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PubMed2002

Consultation audio tapes: an underused cancer patient information aid and clinical research tool.

Patients with cancer are known to value consultation audio tapes as an information aid and frequently accept the offer to tape record their consultations with oncologists. Systematic reviews have shown that providing patients with an audio tape of their consultations improves how much information they remember. In surveys, many Australian doctors were unenthusiastic about providing consultation audio tapes to patients citing issues such as patient confidentiality and medico-legal concerns as reasons for their reluctance. In addition to clinical benefits, consultation audio tapes are a valuable research tool for documenting information provision and analysing the interactions between patients and oncologists. For example, audio tapes of clinical-trial consultations have raised concerns about the quality of informed consent given by patients. Consultation audio tapes have also been used to monitor strategies for improving patient understanding. In three randomised trials, provision of a question prompt sheet significantly increased the number of questions asked by patients about their prognosis, suggesting that this topic was not generally discussed adequately. Oncologists should consider installing audiotaping facilities and offer all patients a tape of their consultation. Furthermore, scientists who investigate doctor-patient interactions should consider using consultation audio tapes as a research tool.

Humans↗
PubMed2001

Promoting patient participation and shortening cancer consultations: a randomised trial.

Patient participation in medical consultations has been demonstrated to benefit their subsequent psychological well being. Question asking is one way in which patients can be active. We investigated 2 means of promoting cancer patient question asking. One was the provision of a question prompt sheet to patients prior to their initial consultation with their oncologist. The second was the active endorsement and systematic review of the question prompt sheet by their oncologist. 318 patients with heterogeneous cancers, seeing one of 5 medical and 4 radiation oncologists for the first time, were randomised to either receive or not receive a question prompt sheet. Doctors were randomised to either proactively address or passively respond to the question prompt sheet in the subsequent consultation. Anxiety was assessed prior to the consultation. Consultations were audiotaped and content analysed. Anxiety was assessed again immediately following the consultation. Within the next 10 days patients completed questionnaires assessing information needs, anxiety and satisfaction and were given a structured telephone interview assessing information recall. Patients provided with a question prompt sheet asked more questions about prognosis compared with controls and oncologists gave significantly more prognostic information to these patients. Provision of the question prompt sheet prolonged consultations and increased patient anxiety; however, when oncologists specifically addressed the prompt sheet, anxiety levels were significantly reduced, consultation duration was decreased and recall was significantly improved. A patient question prompt sheet, used proactively by the doctor, is a powerful addition to the oncology consultation.

Adolescent↗
PubMed2004

Is consultation at the psychiatric outpatient clinic a useful service for patients and their doctors?

The aim of this retrospective study was to examine the views of patients and general practitioners on consultation after referral to a psychiatric outpatient clinic. Consultation was defined as less than five sessions. One hundred and sixty patients who had consultations at a mean of 42 months before were invited to the study. Ninety-one took part, and they filled in a questionnaire on their views and Symptom Checklist 90-R. Thirty-eight (79%) of 48 GPs gave their opinions on a questionnaire of 128 (80%) written feedbacks from the 160 consultations. The patient and the GP questionnaires showed good psychometric properties. Fifty-one (56%) patients considered the help received at the psychiatric outpatient clinic as good or very good. In 73 (57%) of the cases, the GPs found the consultations helpful. At follow-up, the patients had a significantly reduced mental symptom load. Going to work and living with a spouse were characteristics of patients satisfied with the consultation. Administrative variables did not influence satisfaction. A clear focus and emphasis on patient information as to the nature and treatment opportunities of the mental disorders seems to be a cheap and relevant way of improving patients' satisfaction with consultations. The patients were least satisfied with consultation given by psychiatric nurses. In conclusion, there is need for improvement, but consultations should continue as an important part of the psychiatric service for primary care.

Adult↗
PubMed2000

Clinical value of real-time tertiary fetal ultrasound consultation by telemedicine: preliminary evaluation.

