care to satisfy unmet patient care needs at the WPBVAMC. Secondary objectives for program feasibility included identifying the volume and type of pain consults, categorizing pharmacist interventions, classifying providers’ satisfaction, and determining types of responses to pharmacists’ medication recommendations.
Methods
This QI project ascertained the feasibility of the IPPCS by evaluating all consults obtained during the pilot period from November 2, 2015 through May 6, 2016. The IPPCS was accessible Monday through Friday during normal business hours. Goal turnaround time for consult completion was 24 to 72 hours, given the lack of coverage on holidays and weekends. The target population included veterans hospitalized at the WPBVAMC inpatient ward or nursing home with uncontrolled pain on IV and/or oral analgesic medications. All IPPCS consults submitted during the pilot period were included in the sample.
The WPBVAMC Scientific Advisory Committee (SAC) approved this QI program prior to initiation. Following supervisory support from the OCPC, PMR, and Clinical Pharmacy departments, hospital technologists assisted in creating a consult link in the Computerized Patient Record System (CPRS), which allowed providers to submit IPPCS requests for specific patients efficiently. Consults were categorized as postoperative pain, acute or chronic pain, malignant pain, or end-of-life pain. Inpatient providers could enter requests for assistance with 1 or more of the following: opioid dose conversions, opioid taper/titration schedules, general opioid treatment recommendations, or nonopioid/adjuvant recommendations.
The Medical Records Committee approved a customized CPRS subjective-objective-assessment-recommendations (SOAR) note template, which helped standardize the pain CPS documentation. To promote consult requests and interdisciplinary collaboration, inpatient clinicians received education about the IPPCS at respective meetings (eg, General Medicine staff and Clinical Pharmacy meetings).
All CPSs involved in this project were residency-trained in direct patient care, including pain and palliative care, and maintained national board certification as pharmacotherapy specialists. Their role included reviewing patients’ electronic medical records, conducting face-to-face pain assessments, completing opioid risk assessments, evaluating analgesic regimen appropriateness, reviewing medication adherence, completing pain medication reconciliation, querying the Florida Prescription Drug Monitoring Program (PDMP), interpreting urine drug testing (UDT), and delivering provider/patient/caregiver education. Parameters used to determine the appropriateness of analgesic regimens included, but were not limited to:
- Use of oral instead of IV medications if oral dosing was feasible/possible/appropriate;
- Dose and adjustments per renal/hepatic function;
- Adequate treatment duration and titration;
- No therapeutic drug class duplications;
- Medication tolerability (eg, allergies, AEs, drug interactions); and
- Opioid risk assessment per Opioid Risk Tool (ORT) score and medical history.
Consulting providers clarified patients’ pain diagnoses prior to pharmacy consultations.
After face-to-face patient interviews, the inpatient pain CPS prepared pain management recommendations, including nonopioid/adjuvant pain medications and/or opioid dose adjustments. The IPPCS also collaborated with pain physicians for intervention procedures, nonpharmacologic recommendations, and for more complex patients who may have required additional imaging or detailed physical evaluations. Pain CPSs documented CPRS notes with the SOAR template and discussed all recommendations with appropriate inpatient teams.
Respective providers received questionnaires hosted on SurveyMonkey.com (San Mateo, CA) to gauge their satisfaction with the IPPCS at the end of the pilot period, which helped determine program utility. Data collected for the pilot included patient demographics; patient admission diagnosis; consulting inpatient service; type of pain and reason for IPPCS request; total morphine equivalent daily dose (MEDD); pertinent past medical history (ie, sleep apnea, psychiatric comorbidities, or substance use disorder [SUD]); ORT score; patients’ reported average pain severity on the 10-point Numeric Pain Rating Scale (NPRS); number of requests submitted; medications discontinued, initiated, or dose increased/decreased; and number of pharmacist recommendations, including number accepted by providers. The ORT is a 5-item questionnaire used to determine risk of opioid-related aberrant behaviors in adults to help discriminate between low-risk and high-risk individuals (Table 1).17
Descriptive statistics were used to evaluate the results, and a Likert scale was used to evaluate responses the from provider satisfaction questionnaires. The IPPCS collected and organized the data using Microsoft Excel (Redmond, WA).
