Cross-Sector Collaboration to Improve Access to Community Services for People Living With Diabetes: Contributions From Actor-Network Theory.

Diabetes is a global public health issue. The Public Health Agency of Canada published a Diabetes Framework 2022 which recommends collaborative work across sectors to mitigate the impact of diabetes on health and quality of life. Since 2020, the INMED-COMMUNITY pathway has been implemented in Laval, Québec developing collaboration between healthcare and community sectors through a participatory action research approach. The aim of this article is to gain a better understanding of the INMED-COMMUNITY pathway implementation process, based on the mobilization of network actor theory. Qualitative analysis of semi-structured interviews conducted from January to March 2023 with 12 participants from 3 different sectors (community, health system, research), were carried out using actor-network theory. The results explored the conditions for effective intersectoral collaboration in a participatory action research approach to implement the INMED-COMMUNITY pathway. These were: (1) contextualization of the project, (2) a consultation approach involving various stakeholders, (3) creation of new partnerships, (4) presence of a project coordinator, and (5) mobilization of stakeholders around a common definition of diabetes. Mediation supported by a project coordinator contributed to the implementation of an intersectoral collaborative health intervention, largely due to early identification of controversies.

Structuring and organizing interprofessional healthcare in partnership with patients with diabetes: the INterprofessional Management and Education in Diabetes care (INMED) pathway.

Type 2 diabetes is a complex chronic disease that requires ongoing monitoring by an interprofessional team to prevent complications. The INMED (INterprofessional Management and Education in Diabetes) care pathway was developed by our team to optimize primary care services for these patients and their families. The objective of this study is to describe the preliminary results of its adoption and implementation. The INMED care pathway is organized into four axes: (a) continuing professional education, (b) self-management support, (c) case management, and (d) ongoing evaluation of the quality of diabetes care and services. A multiple-case study is underway to document its effects on practice change using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Preliminary results on the adoption and implementation revealed some strengths: (a) regular patient follow-up by the case manager, (b) scheduling of physician appointments when required, and (c) regular screening for risk factors. Barriers were also identified: (a) lack of clear understanding of the case manager role, (b) lack of referrals to team members, and (c) lack of use of the motivational interview approach. The INMED care pathway is being adopted by primary care teams but challenges need to be overcome to improve its reach and effectiveness.

Implementation of targeted deprescribing of potentially inappropriate medications in patients on hemodialysis.

PURPOSE: Patients on hemodialysis have a high risk of medication-related problems. Studies using deprescribing algorithms to reduce the number of inappropriate medications in this population have been published, but none have used a patient-partnership approach. Our study evaluated the impact of a similar intervention with a patient-partnership approach. METHODS: The objective was to describe the implementation of a pharmacist-led intervention with a patient-partnership approach using deprescribing algorithms and its impact on the reduction of inappropriate medications in patients on hemodialysis. Eight algorithms were developed by pharmacists and nephrologists to assess the appropriateness of medications. Pharmacists identified patients taking targeted medications. Following patient enrollment, pharmacists assessed medications with patients and applied the algorithms. With patient consent, deprescription was suggested to nephrologists if applicable. Specific data on each targeted medication were collected at 4 and 16 weeks. Descriptive statistics were used to examine the effects of the deprescribing intervention. RESULTS: Of 270 patients, 256 were taking at least one targeted medication. Of the 122 patients taking at least one targeted medication who were approached to participate, 66 were included in the study. At enrollment, these patients were taking 252 targeted medications, of which 59 (23.4%) were determined to be inappropriate. Deprescription was initiated for 35 of these 59 medications (59.3%). At 4 weeks, 33 of the 59 medications (55.9%) were still deprescribed, while, at 16 weeks, 27 of the 59 medications (45.8%) were still deprescribed. Proton pump inhibitors and benzodiazepines or Z-drugs were the most common inappropriate medications, and allopurinol was the most deprescribed medication. CONCLUSION: A pharmacist-led intervention with a patient-partnership approach and using deprescribing algorithms reduced the number of inappropriate medications in patients on hemodialysis.

Pharmacists practising in family medicine groups: An evaluation 2 years after experiencing a virtual community of practice.

