Integrating a Clinical Pharmacist into a Multidisciplinary Pain Center: Feedback and Perspectives

Amélie BOURSIER (  boursier-a@ch-valenciennes.fr ) CH Valenciennes: Centre Hospitalier de Valenciennes https://orcid.org/0000-0003-4462-132X Laurie Ferret CH Valenciennes: Centre Hospitalier de Valenciennes Julie Fulcrand CH Valenciennes: Centre Hospitalier de Valenciennes Julie Delvoye Heiremans CH Valenciennes: Centre Hospitalier de Valenciennes Pascal Charpentier CH Valenciennes: Centre Hospitalier de Valenciennes Laure Dujardin CH Valenciennes: Centre Hospitalier de Valenciennes Antoine Lemaire CH Valenciennes: Centre Hospitalier de Valenciennes

The positive impacts of integrating a CP into hospital clinical services have already been documented in several studies, including improved detection and prevention of errors, improved medication compliance, reduced adverse drug events and fewer inappropriate medication choices (side effects, best available alternative). (9)(10)(11)(12)(13) Nevertheless, to our knowledge, this is the only initiative in a French SDC that integrated directly into the team a CP who do not depend on the hospital pharmacy, on the opposite to French current model.
The purpose of this article is to discuss an innovative model of CP development in a hospital chronic pain management structure, in accordance with the description of our original experience in a French community hospital.

Method for implementing clinical pharmacy activities
Since 2017, the SDC ward has bene ted from CP activities. The affectation of 2 CP to the SDC ward (equivalent of 1 full-time CP) was part of a process to optimize medication management in chronic pain patients in our institution. All types of SDC stays are concerned by clinical pharmacy activities (consultations, HDC and FH). They were implemented gradually. Before the CPs joined the healthcare team, various clinical pharmacy activities were proposed to the SDC medical and nursing staff. Physicians, managers, and nurses selected the activities they believed to provide the greatest added value to the quality of care, either through the direct impact on the patient or by facilitating the caregivers' work.
The activities chosen were: Pharmaceutical advice on treatments and therapeutic strategies, Medication reconciliation on admission to hospital, (14) Medication reconciliation on discharge from hospital and providing a drug intake plan, to summarize the treatments to be taken, along with the indications, time, and conditions of use (Appendix 1), (14) Cancer pain and supportive care consultations carried out in duo with a doctor.
Follow-up by telephone with the CP could be organized for patients seen during pain and cancer consultations, upon medical decision, allowing follow-up of the e cacy, and tolerance of the treatment, and patient compliance with it. Dose adjustments could be supervised by the CP when necessary, according to the doctor's instructions, Drafting of drug protocols in partnership with the staff.
These activities were carried out by a CP with one fth time contract since January 2017. Cancer pain consultations and telephone follow-ups were distributed among several CPs in the hospital, with half a day of consultations per week.
After one year of implementation, additional requests were made by the healthcare team. With the recruitment of another CP in January 2018, the following activities started: Participation in Multidisciplinary Consultation Meetings (MCP), Telephone follow-up of patients to help them reduce opioids and adapt treatment in conjunction with the patient's referring hospital practitioner, Pharmaceutical interviews during hospitalization focused on understanding analgesic treatment. These were carried out in particular with all patients in HDC for installation of capsaicin patches: assessment of the patient's knowledge of the different types of pain and their analgesics, global evaluation of the management of home treatments (including compliance/adherence)( Appendix 2).

Request procedures and traceability
Each CP intervention was motivated by a medical or paramedical request, and a pharmaceutical observation was registered in the electronic health record.
Clinical pharmacy activities were also registered on an Excel® table in order to establish an activity report. Data were extracted between January 1, 2017 and June 30, 2019.

Evaluating caregiver satisfaction
The healthcare team evaluated the clinical pharmacy missions using a satisfaction questionnaire (see Appendix 3) based on that of Jennings et al. (15). It was sent to the entire medical and paramedical team (4 hospital practitioners, 1 manager, 6 nurses, 1 psychologist, 1 physiotherapist).

Statistics
A univariate descriptive analysis of the clinical pharmacy activity monitoring data was performed. The quantitative variables are described using the mean and the standard deviation, plus the qualitative variables with their absolute values and percentages.

Results
During the period studied, the CP intervened 1839 times, mainly for outpatients, i.e. during consultations or during the phone follow-up. Each intervention could include several activities.  Advice was the main activity of the CP. It is important to note that advice could be provided as part of other activities (telephone follow-ups, interviews during hospitalization, drug conciliations, for example) or in isolation, on request or spontaneously.

Provision of pharmaceutical advice
The advice was primarily intended for hospital physicians and patients, as shown in Fig. 3. Central nervous system drugs were the main therapeutic class concerned by pharmaceutical advice, with 79% of the advice. Within this therapeutic class, analgesics were the subject of 80.2% of the advice given. (16) Carrying out pharmaceutical interviews during HDC for capsaicin patch placement Since February 2, 2018, 254 pharmaceutical interviews have been conducted with 103 different patients. During their rst pharmaceutical interview, patients' knowledge of their analgesic treatment was assessed.
In total, 66% of patients knew the difference between drugs for acute episodes of pain and background treatments, 42% knew the difference between neuropathic and nociceptive pain, and 34% knew other indications for anti-neuropathic treatments.
This rst pharmaceutical interview allowed 64% of patients to improve their knowledge of their analgesic treatment.

