Why is opioid use before hip or knee replacement a problem?

Patients who require THA or TKA suffer from end stage osteoarthritis with chronic pain. Opioids often provide no better pain relief that simple analgesics and yet they carry the risk of additional side effects such as drowsiness and the risk of falls. Moreover, opioid use before surgery is linked to worse outcomes including slower recovery and persistent opioid use three months after surgery.

THA and TKA are among the most common elective surgical procedures performed around the world and numbers are expected to at least double over the next decade.

The OpioidHALT trial (Feasibility of responsible pre-operative opioid use for Hip and knee ArthropLasTy (OpioidHALT) pilot study) was designed to examine the feasibility and acceptability of an intervention to reduce opioid use before elective THA or TKA compared to usual practice.

How OpioidHALT tackles pre-operative opioid use?

There is little published evidence for the effectiveness of opioid dose tapering. One previous retrospective study showed that patients who tapered their opioids before surgery might have better post-surgical outcomes. However, as the study was not randomised it was not known if there was something different about the patients who tapered their doses.

The OpioidHALT study involved video or telephone consultations with a pharmacist starting three months before the date of the operation. The pharmacist worked with each patient to develop an opioid tapering plan that was evaluated for safety by a pain specialist. Patients determined the level of opioid tapering that they wished within the framework of national guidelines i.e. 10 to 25% of the patient’s baseline opioid dose tapered per month.

What the OpioidHALT pilot study tells us

The initial consultations in the OpioidHALT study took about one hour. Follow-up appointments started one week after each dose reduction and were typically shorter, Patients were educated about how to identify and manage opioid withdrawal symptoms. “If necessary, the patient was put back on a higher opioid dose”, says Dr Liu.

OpioidHALT was a pilot study designed to determine whether the intervention delivered by pharmacists led to successful tapering of opioid doses. The results showed that in the intervention group 90% of patients tapered their opioid doses by at least 50% before surgery compared with17% in the usual care group.

Although the pilot study was not powered to evaluate other outcomes, some of the emerging findings suggest important impacts. In the intervention group there were –

• Fewer opioids consumed in hospital
• Smaller quantities of opioids supplied on discharge
• Fewer days in hospital
• Fewer patients taking opioids three months post-operation

Patients in the intervention group also had improved physical function and improved overall body pain intensity.

Why pharmacists should manage pre-operative opioid use

As a result of the impressive results from the OpioidHALT study Dr Jonathan Penm has now received funding of $1.5 million to run the definitive trial (OpioidHALT II). Recruitment started two months ago.

Recordings of the consultations showed that many patients were keen to discontinue opioid use but needed help with the process. “We’ve got patients who are crying [out] to have pharmacists to be more involved in their care …. and that’s something that a lot of pharmacists can do”, says Dr Penm. He adds that the whole multidisciplinary research team says “This is a really good intervention, we should be doing this, pharmacists should be leading it”

About Dr Shania Liu and Dr Jonathan Penm

Dr Shania Liu  BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FSHP, FHEA completed her PhD at the University of Sydney looking at a pharmacist-led opioid tapering program for patients undergoing total hip and knee arthroplasty. Currently, she is a post-doctoral research fellow working at the University of Alberta in Canada where she is leading two large randomised trials looking at pharmacist-partnered management of chronic conditions such as cardiovascular disease. She also  continues to be involved in the pharmacist-led opioid tapering work looking at the impacts of opioid tapering before hip and knee replacement surgery.

At the 2024 FIP Congress Dr Liu was awarded the International Pharmaceutical Federation Early Career in Pharmaceutical Practice Recognition Award. The purpose of the award is to recognise an outstanding early career pharmacist who has made important contributions to their field of practice at a national level, and who is emerging internationally.

Dr Jonathan Penm BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FFIP, FSHP, FPS, FHEA, FANZCAP (PainMgmt, Research) is a senior lecturer at the University of Sydney School of Pharmacy in Australia. He is involved in both teaching and research and is also affiliated with the Prince of Wales Hospital, where he is involved in research with the pain team. His area of interest is evaluating hospital pharmacy services to reduce patient harm and the need for hospital care.  He currently runs several randomised controlled trials and is the Principal Investigator for OpioidHALT II.

Read and watch the full series on our website or on YouTube.