BACKGROUND: In 2018, a virtual community of practice (CoP) for pharmacists working in family medicine groups (FMGs) in Quebec province was developed. The aim of this CoP-called Réseau Québécois des Pharmaciens GMF (RQP GMF)-was to foster best practices by supporting FMG pharmacists. This study assesses the processes and outcomes of this CoP 2 years after its creation. METHODS: We performed a cross-sectional web-based study from March to May 2020. All FMG pharmacists who were registered as members of the RQP GMF (n = 326) were sent an invitation via a newsletter. The link to the questionnaire was also publicized in the CoP Facebook group. The questionnaire comprised a 38-item validated instrument assessing 8 dimensions of the CoP. A descriptive analysis was performed. RESULTS: A total of 112 FMG pharmacists (34.4%) completed the questionnaire. Respondents agreed that the RQP GMF was a joint enterprise (mean score, 4.18/5), that members shared their knowledge (mean score, 3.94/5) and engaged mutually (mean score, 3.50/5) and that the RQP GMF provided support (mean score, 3.92/5) and capacity building (mean score, 4.01/5). In general, they were satisfied with the implementation process (mean score, 3.68/5) and with activities proposed (mean score, 3.79/5). A lower proportion of respondents agreed that their participation in the RQP GMF generated external impacts, which led to a smaller mean score (3.37/5) for this dimension. CONCLUSION: The RQP GMF, one of the first communities of practice for pharmacists practising in family medicine groups, attained most of the objectives initially intended by the CoP. These results will facilitate the adaptation of processes and activities to better fulfil members' needs. Can Pharm J (Ott) 2021;154:xx-xx.

How interprofessional teams of students mobilized collaborative practice competencies and the patient partnership approach in a hybrid IPE course.

To develop collaborative competencies of future health and social services professionals, the Université de Montréal (UdeM) offers interprofessional education (IPE) in partnership with patients. To meet the challenges of IPE, UdeM turned to digital tools to enable interprofessional teams of students to collaborate online and face-to-face. The collaborative flipped classroom for IPE with patient partnership is the conceptual framework for the pedagogical method used for this study. It is based on: 1) a competency framework and 2) collaborative learning concept and dimensions. The study aimed to: 1) demonstrate how interprofessional teams of students mobilize framework competencies and care approaches during online and face-to-face collaborative learning activities; and 2) analyze how students collaborate during a hybrid IPE course using a patient partnership approach. Using a qualitative methodology, the contents of the online collaborative journals (OCJs) of 12 interprofessional student teams were analyzed, along with the individual comments (n = 994) of IPE course learners collected through the Interprofessional Team Collaboration questionnaire (n = 321). The results suggest that the course under study enabled teams to collaborate online and face-to-face throughout the term, and indicate that students were better prepared to adopt a patient partnership approach.

Issues with deprescribing in haemodialysis: a qualitative study of patient and provider experiences.

RATIONALE, AIMS AND OBJECTIVES: Patients undergoing haemodialysis receive on average 10-17 medications, which increase the risk of falls, adverse drug reactions and hospitalizations. Supervised discontinuation of potentially inappropriate medications may lower these risks. Although many calls have been made for deprescribing in the haemodialysis setting, little is known about how patients and providers in this setting experience it. The aim of this study is to explore patient and provider experiences and perceptions of one of the rare deprescribing intervention in haemodialysis. METHODS: Ten semi-structured interviews were held with patients, and a focus group was done with dialysis clinic team members at a Montreal area health network's haemodialysis clinic after the implementation of a standardized deprescribing intervention using the patient-as-partner approach. The interviews and focus group were recorded, and verbatims were coded to determine emerging themes. Grounded theory was used for interview guide design and data analysis. RESULTS: The three emerging themes were (1) ambivalence towards medication creating a favourable context for deprescribing, (2) the empowering elements of the deprescribing process and (3) the uncertain future of deprescribing in the clinics even though the intervention was considered successful. CONCLUSION: Haemodialysis patients and providers viewed deprescribing favourably, believed the intervention was valuable, and offered suggestions for long term implementation while expressing concerns about feasibility. Notwithstanding the underlying uncertainties, a structured and integrated approach in routine practice involving all members of the care team may facilitate the continuity of deprescribing as an intervention in the setting of a haemodialysis clinic.

Pharmaceutical practices before and throughout the opioid crisis: A scoping review.