Results
By the end of the pilot period in May 2016, the IPPCS had received 100 consult requests and completed 81% (Figure). The remaining consults included 11% forwarded to other disciplines. The service discontinued 8% of the requests, given patients’ hospital discharge prior to IPPCS review.
Baseline patient data are outlined in Tables 2, 3, 4, and 5. For each of the 100 consults, providers could select more than 1 reason for the request. The nonopioid/adjuvant treatment recommendations were the most common at 49% (62/128). Patients could have more than 1 pertinent medical comorbidity, with psychiatric illnesses the most prevalent at 68% (133/197). A mean ORT score of 8.1 indicated a high risk for opioid-related aberrant behavior. Overall, half the patients (37/73) were high risk, 25% (18/73) were medium risk (ORT 4-7), and 25% (18/73) were low risk (ORT 0-3). Patients’ reported average pain was often severe (NPRS 7-10) at 54% (40/74) or moderate (NPRS 4-6) at 39% (29/74).
The IPPCS recommended various medications for initiation, discontinuation, or dosage changes (Table 6). For example, the IPPCS recommended initiation of topical agents in 38% (48/128) of cases. The inpatient pain CPS offered opioid initiation in 17% (22/128) of cases, with immediate-release oral morphine as the most predominant. Notably, opioids remained the most common medications suggested for discontinuation at 74% (38/51), including 47% (18/38) for IV hydromorphone. Dose titration recommendations mainly included anticonvulsants at 33% (16/48), and most dose reductions involved opioids at 78% (7/9), namely, oxycodone/acetaminophen and IV hydromorphone.
Providers accepted 76% (179/234) of IPPCS pharmacist medication recommendations. The most common included initiation/optimization of adjuvant therapy (eg, anticonvulsants, serotonin-norepinephrine reuptake inhibitors [SNRIs], and topical agents) at 46% (83/179), followed by opioid discontinuation (eg, IV hydromorphone) at 22% (40/179). Although this project primarily tracked medication interventions, examples of accepted nonpharmacologic recommendations included UDT and referrals to other programs (eg, pain psychology, substance abuse, mental health, acupuncture, chiropractor, PT/OT/PMR, and interventional pain management), which received support from each respective discipline. Declined pharmacologic recommendations mostly included topicals (eg, lidocaine, trolamine, and capsaicin cream) at 35% (19/55). However, findings also show that providers implemented 100% of medication recommendations in whole for 58% (47/81) of consults.
Likert scale satisfaction questionnaires offered insight into providers’ perception of the IPPCS (Table 7). One provider felt “neutral” about the consult submission process, given the time needed to complete the CPRS requests, but all other providers “agreed” or “strongly agreed” that the IPPCS was user-friendly. More importantly, 100% (15/15) “agreed” or “strongly agreed” that the inpatient pain CPS answered consults promptly with reasonable, evidence-based recommendations. All respondents declared that they would recommend the IPPCS to other practitioners and felt comfortable entering requests for future patients.
Discussion
The IPPCS achieved a total of 100 consults, which served as the sample for the pilot program. With support from the OCPC, PMR, and Clinical Pharmacy Department Administration, the IPPCS operated from November 2, 2015 through May 6, 2016. Results suggested that this new service could assist in managing inpatient pain issues in collaboration with inpatient multidisciplinary teams.
The most popular reason for IPPCS consults was acute on chronic pain. Given national efforts to improve opioid prescribing through the VA Opioid Safety Initiative (OSI) and the 2016 CDC Guideline for Opioid Prescribing, most pain consults requested nonopioid/adjuvant recommendations.18,19 Despite the wide MEDD range in this sample, the median/mean generally remained below recommended limits per current guidelines.18,19 However, the small sample size and lack of patient diversity (mostly white male veterans) limited the generalizability to non-VA medical facilities. Veterans often experienced both chronic pain and psychiatric disturbances, which explained the significant number of underlying mental health comorbidities observed. This affirmed the close interrelationship between pain and psychiatric issues described in the literature.20
Providers’ acceptance of pharmacologic and nonpharmacologic treatment modalities supported a comprehensive, multidisciplinary, and biopsychosocial approach to effective analgesic management. During this pilot, the most common pharmacy medication recommendations, namely, discontinuation of inappropriate opioids (eg, IV hydromorphone in patients who are controlled on and/or able to tolerate oral medications) and dose titration of adjuvant medications (eg, anticonvulsants for neuropathic pain), revealed that the IPPCS provided needed expertise and alternatives for complex pain patients. The IPPCS was well received, as inpatient providers accepted and implemented a large proportion of pharmacist recommendations. Despite risks of bias with a nonvalidated questionnaire, providers offered positive feedback. In the future, distributing satisfaction evaluations to patients also would provide more insight into how others perceived the IPPCS.
