Current interventions to promote safe and appropriate pain management.

PURPOSE: Describe patient-, clinician-, system-, and community-level interventions for pain management developed and employed by 9 healthcare systems across the United States and report on lessons learned from the implementation of these interventions. SUMMARY: The high cost associated with pain coupled with the frequent use of opioid analgesics as primary treatment options has made novel pain management strategies a necessity. Interventions that target multiple levels within healthcare are needed to help combat the opioid epidemic and improve strategies to manage chronic pain. Patient-level interventions implemented ranged from traditional paper-based educational tools to videos, digital applications, and peer networks. Clinician-level interventions focused on providing education, ensuring proper follow-up care, and establishing multidisciplinary teams that included prescribers, pharmacists, nurses, and other healthcare professionals. System- and community-level interventions included metric tracking and analytics, electronic health record tools, lockbox distribution for safe storage, medication return bins for removal of opioids, risk assessment tool utilization, and improved access to reversal agents. CONCLUSION: Strategies to better manage pain can be implemented within health systems at multiple levels and on many fronts; however, these changes are most effective when accepted and widely used by the population for which they are targeted.

Population health management in a small health system: Impact of controlled substance stewardship in a patient-centered medical home.

PURPOSE: The success of a patient-centered medical home in providing population health management (PHM) services through controlled substance stewardship is described. SUMMARY: In 2013, Penobscot Community Health Care (PCHC), in Bangor, Maine, was fully engulfed in the prescription opioid crisis. At PCHC, patients' opioid doses were startlingly high. Within the organization, measures to ensure that prescriptions were being used as prescribed, and not diverted, were underutilized. PCHC responded to these challenges by developing a comprehensive approach to controlled substance stewardship, defined as a coordinated effort to promote the appropriate use of controlled substances, improve patient outcomes, reduce misuse and abuse, and decrease patient morbidity and mortality attributed to these high-risk medications. Since the establishment of the program, over 1,300 patient reviews have been conducted. During this time, the number of PCHC patients receiving chronic opioids has decreased by 67.2% and continues to drop, with a corresponding 65.6% decrease in the number of patients receiving benzodiazepines. Premature deaths were reviewed to identify associations with opioids prescribed at the time of death, which revealed a decline of 50% between 2013 and 2015. Since program inception, the reviews conducted based on internal quality-improvement reports have been expanded to include patients on combinations of opioids and benzodiazepines, high-dose opioids, and carisoprodol. CONCLUSION: Systematic approaches addressing areas of critical need in high-risk populations are integral to PHM efforts in small health systems. The pharmacy team can serve a unique role in identifying, developing, and implementing key PHM services. Coupled with strategic community partnerships, successful PHM integration can assist in the financial survival of small health systems.

Cost effectiveness of a benzodiazepine vs a nonbenzodiazepine-based sedation regimen for mechanically ventilated, critically ill adults.

PURPOSE: Nonbenzodiazepine sedation (eg, dexmedetomidine or propofol) may be more cost effective than benzodiazepine (BZ) sedation despite its higher acquisition cost. MATERIALS AND METHODS: A cost effectiveness (CE) analysis of noncardiac surgery, critically ill adults requiring at least 1 day of mechanical ventilation (MV) and administered either BZ or non-BZ sedation, that cycled health states and costs daily using a Markov model accounting for daily MV use until intensive care unit (ICU) discharge, was conducted from a third-party perspective. Transition probabilities were obtained from a published meta-analysis, and costs were estimated from best evidence. Sensitivity analyses were run for all extubation and discharge probabilities, for different cost estimates and for the specific non-BZ administered. RESULTS: When non-BZ rather than BZ sedation was used, the incremental cost-effectiveness ratio to avert 1 ICU day while MV or while either MV or non-MV was $3406 and $3136, respectively. The base-case analysis revealed that non-BZ sedation (vs BZ sedation) resulted in higher drug costs ($1327 vs $65) but lower total ICU costs (percent accounted for MV need): $35380 (71.0%) vs $45394 (70.6%). Sensitivity analysis revealed that BZ sedation would only be less costly if the daily rate of extubation was at least 16%, and the daily rate of ICU discharge without MV was at least 77%. The incremental CE ratio to avert 1 ICU day while MV or non-MV was similar between the dexmedetomidine and propofol non-BZ options. CONCLUSIONS: Among MV adults, non-BZ sedation has a more favorable CE ratio than BZ sedation over most cost estimates.

A review of advances in collaborative pharmacy practice to improve adherence to standards of care in diabetes management.

The prevalence of diabetes in the United States is increasing and so is the need to provide diabetes care. Given the time commitment and complexity of diabetes management, an interdisciplinary approach is recommended. Pharmacists are integral members of the diabetes care team because of their accessibility and expertise in medication management. Pharmacists are receiving specialized training and becoming more involved in direct patient care through collaborative practice opportunities such as medication therapy management and collaborative drug therapy management. These collaborative practice models increase patient access to care and allow pharmacists to optimize drug therapy and provide important education to promote diabetes self-management. Studies show pharmacists practicing in a variety of outpatient environments can reduce HbA1c, LDL and BP as well as improve adherence to recommended American Diabetes Association guidelines (yearly monofilament exams, dilated eye exams, microalbumin screening, etc). Pharmacists working as part of the health care team can ensure optimal diabetes management.