METHODS: Opioid misuse has reached epidemic status in many countries. This crisis-recognized since 2014-questions the practices of prescribing and dispensing. Did this public health issue change pharmaceutical practices? This literature review presents pharmaceutical practices regarding treatment of noncancer pain. We will assess whether these practices changed after the declaration of the crisis. We will also present barriers and facilitators to their implementation in real life to understand the distance between them and current practices. A scoping review of the literature was conducted on PubMed, Medline, and Embase for references dealing with pharmaceutical practices regarding noncancer pain management, in French and English, from 2000 to 2018. RESULTS: The search yielded 250 results, with 25 studies surviving the exclusion process. Twenty studies took place in the United States, the country most affected by the crisis. Interventions took place as interprofessional collaboration (n = 14), patient counseling (6), or a combination of these (5). Although the nature of the interventions remained constant through the crisis, the number of publications greatly increased over time. The studies demonstrated pharmacists' upstream contributions regarding pain management and opioid use. Several large-scale implementation issues, including knowledge gaps and communication barriers, have been reported in these studies and in others that gathered opinions and perspectives of prescribers, pharmacists, and patients. CONCLUSION: Our review showed that the opioid crisis did not modify the nature of pharmaceutical practices regarding pain treatment and opioid management, but the number of studies reporting these practices greatly increased since its onset. Barriers to implementing the best practices to reduce opioid harm have been identified to explain slow integration in daily practice. Adjustments to teaching and practice methods such as a reviewed pain treatment curriculum, standardized tools, and decision-making algorithms could prove beneficial.

Pharmacists practising in family medicine groups: What are their activities and needs?

WHAT IS KNOWN AND OBJECTIVE: Pharmacists' responsibilities and practices have expanded over the years to be more clinical. Working in other settings and collaborating with other healthcare professionals can lead to new needs that are unmet by actual training. This study was performed to describe the characteristics and practices of pharmacists working in family medicine groups (FMGs) and to assess their needs to develop a practice-based network fostering best practices. METHODS: A Quebec province-wide cross-sectional study was performed from May to August 2018. Pharmacists practising in FMGs were identified through phone calls to all listed FMGs and via direct emails. All identified pharmacists were emailed an invitation to complete an online questionnaire comprising questions to assess their sociodemographic characteristics, to describe their FMG and to assess their needs to reach an optimal practice. The link to the questionnaire was also publicized in a Facebook group of FMG pharmacists and by several professional organizations. A descriptive analysis was performed and discussed with two committees: a working group of FMG pharmacists and an advisory committee comprising key stakeholders. RESULTS AND DISCUSSION: A total of 299 FMG pharmacists were identified, and 178 (59.5%) completed the online questionnaire. Most were women (71.9%), were less than 40 years old (71.9%) and also practised as community pharmacists (76.4%). Reviewing medication to optimize pharmacotherapy and answering questions related to specific issues were the most frequent activities, with 86.0% and 90.4% of pharmacists, respectively, reporting that they performed these often or very often. The most frequently mentioned needs were training and mentorship adapted to the FMG practice and improvement in the understanding that other healthcare professionals have about the role of the FMG pharmacist. Performing comprehensive medication assessments and developing thorough pharmaceutical care plans were among the clinical competencies that pharmacists wanted to develop. Scientific and interprofessional communication was also among the abilities they wished to optimize. WHAT IS NEW AND CONCLUSION: This study provided unique information about pharmacists practising in FMGs and elicited several needs. The results will inform the development of a practice-based network aimed at fulfilling these needs.

The Creation of a Practice-Based Network of Pharmacists Working in Family Medicine Groups (FMG).

A needs assessment study of pharmacists working in family medicine groups (FMG) demonstrated the necessity to build a practice-based network. This network would foster a faster integration into FMG and a more efficient collaborative practice. It would also take advantage of an existing practice-based research network (PBRN)-the STAT (Soutien Technologique pour l'Application et le Transfert des pratiques novatrices en pharmacie) network. A working group of nine FMG pharmacists from the different regions of the province of Quebec, Canada, and a committee of partners, including the key pharmacy organizations, were created. Between January 2018 and May 2019, nine meetings took place to discuss the needs assessment results and deploy an action plan. The practice-based network first year activities allowed identifying pharmacists working in FMGs across the province. A directory of these pharmacists was published on the STAT network. The vision, mission, mandate, name («Réseau Québécois des Pharmaciens GMF¼) and logo were developed. The first few activities include: Bi-monthly newsletters; a mentorship program; short evidence-based therapeutic letters (pharmacotherapeutic capsules) and a start-up kit to facilitate integration of these pharmacists. The Quebec FMG pharmacist practice-based network has been launched. It is planned to evaluate the members' satisfaction in late Spring 2020 with regards to activities and resources provided.

[The Montreal model: the challenges of a partnership relationship between patients and healthcare professionals]. / Le <> : enjeux du partenariat relationnel entre patients et professionnels de la santé.

