Improving Clinical Pharmacy Interventions – Chronic Non-Cancer Pain Management in Older Inpatients: The Role of Quality Indicators on Ward Rounds

Background

Chronic non-cancer pain (CNCP) significantly reduces the quality of life of affected patients. As 28-88% of older adults may suffer from CNCP, this is a relevant problem in daily clinical practice. CNCP is associated with multimorbidity in 88%, with depression and insomnia being frequent co-morbidities. Particularly older adults suffering from CNCP also have more physical and cognitive deficits. CNCP affects more women than men and more people with poor socioeconomic backgrounds, in particular those with past unemployment.

Quality indicators (QIs) are measurable quantities used to assess and track the quality of care, among and within institutions. As such, QIs can help to standardise healthcare processes, and therefore improve the quality of care delivered. QIs can be incorporated in (electronic) trigger tools to efficiently identify patients at high risk for compromised care. Therefore, QIs are integral for the continuous quality improvement in the healthcare system and must be developed with great rigour.

In a previous project, we systematically screened the literature on QIs for the pharmacological management of CNCP in older adults. We then achieved face validity among a panel of experts on a subset of the identified QIs using a RAND/UCLA Delphi study. This Delphi study resulted in the inclusion of 51 QIs and the exclusion of 33 QIs. This Delphi study followed a rigorous methodology and allowed experts to construct a shared vision of the pharmacological management of CNCP in older inpatients. However, this set of QIs still needs to be validated using clinical data and real patients. At the same time, there are currently no published clinical pharmacist interventions in older patients with CNCP.

Aims

To adress the aforementioned gaps in the literature, this pre-post study aims to:

1. Test a previously developed set of QIs for the management of CNCP in older inpatients.
2. Evaluate the clinical applicability of this set of QIs.
3. Determine whether pharmacist interventions and number of fulfilled QIs change after the implementation of the set of QIs.
4. Describe, whether a clinical pharmacist interventions for older inpatients with CNCP is feasible and beneficial.

Methods

This study will use a retrospective chart review on data gathered during the a previous project to describe pharmacist intervention prior implementation of the QIs. Then we will introduce the set of QIs in the weekly ward rounds accompanied by clinical pharmacists. Clinical pharmacists will do this when preparing for the ward rounds. For physicians, the process will likely remain the same. However, we hypothesise that clinical pharmacists will make more interventions related to CNCP management. Finally, we will evaluate pharmacists’ and physicians’ experiences with the QIs. We will also quantitavely evaluate the QIs (number of interventions, number of accepted interventions etc.) Patients will also be interviewed prior to the ward round to evaluate CNCP medication history and current pain intensity and interference, and quality of life. Four weeks after discharge from the geriatric ward, we will call the patients to re-evaluate whether our intervention has changed their quality of life.

Expected Results

We hypothesise that the use of QIs will increase pharmacist interventions for CNCP. We anticipate that some QIs will be used infrequently and that the number of QIs may be reduced. As there is a lack of evidence for the management of CNCP in older patients, we believe that providing clinical pharmacists with a list of QIs will increase their confidence to intervene. We hypothesise that the use of these QIs will improve interprofessional collaboration between internists, geriatricians and pharmacists.

Conclusion

We expect clinical pharmacists to improve medication safety in the very vulnerable population of older inpatients with CNCP. We hope to end up with a refined list of QIs suitable for clinical pharmacists.