Limitations
Reasons for unaccepted recommendations included perceived limited effectiveness and/or feasibility of topical agents for acute pain, as providers seemed to favor systemic therapy for supposedly more immediate analgesia. Prescriber preference may explain why inpatient teams sometimes declined adjuvant therapy recommendations. However, the 2016 American Pain Society Guidelines on the Management of Postoperative Pain support a multimodal approach and confirm that adjuvants can reduce patients’ opioid requirements.21
Consulting teams did not execute some opioid recommendations, which may be due to various factors, including patient-related or provider-related factors in the inpatient vs outpatient setting. Lack of retrospective analysis for comparison of results pre- and post-IPPCS implementation also limited the outcomes. However, this project was piloted as a QI initiative after providers identified significant needs for inpatient pain management at the WPBVAMC. No retrospective analysis was undertaken, as this project analyzed only responses during the pilot program.
Other obstacles of the IPPCS included request appropriateness and triaging. The inpatient pain CPS deferred management of some consults to other disciplines (eg, gastroenterology) for more appropriate care. The IPPCS deferred certain cases of acute pancreatic pain or generalized abdominal pain for further workup to address patients’ underlying issues. The inpatient pain CPS relayed pertinent information regarding appropriate consults to inpatient teams. In the future, developing more specific inclusion/exclusion criteria and delivering provider education about proper IPPCS requests may resolve this issue.
Challenges with pain consults from inpatient psychiatry stemmed from patients’ skepticism and unwillingness to accept nonopioid/adjuvant therapies. Additionally, comorbid psychiatric disorders are often associated with SUDs and potentially opioid-related aberrant behavior. More than 40% of opioid-dependent individuals have comorbid psychiatric disorders, especially depression, anxiety, and bipolar disorder.22 Poorly-managed pain also drives SUD, as 80% of these patients illegally obtain prescription opioids. Thus, undertreatment of pain may push individuals to secure pain medications from illegal/illicit sources to achieve analgesia.23 Following pain physician consultation, the IPPCS continued inpatient opioids for 12% (10/81) of patients with a SUD history, including 5 with postoperative pain or other acute processes, since patients were kept in a monitored health care environment. The remaining included 4 with malignant pain and 1 with end-of-life pain. Overall, the IPPCS recommended that inpatient teams discharge these patients on as little opioids as possible, as well as to make referrals to substance abuse programs when necessary. Effective pain management of patients with aberrant behavior requires a comprehensive interdisciplinary team approach. To mitigate risk, effectively treat pain, and maintain patient safety, clinicians must recognize biologic, chemical, social, and psychiatric aspects of substance abuse.21
Another limitation during this pilot was an inability to promptly assess the impact of recommendations, given limited opportunities to reevaluate patients. In the future, more dedicated time for the inpatient pain CPSs to respond to consults may allow for better follow-up rather than initial consults only. Providers sometimes discharged patients within 24 hours of submitting consults as well, which left no time for the inpatient pain CPS consultation. However, the IPPCS forwarded appropriate requests to pain CPS e-consult services for chart review recommendations. Encouraging providers to submit consults earlier in patients’ hospital admissions may help reduce the number of incomplete IPPCS requests. Although expanding service hours would require more dedicated CPS staffing resources, it is another option for quicker consult completion and prompt follow-up.
Future Directions
Future efforts to expand this project include ensuring patient safety through judicious opioid use. Smooth transitions of care will particularly help to improve the quality of pain management. Current WPBVAMC policies stated that the primary care provider (PCP) alone must agree to continue prescribing outpatient analgesic medications, including opioids, prescribed from the OCPC once patients return to Primary Care. Continued provider education would ideally promote efficient utilization of the IPPCS and OCPC.
The pain pharmacy SOAR note template also could undergo additional edits/revisions, including the addition of opioid overdose risk assessments. For improved documentation and standardization, the template could autopopulate patient-specific information when the inpatient pain CPS chooses the designated note title. The IPPCS also hoped to streamline the CPRS consult link for more convenience and ease of use. Ultimately, the IPPCS wished to provide ongoing provider education, inpatient opioid therapy, and other topics upon request.