A promising approach to improve the population's health and the quality of care and services provided by the health system consists of patient engagement at all levels of the health system together with training of health professionals. Since 2010, a new rational model based on the partnership between patients and healthcare professionals has been developed at the University of Montreal's Faculty of Medicine. This patient partnership model is based on the recognition of the patient's experiential knowledge gained from living with a disease, which is complementary to the healthcare professional's scientific knowledge. This partnership is part of a continuum of patient engagement and can be applied in healthcare, professional training, education and research settings. This article describes the theoretical basisfor patient partnerships and how this new model can be implemented in clinical, organizational and systemic levels, as well as the success factors in both patients and healthcare professionals. The Montreal Model provides relevant outlooks for chronic disease management by making patients essential partners in all decisions affecting them and by treating them as experts in the organisation of care. This model should have a significant impact on the population's health by improving physical, psychological health, as well as the patient's well-being. As part of this new framework, several research programs are currently underway to evaluate the impact of this model.

Innovating in teaching collaborative practice with a large student cohort at Université de Montréal.

Université de Montréal implemented an interprofessional education (IPE) curriculum on collaborative practice in a large cohort of students (>1,100) from 10 health sciences and psychosocial sciences training programs. It is made up of three one-credit undergraduate courses (CSS1900, CSS2900, CSS3900) spanning the first 3 years of training. The course content and activities aim for development of the six competency domains identified by the Canadian Interprofessional Health Collaborative. This paper describes the IPE curriculum and highlights the features contributing to its success and originality. Among main success key factors were: administrative cooperation among participating faculties, educators eager to develop innovative approaches, extensive use of clinical situations conducive to knowledge and skill application, strong logistic support, close cooperation with health care delivery organizations, and partnership between clinicians and patients. A distinguishing feature of this IPE curriculum is the concept of partnership in care between the patient and caregivers. Patients' representatives were involved in course planning, and patients were trained to become patients-as-trainers and cofacilitate interprofessional discussion workshops. They give feedback to students regarding integration and application of the patient partnership concept from a patient's point of view.

A cluster randomized controlled Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia: the TEAM study.

BACKGROUND: Few studies have reported the efficacy of collaborative care involving family physicians and community pharmacists for patients with dyslipidemia. METHODS: We randomly assigned clusters consisting of at least two physicians and at least four pharmacists to provide collaborative care or usual care. Under the collaborative care model, pharmacists counselled patients about their medications, requested laboratory tests, monitored the effectiveness and safety of medications and patients' adherence to therapy, and adjusted medication dosages. After 12 months of follow-up, we assessed changes in low-density lipoprotein (LDL) cholesterol (the primary outcome), the proportion of patients reaching their target lipid levels and changes in other risk factors. RESULTS: Fifteen clusters representing a total of 77 physicians and 108 pharmacists were initially recruited, and a total of 51 physicians and 49 pharmacists were included in the final analyses. The collaborative care teams followed a total of 108 patients, and the usual care teams followed a total of 117 patients. At baseline, mean LDL cholesterol level was higher in the collaborative care group (3.5 v. 3.2 mmol/L, p = 0.05). During the study, patients in the collaborative care group were less likely to receive high-potency statins (11% v. 40%), had more visits with health care professionals and more laboratory tests, were more likely to have their lipid-lowering treatment changed and were more likely to report lifestyle changes. At 12 months, the crude incremental mean reduction in LDL cholesterol in the collaborative care group was -0.2 mmol/L (95% confidence interval [CI] -0.3 to -0.1), and the adjusted reduction was -0.05 (95% CI -0.3 to 0.2). The crude relative risk of achieving lipid targets for patients in the collaborative care group was 1.10 (95% CI 0.95 to 1.26), and the adjusted relative risk was 1.16 (95% CI 1.01 to 1.34). INTERPRETATION: Collaborative care involving physicians and pharmacists had no significant clinical impact on lipid control in patients with dyslipidemia. International Standard Randomized Controlled Trial register no. ISRCTN66345533.

Primary care practices and determinants of optimal anticoagulation management in a collaborative care model.