Telephone follow-up of patients
Two types of telephone follow-up were carried out: assistance with decreasing doses of opioids following discharge from the SDC (38 telephone follow-ups for a total of 5 patients monitored), and pharmaceutical support after consultations (630 telephone follow-ups for a total of 104 patients monitored).
Healthcare team's satisfaction Figure 6 presents the healthcare team's satisfaction with the clinical pharmacy activities.

Discussion
This study describes an original experience of integrating clinical pharmacy into an SDC. This review at 2.5 years describes the activities for which caregivers requested assistance from the CP. It also provides better understanding of the ways in which a clinical pharmacy activity can be developed.

Solicitation of the clinical pharmacist
The CP was requested by the health team for 3 main activities: providing pharmaceutical advice (59%), telephone pharmaceutical follow-up of patients (18%), and conducting interviews with patients during hospitalization (11%).

Advice
It should be noted that the medical team got used to the clinical pharmacy approach very quickly: they were the source of most requests. Advice mainly concerned therapeutic strategy. This close cooperation between physicians and CP plays a part in patient safety. Several studies have shown that the presence of a CP in a hospital unit signi cantly reduces medication errors (10,17) and promotes acceptance of pharmacist recommendations compared to written advice. (10,18) The studies published mainly concern the positive impact of pharmaceutical interventions formulated by pharmacists during prescription validation, i.e. retroactively, after drug prescription. (18)(19)(20)(21) However, in our experience, proactive advice was the main activity when the CP was part of the care team. Nevertheless, there is little data available in the literature on the impact of advice provided proactively by pharmacists for medical teams. (22,23) Integrating a CP into the SDC staff made him or her a closer partner of the team. This approach promoted trust and mutual understanding. The essentially proactive nature of this approach is adapted to the organization of a hospital ward, and is complementary to the activities carried out at the hospital pharmacy.
This approach also reinforces the relations between the ward staff and the hospital pharmacy. Several studies have shown its role in saving time for various professionals, both in the services and at the hospital pharmacy.