Congenital fetal abnormalities are major causes of perinatal mortality and morbidity. The performance of ultrasound in the diagnosis and assessment of fetal anomalies varies enormously between tertiary referral centers and general units. Telemedicine offers a chance for tertiary realtime ultrasound consultations using standard telephone lines for remote sites. Preliminary investigations by our group have shown that real-time transmission of fetal ultrasound images over long distances via telephone (integrated systems digital network [ISDN]) lines is technically feasible. A live link of up to 2 Mb/s was established between Mater Mothers Hospital in Brisbane and Kirwan Hospital for Women in Townsville, which are 1,500 km apart. The objective of the current study was to evaluate the clinical value of a tertiary teleultrasound consultation service. Patients requiring tertiary ultrasound consultations were recruited from North Queensland. Clinicians from the referral site established an initial diagnosis and management plan. Using standard ISDN lines, the real-time ultrasound images were transmitted to the maternal fetal medicine subspecialists in Brisbane. The ultrasound examination was completed under the direction of the subspecialist. The subspecialist explained the findings to the patient at the end of the session, and discussed the diagnosis and management plans with the clinicians involved. Any diagnosis and management variations were classified into minor and major upon agreement by the two teams of clinicians involved. The clinicians and patients in Townsville rated the value of the consultation, and the subspecialists rated the confidence of their diagnoses on five-point scales. Pregnancy outcomes were obtained and the data analyzed. Over a 3-month period, 24 teleultrasound consultations were carried out. The indications for referral were: assessment of growth restriction/fetal wellbeing in the third trimester (6); detailed assessment for high-risk patients (5); evaluation of markers for anomalies (5); isolated fetal anomalies (1); and complex fetal problems such as twin/twin transfusion, multiple anomalies, etc. (7). Overall, the consultations resulted in some modifications to the clinical diagnosis in 45.8% of the cases, and modifications to the management plan in 33.3% of the cases (about half of which were minor variations). The clinicians rated the teleconsultations highly (mean rating 4.7, SD 0.44). The patients also rated the consultations highly, and were comfortable that their privacy and confidentiality were maintained during the consultation. The subspecialists were confident in making their diagnoses by telemedicine (mean score for confidence 4.2, SD 0.43). All the pregnancies have now been completed, with all antenatal diagnoses confirmed to be correct postnatally. Tertiary real-time ultrasound consultation by telemedicine is not only technically feasible, it is welcomed by the clinicians and patients involved. It also contributes to diagnostic and management differences. Larger scale clinical trials are needed to evaluate the true benefits and costs involved. The social benefits in bridging the healthcare gap between the country and the city, and in enabling patients in remote areas to stay close to their family under times of stress is well recognized by all involved.

Congenital Abnormalities↗
PubMed1995

The usefulness of distinguishing different types of general practice consultation, or are needed skills always the same?

We hypothesized that it might be important to distinguish different types of consultation in order to understand better how help is delivered in general practice. This paper provides preliminary data on the ways that consultations can differ in how they unfold, and on how such differences might affect the helping process and the outcomes of each consultation. Several types of general practice consultation were noticed amongst 210 transcripts. Having established adequate inter-rater reliability of the classification system, we explored the differences between consultations of three broad types: Psychosocial, Complex, and Straightforward. Some of the questions asked in this preliminary study included: 1) do certain sorts of doctor, or patient, engage in certain sorts of consultation? 2) are there any relationships between the type of consultation and its length, patient-centredness or outcomes? 3) are the correlations between process and outcome clearer within categories of consultation than they are if consultations are treated as homogeneous? Findings provide a foundation for further investigations.

Clinical Competence↗
PubMed2002

Special status consultation for frequent attenders. Who are the candidates?