BACKGROUND: In a collaborative care model (CCM) for managing oral anticoagulant therapy, patients are followed at a pharmacist-managed anticoagulation service and, once stabilized, are transferred to their primary care physician. The objective of this study was to describe physicians' clinical practices and the practice characteristics associated with better international normalized ratio (INR) control in a CCM. METHODS: A telephone questionnaire about their practices was administered to 121 physicians exposed to a CCM. The physicians followed 121 patients for a mean of 14.5 weeks. The percentage of time within the exact INR target range was computed and dichotomized (> or = or < median time within target range). Determinants of better INR control were identified using logistic regression models. RESULTS: The survey revealed that, after discharge from the pharmacist-managed anticoagulation service, patients are followed mainly by physicians and their secretaries. Physicians do not often consult other health professionals. Few report using technological resources to obtain INR results (39.7%), document medical follow-up (6.6%), or detect drug (32.2%) and food (9.9%) interactions. The median percentage of time within the exact INR target range was 84%. Determinants of better INR control include using computerized support to monitor patients (odds ratio [OR] 9.16, 95% CI 1.77-47.4) and detect drug interactions (OR 3.49, 95% CI 1.71-7.10) and consulting specialists (OR 5.92, 95% CI 1.49-32.48). CONCLUSIONS: Primary care physicians are poorly supported by technological and human resources to monitor patients on oral anticoagulant. Even in a CCM, interprofessional collaboration and better technological support may be associated with optimal INR control.

Physician-pharmacist collaborative care for dyslipidemia patients: knowledge and skills of community pharmacists.

INTRODUCTION: In a physician-pharmacist collaborative-care (PPCC) intervention, community pharmacists were responsible for initiating lipid-lowering pharmacotherapy and adjusting the medication dosage. They attended a 1-day interactive workshop supported by a treatment protocol and clinical and communication tools. Afterwards, changes in pharmacists' knowledge, their skills, and their satisfaction with the workshop were evaluated. METHODS: In a descriptive study nested in a clinical trial, pharmacists assigned to the PPCC intervention (n = 58) completed a knowledge questionnaire before and after the workshop. Their theoretical skills were evaluated with the use of a vignette approach (n = 58) after the workshop and their practical skills were assessed by direct observation with study patients (n = 28). RESULTS: The mean (SD) overall knowledge score was 45.8% (12.1%) before the workshop; it increased significantly to 89.3% (8.3%) afterwards (mean difference: 43.5%; 95% CI: 40.3%-46.7%). All the pharmacists had an overall theoretical-skill score of at least 80%, the minimum required to apply the PPCC in the trial. From 92.9% to 100% of the pharmacists' interventions with study patients complied with the treatment protocol. DISCUSSION: In primary care, a short continuing-education program based on a specific treatment protocol and clinical tools is necessary and probably sufficient to prepare pharmacists to provide advanced pharmaceutical care.

Effectiveness of a medication discharge plan for transitions of care from hospital to outpatient settings.

PURPOSE: The effect of a medication discharge plan (MDP) on the rate of medication discrepancies between hospital and outpatient settings was evaluated. METHODS: In a pragmatic, open, randomized, controlled trial, MDPs were completed for all patients before discharge from the hospital. Patients were then assigned to either an MDP group, for whom MDPs were sent to community pharmacies and treating physicians, or a usual care group, for whom an MDP was not sent. Discrepancies between MDPs and community pharmacy dispensing records and medication use reported by patients during a telephone interview were documented. The percentage of patients with discrepancies and the mean percentage of medications with discrepancies were compared between the two groups. The clinical severity of discrepancies was blindly evaluated. RESULTS: A total of 83 patients agreed to participate in the study. The percentage of patients with at least one discrepancy was high and similar in both groups when MDPs were compared with pharmacy dispensing records and patient self-reports. Comparison of MDPs to pharmacy dispensing records revealed discrepancies for 13-15% of medications; more than a third were clinically significant. Comparison of MDPs to patient self-reports revealed discrepancies for 10-12% of medications; 48% were clinically significant. No significant differences were observed between the two groups. CONCLUSION: The rate of medication discrepancies was not decreased in patients whose MDP was provided to their community pharmacy and physician at the time of hospital discharge compared with the rate in patients who received usual care.

Is long-term pharmacist-managed anticoagulation service efficient? A pragmatic randomized controlled trial.