Conclusion
The IPPCS received positive provider feedback and collected 100 consults (averaging 4 per week) during the 6-month pilot QI project. Most consults were for acute or chronic pain and requested nonopioid/adjuvant recommendations. The new service intended to fulfill unmet needs at the WPBVAMC by expanding the facility’s current pain programs. Prescribers reported a high level of satisfaction and a willingness to not only refer other clinicians to the program, but also continue using the consult. Providers unanimously agreed that the pain CPS provided reasonable, evidence-based recommendations. This project demonstrated that the IPPCS can aid in meeting new demands amid the challenging landscape of pain practice.
1. D’Arcy Y. Treating acute pain in the hospitalized patient. Nurse Pract. 2012;37(8):22-30.
2. Marks AD, Rodgers PE. Diagnosis and management of acute pain in the hospitalized patient. Am J Med. 2014;3(3):e396-e408.
3. Paice JA, Von Roenn JH. Under- or overtreatment of pain in the patient with cancer: how to achieve proper balance. J Clin Oncol. 2014;32(16):1721-1726.
4. Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening trends in the management and treatment of back pain. JAMA Intern Med. 2013;173(17):1573-1581.
5. Palomano RC, Rathmell JP, Krenzischek DA, Dunwoody CJ. Emerging trends and new approaches to acute pain management. J Perianesth Nurs. 2008;23(suppl 1):S43-S53.
6. U.S. Department of Health & Human Services, Office of the Surgeon General. Facing addiction in America: the surgeon general’s report on alcohol, drugs, and health, executive summary. https://addiction.surgeongeneral.gov/executive-summary.pdf. Published November 2016. Accessed November 1, 2017.
7. Bagian JP, Cohen M, Barnsteiner JH, et al. Safe use of opioids in hospitals. Sentinel Event Alert. 2012;49:1-5.
8. Atkinson TJ, Gulum AH, Forkum WG. The future of pain pharmacy: directed by need. Integrated Pharm Res Pract. 2016;2016(5):33-42.
9. Lothian ST, Fotis MA, Von Gutten CF, et al. Cancer pain management through a pharmacist-based analgesic dosing service. Am J Health Syst Pharm. 1999;56:1119-1125.
10. Lynn MA. Pharmacist interventions in pain management. Am J Health Syst Pharm. 2004;61(14):1487-1489.
11. Strickland JM, Huskey A, Brushwood DB. Pharmacist-physician collaboration in pain management practice. J Opioid Manag. 2007;3(6):295-301.
12. Fan T and Elgourt T. Pain management pharmacy service in a community hospital. Am J Health Syst Pharm. 2008;65(16):1560-1565.
13. Andrews LB, Bridgeman MB, Dalal KS, et al. Implementation of a pharmacist-directed pain management consultation service for hospitalised adults with a history of substance abuse. Int J Clin Pract. 2013;67(12):1342-1349.
14. Poirier RH, Brown CS, Garcia YT, Gann NY, Sandoval RA, McNulty JR. Implementation of a pharmacist directed pain management service in the inpatient setting. http://www.ashpadvantage.com/bestpractices/2014_papers/Kaweah-Delta.htm. Published 2014. Accessed November 1, 2017.
15. Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nded. San Francisco, CA: Jossey-Bass; 2009.
16. Nahin, RL. Severe pain in veterans: the effect of age and sex, and comparisons with the general population. J Pain. 2017;18(3):247-254.
17. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the opioid risk tool. Pain Med. 2005;6(6):432-442.
18. Nazario M. Opioid therapy risk management: the VA opioid safety and naloxone distribution initiatives. http://jfpsmeeting.pharmacist.com/sites/default/files/slides/Opioid%20Therapy%20Risk%20Management.pdf. Published October 15, 2015. Accessed November 1, 2017.
19. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. MMWR Rep. 2016;65(1):1-49.
20. Outcalt SD, Kroenke K, Krebs EE, et al. Chronic pain and comorbid mental health conditions: independent associations of posttraumatic stress disorder and depression with pain, disability, and quality of life. J Behav Med. 2015;38:535.
21. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131-157.