BACKGROUND: The need to optimize frequent attender (FA) care and to economize on scarce resources in primary care has given rise to calls for intervention. However, precise knowledge of the specifics of this need is scarce, as is knowledge of how best to orchestrate intervention vis-à-vis particular FA groups. The aim of the study was to analyse the need for a special FA status consultation and to analyse if such need springs from physical, mental or social factors among FAs. METHOD: Half of the 270 general practices in the County of Aarhus, Denmark, were randomly allocated to the study group (in total 132 practices; 220 general practitioners (GPs)). From these practices age- and gender-stratified samples of FAs were drawn. FAs were defined as the top 10 per cent attenders in 12 months. Questionnaires were used to elicit FA and GP attitudes to the introduction of a status consultation and to obtain GPs' evaluation of their FAs' physical, mental and social status. The special FA consultation was introduced as a reimbursed half-hour consultation where the FA and the GP could discuss the patient's current and future care status. RESULTS: Over three-quarters of the FAs would accept the offer to have the status consultation, and the GPs would recommend it for one-fourth of their FAs. The expressed need was highly associated with an expected positive effect on health (prevalence ratio (PR) for GPs: 11.7 (8.9-15.5), PR for FAs: 1.6 (1.5-1.8)) and a decrease in attendance (PR for FAs: 1.4 (1.3-1.5)). The GPs quoted physical, mental and social indications for the consultation. The FAs who had high levels of functional symptoms were most likely to accept the consultation. CONCLUSIONS: There was an expressed need for an FA status consultation, which may lead to a positive effect on health and attendance. The GPs pointed to physical, mental and social indicators for a special FA consultation.

Adult↗
PubMed1984

Educational influences on consultation rates of house staff physicians in a primary care clinic.

Consultation rates of medical house staff physicians were examined in a primary care setting in order to determine the factors that lead to the use of consultants. The factors that were studied in the regression analysis were clinical experience and teaching in medical school, intensity of use of services, residency year, Alpha Omega Alpha (AOA) membership, and future practice plans. The factors were marginally useful in predicting surgical consultations but were helpful in explaining the use of other consultations. House staff physicians with a pattern of intense ancillary service utilization also requested more consultations. Senior house staff physicians requested fewer consultations than junior house staff members. AOA members and future academic physicians used more consultations than other physicians. Consultation rates were highest for specialties requiring the lowest quantity of education in medical school. Consultation patterns reflect past educational experiences and future practice plans of medical house staff physicians and may be useful in the formulation of the curriculum of medical schools and residencies.

Adult↗
PubMed1997

The efficacy and effectiveness of process consultation in improving staff morale and absenteeism.

OBJECTIVES: The purpose of this randomized controlled trial was to test the efficacy and effectiveness of process consultation consisting of a series of nurse manager-consultant problem-solving meetings for leadership development that would lead to their staff's improved morale, quality of care, and reduced absenteeism. METHODS: Thirteen consenting clinical inpatient units were stratified for four variables known to affect outcome and were then randomly assigned to treatment and control conditions. The nurse managers from the seven experimental units were paired with outside nurse consultants from the McMaster University School of Nursing (Hamilton, Ontario, Canada) in a cooperative form of retraining in problem-solving through process consultation. Morale was determined through measures of perceptions of the work environment, an attitude scale concerning work (alienation), a personality measure (hardiness), and one of each scale for work satisfaction and for sources of satisfaction and dissatisfaction. Demographic data and information regarding family life responsibilities were collected as well. Assessment of quality of care was determined by the frequency and type of incident reports and by patients' perception of their satisfaction. A ratio of absence hours to total paid hours of work was used to compare experimental and control units' absenteeism rates. RESULTS: Experimental subjects reported a statistically significant improvement in the characteristics of their work setting and in the quality of working relationships. The consultation process facilitated a perceived change in the organizational context of the experimental hospital units with less centralization of authority and more clarity about expectation. These organizational changes were accompanied by improved working relationships and less alienation from work. There was no statistically significant difference in absenteeism. However, a subanalysis of the units by "dose" of the intervention identified those who benefited from the effects of the consultation. Subjects whose nurse managers participated more actively in the consultation process accounted for the changes in working relationships and perceived organizational changes. The "low-dose" experimental subjects were more like the control subjects, with the exception of absenteeism, for which they had higher rates. CONCLUSIONS: The findings of this study suggest that process consultation can alter the staff's perceptions of the characteristics of the work setting, can reverse negative attitudes (alienation), and can create a more positive and supportive working environment (improved working relationship). However, the results suggest the need to target this type of intervention to managers who have the personal resources to engage in self-evaluation and personal development and thus to participate in the consultative process.

Absenteeism↗
PubMed1992

Nephropathology consultation via digitized images.

