Thinking out loud (intervention tension)

I have found myself thinking (especially recently) about the inherent tension between the robustness of healthcare innovations designed for clinical practice and the extent to which such systems are often overwhelmed. Unfortunately, the term 'overwhelmed' may not be especially hyperbolic (see, for example, the National Academy of Medicine's page on Clinician Well-Being and Resilience, and the national report issued 10/3/2022 [1]).

Let's take the specific example of prevention efforts recommended for use in primary care. In 2003, Yarnall et al [2] found that the "physician time required to provide all services recommended by the US Preventive Services Task Force (USPSTF) at the recommended frequency, to a patient panel of 2500... [was] 7.4 hours per working day." This topic was revisited in 2020, and the estimate had increased to 8.6 hours per working day, despite the fact that "compared to 2003, there [were] fewer recommendations in 2020" [3]. If those parameters hold true, even if physicians did not not perform any services except recommended preventive care, they would still be unable to provide all such care.

Those barriers seem similar, in some ways, to the concerns experienced by pharmacists, who are also highly trained clinical providers. In our research team's census of Indiana managing pharmacists in 2018, we "pitched" a short (10-15 minute) intervention protocol to get a sense of feasibility [4]. Across hundreds of participants, the intervention (called PharmNet) was seen as potentially useful - but, participants raised concerns because of the rapid pace of modern pharmacy practice. One respondent noted, "With the drive-thru mentality, patients are not open to some interventions and the time that it takes to complete them..." And another wrote, "I suspect that most who use opiates will not like the intervention as there is a whole lot more to the intervention...We get yelled at and complained on already..." [4].

This feedback (and similar information from other sources) led to a lot of revisions to the PharmNet intervention, which we trialed in late spring/early summer of this year (2022) in a pilot pharmacy. "The intention," we wrote, "was to study procedures that have as minimal an impact as possible on pharmacy costs and operational functioning while maximally facilitating harm reduction from opioid overdose – in other words, to find an optimal intersection point of those concerns" [5].

The initial data from the pilot implementation study were promising (see more in the write-up here: [5]), but as always, while it's important to consider such information when making decisions, one should not presume that it represents what is likely to be true in all cases. So, the next step will be a pilot cluster randomized trial focused on similar outcomes. Stay tuned...

(with much thanks to collaborators Beth Meyerson and Lori Eldridge)