BACKGROUND: Some pharmacist-managed anticoagulation services (PMAS) provide initial follow-up to patients on oral anticoagulant, who are transferred to their physician once they are stabilized. This may be as effective as and less expensive than long-term PMAS follow-up. METHODS: Once PMAS patients were stabilized and ready for discharge, they were randomized to be transferred to their physician or stay with the PMAS. Quality of international normalized ratio (INR) control, incidence of complications, health-related quality of life, use of health care services, and direct incremental cost of PMAS follow-up were evaluated. RESULTS: One hundred thirty-eight physicians and 250 patients participated. Patients were initially followed at the PMAS for a mean of 11.3 weeks and afterwards were followed by their physician (n = 122) or by the PMAS pharmacists (n = 128) for a mean of 14.9 and 14.5 weeks, respectively. Pharmacist-managed anticoagulation services' and physician's patients were within the exact target range 77.3% and 76.7% of the time (95% CI of the difference -4.9% to 6.0%) and within the extended range 93.0% and 91.6% of the time (95% CI -2.1% to 4.7%), respectively. Pharmacist-managed anticoagulation services patients have seen their family physician less often (95% CI -3.1 to -0.1 visit per year). Number of INR tests, incidence of complications, and health-related quality of life were similar in both groups. The incremental cost of PMAS follow-up was estimated at CAN$123.80 per patient year. CONCLUSION: Once PMAS patients are well stabilized, maintaining a PMAS follow-up or transferring them to their physician is associated with excellent INR control. However, long-term PMAS follow-up may be more expensive.

Reliability, validity and ease of use of a portable point-of-care coagulation device in a pharmacist-managed anticoagulation clinic.

UNLABELLED: In a pharmacist-managed anticoagulation clinic, portable point-of-care coagulation devices may facilitate patient monitoring by providing rapid INR measurement. Few studies, however, have validated this type of device. OBJECTIVE: To evaluate the reliability, validity and ease of use of the CoaguChek S, a new portable coagulation device. METHODS: A total of 100 patients followed at a pharmacist-managed anticoagulation clinic attended two study visits. INRs were measured using the CoaguChek S and the standard laboratory technique. RESULTS: Reliability: The test-retest reliability (precision) of the CoaguChek S, estimated by the intraclass correlation coefficient (ICC) and a 95% confidence interval (95% CI), was high (0.98 (0.98-0.99)) and comparable to the standard laboratory technique (0.99 (0.98-0.99)). Interrater reliability was also high (0.97 (0.95-0.98)). Reliability coefficients did not vary with the test-strip lot number nor the CoaguChek S operator. VALIDITY: When compared with standard laboratory procedure, the ICC (95% CI) was equal to 0.93 (0.91-0.95). The mean difference (95% CI) between INR measured by the laboratory and the CoaguChek S was equal to -0.02 units (-0.06-0.03). The mean absolute and relative absolute differences (95% CI) were equal to 0.24 units (0.21-0.27) and 9% (8%-10%), respectively. Differences tended to increase for INRs greater than 3 units as seen by a mean difference (95% CI) of -0.17 units (-0.35-0.02). This represented a mean absolute difference (95% CI) of 0.44 units (0.33-0.55) and a mean relative absolute difference of 12% (9%-15%). Concordance between therapeutic decisions based on CoaguChek S and laboratory results was high (Kappa = 0.68). In 34 cases (18%), the therapeutic decision would have been different. However, in 15 of these discordant observations, the difference between the CoaguCheck S and laboratory INR was

Comparison of hydromorphone continuous subcutaneous infusion and basal rate subcutaneous infusion plus PCA in cancer pain: a pilot study.

In this pilot randomized, double-blind, cross-over study, the effectiveness and safety of hydromorphone administration by continuous subcutaneous (s.c.) infusion (mode A) and by continuous basal rate s.c. infusion + PCA (mode B) were compared in 8 cancer patients. Patients experimented with each infusion mode during 48 h. Statistical analysis was performed on data collected in 7 patients during 36 h from 22:00 h on day 1 to 10:00 h on day 3 and from 22:00 h on day 3 to 10:00 h on day 5. Mean hydromorphone dose +/- S.D. was 56.6 +/- 30.1 and 40.4 +/- 24.5 mg/36 h for modes A and B, respectively. There was no statistically significant difference observed in mean pain intensity, but the absence of significant difference may be related to the small sample size and high individual variability. Both methods provided adequate overall pain control in most patients. However, a large interindividual variation was detected. Indeed, some patients reported in the subjective questionnaire that they felt marked discomfort during hydromorphone administration with mode B. Only 2 patients chose mode B at the end of the study, but it was interesting to note that those 2 patients were the youngest of the group. This study demonstrated the effectiveness and safety of both modes of hydromorphone administration. The data suggest that it may be possible to identify particular cancer patients which can really benefit from an association of a basal rate infusion and PCA for opiate administration.