Investigations into a digitized image communications system were prompted by a need to bring expert consultation to physicians in community practice. Pathologists desired the capability to concomitantly view, annotate, and discuss images with referring physicians at distant sites. Methods included evaluation of the human and procedural domain into which the system was to be integrated. The GDCN computer consultation system has the consultant nephropathologist first evaluate the processed biopsy slides, digitize representative images, transmit them with the diagnosis to referring nephrologist, and, finally, conduct an interactive consultation and review of the biopsy and case. Image resolution and compression variables must be set for each individual medical consulting application. For the GDCN, it was found that the 640 x 496 x unlimited color with compression ratios not exceeding 1:32 are acceptable. An obvious improvement of this computerized system over the noncomputerized review sessions is the ability to immediately share and discuss a new image that had not been previously sent. In the old noncomputerized consultation, only images that had been mailed could be discussed. The computerized sessions allow transmission (10 sec) of a new image that the consultation might demand. The computerized sessions also provide the ability to show the referring nephrologist an area of biopsy interest that the pathologist had not previously transmitted. Biopsy slides can be viewed during the consultation, an area digitized, and that image transmitted to the nephrologist during the consultation. Hardware and costs for the sending station were: [table: see text] This system far exceeds the requirements for this particular application; however, it is sufficient to support future, higher-technology computer applications. If necessary, this same system could be used with a less expensive computer, a less expensive camera, software compression, and a single monitor. These alterations could lessen the expenditures by some $8000 and result in a total cost of $10,000. Hardware and costs for the receiving station were: [table: see text] Cost of the receiving station could be reduced by using a less expensive computer and a single monitor system, thereby saving up to $5000 and resulting in a total cost of $7,400. DCCEC and GDCN have elected to use the more expensive, user-friendly and more rapid image transmission system SEND-->IT, rather than the less expensive system mainly because of experience with incorporating the system into the daily activities of the GDCN. SEND-->IT best met the essentials for GDCN.(ABSTRACT TRUNCATED AT 400 WORDS)

Biopsy↗
PubMed1986

The "five minute" consultation: effect of time constraint on clinical content and patient satisfaction.

An experiment was carried out in which patients who were seeking appointments for a consultation in a general practice in south London attended consulting sessions booked at 5, 7.5, or 10 minute intervals. The particular session that the patient attended was determined non-systematically. The clinical content of the consultation was recorded on an encounter sheet and on audio-tape. At the end of each consultation patients were invited to complete a questionnaire designed to measure satisfaction with the consultation. The stress engendered in doctors carrying out surgery sessions booked at different intervals of time was also measured. At surgery sessions booked at 5 minute intervals, compared with 7.5 and 10 minute intervals, the doctors spent less time with the patients and identified fewer problems, and the patients were less satisfied with the consultation. Blood pressure was recorded twice as often in surgery sessions that were booked at 10 minute intervals compared with those booked at 5 minute intervals. There was no evidence that patients who attended sessions booked at shorter intervals received more prescriptions, were investigated or referred more often to hospital specialists, or returned more often for further consultations within four weeks. There was no evidence that the doctors experienced more stress in dealing with consultations that were booked at 5 minute intervals than at consultations booked at 7.5 and 10 minute intervals, though they complained of shortage of time more often in surgery sessions that were booked at shorter intervals.

Appointments and Schedules↗
PubMedDate not supplied

A follow-up study of psychiatric consultations in the general hospital: What happens to patients after discharge?

BACKGROUND: An appropriate follow-up is considered essential in the consultation-liaison psychiatry setting, but it is often neglected. This study evaluated the effectiveness of the psychiatric consultation process in the general hospital, by investigating what occurred to patients 3-5 months after discharge. METHODS: We used a three-part questionnaire: (1) the results of the consultation process; (2) a telephone interview with patients, and (3) a telephone interview with the patients' primary care physician, to whom the patients were referred after discharge from hospital. We contacted all consecutive, unselected patients referred to psychiatric consultation from January to July 1999. Complete data were available for 119 patients from an initial group of 318. RESULTS: The consultation process was well accepted by patients and useful to general hospital physicians to complete the final diagnosis of the patient when discharged from hospital. In most cases (78.9%), the psychiatric letter was attached to the discharge letter. The second part of the questionnaire indicated that most patients were satisfied with the consultation process. They thought it helped focus their problems and 60% asserted that they felt better after following their psychiatrists' instructions or therapy. The primary care physicians agreed with the diagnostic results of the psychiatric consultation, mainly followed the psychiatrists' advice, and generally expressed positive comments about the consultation-liaison service. CONCLUSIONS: Compliance of hospital physicians, patients, and primary care physicians was good. Follow-up studies on outcome of psychiatric consultations are few and further analysis is strongly recommended.