22. NIDA/SAMHSA Blending Initiative. https://www.drugabuse.gov/nidasamhsa-blending-initiative. Updated November 2015. Accessed November 1, 2017.
23. Alford DP, German JS, Samet JH, Cheng DM, Lloyd-Travaglini CA, Saitz R. Primary care patients with drug use report chronic pain and self-medicate with alcohol and other drugs. J Gen Intern Med. 2016;31(5):486-491.
1. D’Arcy Y. Treating acute pain in the hospitalized patient. Nurse Pract. 2012;37(8):22-30.
2. Marks AD, Rodgers PE. Diagnosis and management of acute pain in the hospitalized patient. Am J Med. 2014;3(3):e396-e408.
3. Paice JA, Von Roenn JH. Under- or overtreatment of pain in the patient with cancer: how to achieve proper balance. J Clin Oncol. 2014;32(16):1721-1726.
4. Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening trends in the management and treatment of back pain. JAMA Intern Med. 2013;173(17):1573-1581.
5. Palomano RC, Rathmell JP, Krenzischek DA, Dunwoody CJ. Emerging trends and new approaches to acute pain management. J Perianesth Nurs. 2008;23(suppl 1):S43-S53.
6. U.S. Department of Health & Human Services, Office of the Surgeon General. Facing addiction in America: the surgeon general’s report on alcohol, drugs, and health, executive summary. https://addiction.surgeongeneral.gov/executive-summary.pdf. Published November 2016. Accessed November 1, 2017.
7. Bagian JP, Cohen M, Barnsteiner JH, et al. Safe use of opioids in hospitals. Sentinel Event Alert. 2012;49:1-5.
8. Atkinson TJ, Gulum AH, Forkum WG. The future of pain pharmacy: directed by need. Integrated Pharm Res Pract. 2016;2016(5):33-42.
9. Lothian ST, Fotis MA, Von Gutten CF, et al. Cancer pain management through a pharmacist-based analgesic dosing service. Am J Health Syst Pharm. 1999;56:1119-1125.
10. Lynn MA. Pharmacist interventions in pain management. Am J Health Syst Pharm. 2004;61(14):1487-1489.
11. Strickland JM, Huskey A, Brushwood DB. Pharmacist-physician collaboration in pain management practice. J Opioid Manag. 2007;3(6):295-301.
12. Fan T and Elgourt T. Pain management pharmacy service in a community hospital. Am J Health Syst Pharm. 2008;65(16):1560-1565.
13. Andrews LB, Bridgeman MB, Dalal KS, et al. Implementation of a pharmacist-directed pain management consultation service for hospitalised adults with a history of substance abuse. Int J Clin Pract. 2013;67(12):1342-1349.
14. Poirier RH, Brown CS, Garcia YT, Gann NY, Sandoval RA, McNulty JR. Implementation of a pharmacist directed pain management service in the inpatient setting. http://www.ashpadvantage.com/bestpractices/2014_papers/Kaweah-Delta.htm. Published 2014. Accessed November 1, 2017.
15. Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nded. San Francisco, CA: Jossey-Bass; 2009.
16. Nahin, RL. Severe pain in veterans: the effect of age and sex, and comparisons with the general population. J Pain. 2017;18(3):247-254.
17. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the opioid risk tool. Pain Med. 2005;6(6):432-442.
18. Nazario M. Opioid therapy risk management: the VA opioid safety and naloxone distribution initiatives. http://jfpsmeeting.pharmacist.com/sites/default/files/slides/Opioid%20Therapy%20Risk%20Management.pdf. Published October 15, 2015. Accessed November 1, 2017.
19. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. MMWR Rep. 2016;65(1):1-49.
20. Outcalt SD, Kroenke K, Krebs EE, et al. Chronic pain and comorbid mental health conditions: independent associations of posttraumatic stress disorder and depression with pain, disability, and quality of life. J Behav Med. 2015;38:535.
21. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131-157.
22. NIDA/SAMHSA Blending Initiative. https://www.drugabuse.gov/nidasamhsa-blending-initiative. Updated November 2015. Accessed November 1, 2017.
23. Alford DP, German JS, Samet JH, Cheng DM, Lloyd-Travaglini CA, Saitz R. Primary care patients with drug use report chronic pain and self-medicate with alcohol and other drugs. J Gen Intern Med. 2016;31(5):486-491.