Current HDC interviews
Patients are the second bene ciaries of advice. Within our department, advice to patients was provided particularly during HDC for the application of capsaicin patches. These interviews were set up at the behest of the medical team. During these interviews, we frequently found a lack of knowledge among patients about the difference between background and acute analgesic treatments (34%), about the difference between nociceptive and neuropathic pain (58%) and about other indications for their neuropathic pain treatments and the onset and duration of action (66%). These elements have been reported in the literature as obstacles to drug compliance. Providing appropriate information on the drugs taken by the patient (indications, methods of administration, side effects and how to prevent them, drug interactions, etc.) can improve compliance. (24) According to several studies, clinical pharmacy activities have led to improved drug compliance of 10.9 to 14.5%. (9,25) Other studies have shown a positive impact of clinical pharmacy services on health in different pathologies. (26,27) Pharmaceutical follow-up by telephone Implementing close pharmaceutical follow-up (668 calls to 109 patients) made personalized accompaniment of the patient possible during a change in analgesic treatment, in particular when a new treatment was introduced. It also made it possible to prevent adverse effects by progressively adapting dosages, improving compliance, and ensuring the correct treatment mode. New medical consultations could be provided only if necessary, thus probably avoiding consultations in hospital emergency departments, and freeing capacity for more urgent painful patients, especially in the elds of cancer pain.
In 2006, Wu et al. published a randomized controlled study of poly-medicated patients who were not compliant at inclusion. In the intervention arm, telephone follow-up with a CP was set up. After 2 years (6 to 8 calls in the intervention group, none in the control group), and after adjustment for confounding factors, the relative risk of death decreased by 41% (RR = 0.59, IC95 = 0.35-0.97). Adherence, assessed by a structured self-report questionnaire describing patient compliance with the prescribed treatment regimen, was improved by 23% (p = 0.038). (28) In 2015, a study also reported patient satisfaction with these telephone follow-ups, carried out when a drug was introduced (OR = 2.2; [1.3-3.6]), with patients feeling less concern about their treatment (OR = 0.5; [0.3-0.9]). (29) Link between community medicine and hospital The interface between hospital and community medicine is a major concern, as it is still one of the weak points in the care pathway in France. (30)(31)(32)(33)(34)(35) Most problems of collaboration and continuity of care are concentrated around hospital admission and discharge. The French Institute for Healthcare Improvement estimates that up to 50% of medication errors in hospitals are due to poor communication of medical information at different transition points, particularly admission. (36) Several studies have shown that when there is a lack of medication reconciliation on admission, the rate of medication errors that could have had serious clinical consequences for the patient is about 5% (37,38). Similarly, on discharge, 36.4% of hospitalization reports contain errors according to Wilson.(39) Mention and justi cation of therapeutic changes made during hospitalization appear to be insu cient in between 2 and 40% of hospitalization reports. (40) It is therefore essential that the link between community and hospital care be strengthened. CP participates in improving this link through its activities of medication reconciliation on admission and discharge, plus telephone follow-ups. The bene ts of medication reconciliation have been fully demonstrated and published. According to the studies and services concerned, reconciliation makes it possible to detect medication errors in 38 to 68% of patients on admission (41)(42)(43) and around 40% of patients on discharge. (41,42) According to Vira et al., drug reconciliation showed that 60% of patients had at least one unintentional discrepancy, taking admission and discharge together. (42) Deployment method Clinical pharmacy started to develop in the 1960s in North America, arriving in France more recently, where hospital pharmacies were given this mission. Our model is different: pharmacists are recruited by, and in, a medical department; they are therefore hierarchically attached to a non-pharmacist head of department.
Within the SDC, we initiated the development of CP by rst offering traditional activities, and then followed up on the team's requests. For example, one of the rst activities set up was medication reconciliation on admission, which is one of the most widespread activities and the one most described in the literature. (14,44) However, after 2.5 years of experience, we noted that this activity represents only 4.6% of the requests (2.3% on admission and 2.3% on discharge).
Finally, the clinical pharmacy activities for which the CP were most solicited are not described in the literature and were developed as the CP integrated into the service. They were increasingly speci c, such as implementing pharmaceutical telephone follow-up. This activity was initially aimed at postconsultation cancer pain patients and then, with the current opioid crisis in the United States and the increased vigilance in France on this subject, hospital practitioners asked the CPs for closer monitoring of patients for whom a reduction in opioid use was necessary.
These telephone follow-ups can be similar to health coaching and thus go far beyond simple advises. In fact, in addition to ensuring that the methods used to treat and manage pain are correct and respected by the patient, these close follow-ups make it possible to maintain a dynamic and educational relationship between the healthcare teams and the patient, encouraging patients in their approach and giving them a sense of responsibility. (35,45) Our experience shows the variability in needs, depending on the speci cities of each department, and the value of adapting the activities deployed to the expectations of the healthcare teams. As the CP becomes part of the unit, activities diversify, allowing the CP to specialize in a speci c areas.
Observations made by pain physicians working with CP are rich and qualitative, especially in the cancer pain or pediatric elds. In particular, physicians report a change in their working mode, notably in consultations, both by learning specialized pharmaceutical elds in contact with pharmacists, but also inversely by delegating medical tasks to the pharmacist. As a result, these changes have a positive impact on the management of consultations: telephone follow-ups avoid systematic reconvening of patients who are doing well, and conversely, allow earlier management of unbalanced treatments or pain emergencies.
Healthcare professionals' satisfaction with the activities of the CP is very high. It re ects the good integration of the CP into the service and the team's interest in the activities implemented.

Limitations
This work presents an assessment of CP activities in a medical department. While the clinical and relational impacts are recognized by all, we did not measure the clinical impact with objective criteria. Proactive advice represents the majority of the CP's work, yet the medico-economic impact of something that was not done cannot be evaluated. Nor did we assess the medico-economic impact of the interventions carried out. However, in the literature, several studies have reported that implementing clinical pharmacy activities is associated with a reduced risk of iatrogenicity, mortality and length of stay. (46)(47)(48)(49) Most studies report that these activities are cost-effective or have a good cost/bene t ratio. (50)(51)(52)(53)(54)(55) Furthermore, we did not rate the potential seriousness of the interventions carried out. This is less amenable to a severity rating, as may be the case for retroactive pharmaceutical interventions for which many articles have been published. (56,57) Conclusion This article presents an innovative model for the development of clinical pharmacy in France.
Beyond the traditional activities of clinical pharmacy that we have already described, and on a systemic scale, the CP had a positive impact that we did not initially anticipate on quality of life at work for the care teams. CP might even improve prevention of psychosocial risks by being a proactive, reactive, and available interlocutor, particularly for nurses. This integrative, specialized, and comprehensive model has been deployed throughout the cancerology and medical specialties department of our hospital, and is now being developed in other units of the institution. In our opinion, this innovative approach is a real operational and qualitative response to the necessary development of medical and surgical hyperspecialization in healthcare institution. Declarations -Ethics approval and consent to participate: This study was made on data registered during our clinical practice, corresponding to the current pharmaceutical care in our medical wards. Therefore, according to the french and european law, we did not need formal ethics approval. (https://www.cnil.fr/fr/RGDP-leregistre-des-activites-de-traitement )

Abbreviations
The study is registered in the internal registry of data processings.
All the patients hospitalized in our health care institution receive an individual and collective written information that the data registered during their hospitalisation can be used for research and are informed of their rights, including the modalities for opposition to the processing of their personal data for research.
-Consent for publication: Not applicable -Availability of data and materials: This study was performed on the clinical pharmacy following data used in clinical practice independently to the study. These data are registered in a securised le in the hospital where the study was performed -Competing interests: The authors declare that they have no competing interests -Funding: Not applicable -Authors' contributions: AB, LD, LF and AL conceived the idea and design of the study.