Aged↗
PubMedDate not supplied

Factors affecting the relationship between the timing of psychiatric consultation and general hospital length of stay.

The purpose of this study was to examine the factors affecting the timing of psychiatric consultations and length of stay in the current managed care era. It also assessed the relationships between the timing of consultations and demographic/clinical characteristics. Medical records of 541 consecutive psychiatric consultation patients at a university teaching hospital in 2001 were reviewed for demographic characteristics, lengths of stay, number of days from admission to consultation, specialty services requesting consultations, reasons for the referral given by the referring physicians, and all five axes of DSM-IV. Earlier consultations independently predicted shorter lengths of stay. Delayed consultations were seen more often in women; surgical patients; those seen with a request to assess depression; and those seen with a diagnosis of adjustment disorder, delirium, or no psychiatric disorder. Delay in psychiatric consultations continues to be associated with longer lengths of stay in the current managed care environment. It is now possible that early detection strategies for high-risk patients with behavioral health problems in the medical setting, such as use of the INTERMED, may lead to reduction in delayed psychiatric consultations and thus shorter lengths of stay.

Demography↗
PubMed2004

Consultants in nhs scotland: a survey of work commitments, remuneration, job satisfaction and retirement plans.

BACKGROUND AND AIMS: UK consultants have reported working long hours, increased stress and reduced morale. This study set out to elicit consultants' views on flexible working and to gather data on consultants' workloads, remuneration, job satisfaction and retirement plans. As such it is the first comprehensive study of consultants in NHS Scotland. METHODS: The Information and Statistics Division of the Scottish Executive Health Dept provided a list of consultants working in NHS Scotland Focus groups and interviews informed the design of a postal self-completion, questionnaire. RESULTS: The response ratewas 61%. Almost two-thirds (65%) of respondents felt their workloads were unreasonable and unsustainable and 67% were unable to provide their desired standards of patient care. Two-thirds (67%) did not normally take meal breaks, 63% had insufficient time for outside interests, whilst 44% felt their health was being adversely affected Many (84%) believed that some of their work could be delegated to someone less qualified but 79% agreed that there were insufficient staff to make this possible. The average planned retirement age was 60 years, with 23% describing their plans as definite and 70% as quite or very likely. When asked what might induce them to postpone retirement, 50% cited reduced workload/work intensity. CONCLUSIONS: In 2003, a majority of consultants in the UK voted in favour of the new consultant contract. This will improve consultant pay and introduce a standard 40-hour working week, including worked on-call. This should address tow of the main areas of consultant dissatisfaction in NHS Scotland. However, staff shortages will require to be addressed if the contract is to be successfully implemented.

Adult↗
PubMed1995

Patients frequently consulting general practitioners at a primary health care centre in Sweden--a comparative study.

The purpose of this study was to describe the sociodemographic patterns, consultations and the nature of problems of frequent attenders (FAs) at general practitioners at a primary health care centre. The design was a comparative study of FAs (> or = 5 consultations during 1991) (n = 179) and a contrast group of patients (CPs) matched by age and sex (1-4 consultations during 1991, n = 179). Data from medical records, appointment system, mortality and marital status were recorded. FAs comprised 1.7% of the inhabitants. Boys, middle-aged females, retired males and females and especially very old females were more frequent among FAs than their sections of the population would imply. FAs accounted for 15% and CPs for 4% of the consultations, 6.3 and 1.7 consultations on average, respectively. The average booked time for consultations during 1991 was 140 minutes for FAs and 35 minutes for CPs. Continuity was higher among older than younger FAs. Contacts other than medical consultations comprised a substantial part of the work with FAs, especially among middle-aged and elderly FAs. Problems arising from the musculoskeletal system, psychological and social problems were most common among FAs, often in combination, while chronic diseases such as cardiovascular diseases and diabetes were not crucial for frequent attending. Few FAs consulted as frequently in the preceding years and the following year, as in 1991, but still they accounted for more consultations than CPs during these years. More female FAs than males and CPs were divorced. The study indicates that FAs require a long-term strategy where continuity and accessibility are often important. They might also have profited by more time. However, FAs were a heterogeneous group of patients and follow-up studies and individual studies of FAs would be of interest.

Adolescent↗
PubMed2003

The feasibility of using pattern recognition software to measure the influence of computer use on the consultation.

BACKGROUND: A key feature of a good general practice consultation is that it is patient-centred. A number of verbal and non-verbal behaviours have been identified as important to establish a good relationship with the patient. However, the use of the computer detracts the doctor's attention away from the patient, compromising these essential elements of the consultation. Current methods to assess the consultation and the influence of the computer on them are time consuming and subjective. If it were possible to measure these quantitatively, it could provide the basis for the first truly objective way of studying the influence of the computer on the consultation. The aim was to assess whether pattern recognition software could be used to measure the influence and pattern of computer use in the consultation. If this proved possible it would provide, for the first time, an objective quantitative measure of computer use and a measure of the attention and responsiveness of the general practitioner towards the patient. METHODS: A feasibility study using pattern recognition software to analyse a consultation was conducted. A web camera, linked to a data-gathering node was used to film a simulated consultation in a standard office. Members of the research team enacted the role of the doctor and the patient, using pattern recognition software to try and capture patient-centred, non-verbal behaviour. As this was a feasibility study detailed results of the analysis are not presented. RESULTS: It was revealed that pattern recognition software could be used to analyse certain aspects of a simulated consultation. For example, trigger lines enabled the number of times the clinician's hand covered the keyboard to be counted and wrapping recorded the number of times the clinician nodded his head. It was also possible to measure time sequences and whether the movement was brief or lingering. CONCLUSION: Pattern recognition software enables movements associated with patient-centredness to be recorded. Pattern recognition software has the potential to provide an objective, quantitative measure of the influence of the computer on the consultation.

Computers↗
PubMed1993

General information tapes inhibit recall of the cancer consultation.

PURPOSE: Studies of tape recordings of cancer consultations have produced conflicting results. At the same time, audiotapes containing general information about cancer are poorly evaluated and are distributed to patients in an ad hoc manner. We compared the effects of both interventions on patient satisfaction, psychologic adjustment, and recall of information following their first consultation with a medical oncologist. PATIENTS AND METHODS: Patients (n = 142) were randomized to receive (1) an audiotape of their consultation, (2) an audiotape describing cancer in general terms, or (3) no tape. Recall of information was assessed in a structured interview 4 to 20 days after the consultation. RESULTS: Satisfaction with the consultation increased linearly from no tape to general tape to consultation tape. Satisfaction with the tape itself was higher in patients who received the consultation tape (satisfaction score, 61%) compared with those who received the general tape (43%). Average recall for all groups was 6.4 of the 25 items of information presented, and 2.4 of the six points identified as particularly important by the oncologist. The consultation tape did not improve recall over the no tape control, but the general tape caused a decrease of almost two items in total recall. Spontaneous (ie, unprompted) recall was significantly poorer with the general information tape. Psychologic adjustment to cancer was unaffected. CONCLUSION: We conclude that individual audiotapes have a limited potential to increase recall of information from the oncology consultation. General information tapes about cancer appear to inhibit recall actively.

Adolescent↗
PubMed2002

Pooled cataract waiting lists: views of hospital consultants, general practitioners and patients.

In the National Health Service general practitioners (GPs) usually refer patients to named consultants; thus, waiting times for a particular procedure can vary greatly even within a single centre. An alternative is to pool the waiting list, with patients treated in turn by the consultant available. We sought opinions on this strategy, from patients, GPs, and consultants, in relation to cataract surgery. Questionnaires were sent to 776 consultant ophthalmologists; telephone interviews were conducted with 50 randomly selected Birmingham GPs; and 85 Birmingham patients listed for cataract surgery were asked whether they would change consultant to be operated on sooner. 503 (64%) of the consultants responded. Of consultants, 30% favoured pooled lists and 67% were against. Of patients, 82% favoured pooled lists and 18% were against. Of GPs, 92% favoured pooled lists and 8% were against. Some consultants thought that pooled lists were suitable for routine cases but not for more complex cases. 82% of patients expressed willingness to change consultant in order to get an earlier operation. In units with surgeons whose cataract-surgery practices are similar, pooled lists are one way to maximize theatre use and equalize waiting times for routine cases. The model could be applied to other routine surgical procedures such as hip replacement, herniorrhaphy and prostatectomy.

Aged↗
PubMedDate not supplied

Impact of a clinical pharmacy consult service on guideline adherence and management of gabapentin for neuropathic pain.

OBJECTIVE: Our objectives were to (1) determine whether a computerized clinical pharmacy approval and follow-up consult process for ordering new prescriptions for gabapentin for the treatment of neuropathic pain decreased the number of patients without documented treatment benefit while increasing follow-up and documentation of effectiveness, and (2) describe gabapentin use patterns at a Veterans Affairs (VA) Medical Center, including the use of first-line therapies prior to gabapentin therapy for neuropathic pain. METHODS: The clinical pharmacy intervention included review of (1) the indication for gabapentin; (2) the required use and failure or contraindication of 3 first-line therapies: nonsteroidal anti-inflammatory drugs (NSAIDs), tricyclic antidepressants (TCAs), and capsaicin cream; (3) the initial pain assessment; and (4) patient follow-up in 4 to 6 weeks, with repeat pain assessment. A retrospective chart review was performed for all patients who received a new prescription for gabapentin from October 2002 to April 2003 at the Portland VA Medical Center (PVAMC). The outcomes of interest for the provider group versus the clinical pharmacy managed group included follow-up at 6 weeks or less versus follow-up at more than 6 weeks, documentation of treatment benefit, how many of the 3 first-line therapies were tried before gabapentin, and whether the gabapentin therapy was discontinued. RESULTS: There were 237 patients who received a new prescription for gabapentin between October 2002 and April 2003. Of these gabapentin prescriptions, 61% (n=144) were prescribed for neuropathic pain. Of the new gabapentin prescriptions for neuropathic pain, 61% (n=88) were made from approved clinical pharmacy consults, 38% (n=54) were ordered without a clinical pharmacy consult, and 1% (n=2) were not included because the patient received the drug despite denial by the clinical pharmacy consult. The rate of follow-up to assess documentation of benefit of therapy with gabapentin was 87% (n=62) in the clinical pharmacy consult group compared with 51% (n=27) in the provider-managed group (chi2=18.07, P<0.001). Of the patients who were assessed by follow-up, 89% (n=55) of the clinical pharmacy consult group received follow-up within 6 weeks versus 52% (n=14) of the provider-managed group (chi2=12.63, P <0.001). Compared with the patients managed by clinical pharmacists, 43% (n=23) of the gabapentin patients in the provider-managed group had no evidence of prior use of any of the 3 agents required by the gabapentin neuropathic pain guideline, 55% (n=29) had evidence of prior use of 1 or 2 first-line agents, and only 2% (n=1) had evidence of prior use of all 3 required first-line agents, versus 100% (n=71) of the patients managed by clinical pharmacy consult. There was no difference in the rate of continuation of gabapentin therapy in the group of patients who received clinical pharmacy consults (65%) compared with the provider-managed group (68%, chi2=0.11, P=0.718). Of the 148 pharmacy consults for new gabapentin prescriptions that were completed during the 7-month period from October 2002 through April 2003, 60 (40%) were denied, which resulted in the lack of gabapentin use in these 60 patients. CONCLUSIONS: A clinical pharmacy intervention as part of the management of a treatment guideline for appropriate gabapentin use promotes documentation of drug therapy effectiveness in neuropathic pain and prevention of gabapentin use prior to a trial with alternative first-line therapies.

Amines↗