Some 575 patients were screened for inclusion in the OpioidHALT study and 442 were excluded because of low opioid use. “That is the reality of clinical trials for you”, says Dr Shania Liu. “We know that approximately a quarter of patients in [this] population don’t use opioids on a regular basis”, she adds. Nevertheless, dosage tapering is still important for the many patients who are using opioids regularly.

OpioidHALT II

As a result of the impressive results from the OpioidHALT study Dr Jonathan Penm has now received funding of $1.5 million to run the definitive trial (OpioidHALT II). Recruitment started two months ago.  “What’s great about it is all of the pilot sites were so impressed by the pilot that they’ve all stayed on for this definitive trial. Other sites have also expressed interest because they’ve been so excited about it”, says Dr Penm. “We’re going to have more pharmacists, a lot more patients – and [it] will be primarily powered to look at those pain and quality of life outcomes”, he explains.

Pharmacists often improve medication regimens but rarely find out how much of an impact the changes have on patients’ lives. One of the useful and important findings in the OpioidHALT study was that the early benefits of reduced opioid use were sustained for three months. “It just shows you the value that pharmacists can provide to their patients – that when we improve their medicines we could be improving it for much, much longer than you realise and having much, much stronger impact”, says Dr Penm.

All the opioid-tapering consultations were recorded and patients’ reactions made a profound impact on Dr Penm.

“Many of them were just so grateful to have someone listen to them,  to validate what they’ve been going through with their pain and to support them through the opioids. In fact, most of them said, “I’ve never had any benefit from these but I just don’t know how to get off them – and I really would love some help”,  so I think we’ve got patients who are crying [out] to have pharmacists to be more involved in their care, to be more present, to listen to them, to validate what they’re going through – and that’s something that a lot of pharmacists can do”, he says.

In summary Dr Penm says:

“Any work of this calibre is extremely difficult to do with one person and we have a very large team. One of the unique aspects is how multidisciplinary it was – we have pharmacists, we have nurses, we have GPs, we have anaesthetists, we have physiotherapists, we have orthopaedic surgeons – and we know how rare it is to get all these people together in one spot and for all of them to say, “This is a really good intervention, we should be doing this, pharmacists should be leading it”. It’s just beautiful to hear. You don’t always hear that the pharmacist is the most obvious choice but in this case they are. They’re happy, they’re competent, they’re capable – and everyone else doesn’t want to do this because it is not their area of expertise. Well, with pharmacy we’re very comfortable because we know this, we know opioids, we see tapering, we know how to taper, we know what to expect”.

About Dr Shania Liu and Dr Jonathan Penm

Dr Shania Liu  BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FSHP, FHEA completed her PhD at the University of Sydney looking at a pharmacist-led opioid tapering program for patients undergoing total hip and knee arthroplasty. Currently, she is a post-doctoral research fellow working at the University of Alberta in Canada where she is leading two large randomised trials looking at pharmacist-partnered management of chronic conditions such as cardiovascular disease. She also  continues to be involved in the pharmacist-led opioid tapering work looking at the impacts of opioid tapering before hip and knee replacement surgery.

Dr Jonathan Penm BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FFIP, FSHP, FPS, FHEA, FANZCAP (PainMgmt, Research) is a senior lecturer at the University of Sydney School of Pharmacy in Australia. He is involved in both teaching and research and is also affiliated with the Prince of Wales Hospital, where he is involved in research with the pain team. His area of interest is evaluating hospital pharmacy services to reduce patient harm and the need for hospital care.  He currently runs several randomised controlled trials and is the Principal Investigator for OpioidHALT II.

Read and watch the full series on our website or on YouTube.

The initial consultations in the OpioidHALT study – when the opioid tapering plans were developed took about one hour. Follow-up appointments started one week after each dose reduction to check on progress and safety; these were typically shorter, explains Dr Shania Liu. Opioid withdrawal symptoms were one obvious concern. Dr Liu emphasises that the tapering rate was very gradual to minimise the risks of opioid withdrawal and patients were educated about what to look out for and how to overcome withdrawal symptoms. “If necessary the patient was put back on a higher opioid dose to ….. ensure that patient safety came first”, she says.  In fact, all adverse events were recorded during the study.

OpioidHALT findings

OpioidHALT was a pilot study designed to determine whether the intervention delivered by pharmacists led to successful tapering of opioid doses, explains Dr Jonathan Penm. “We also found that currently GPs or primary care physicians are generally responsible for opioid tapering, but that’s not their happy place – they were not comfortable, they did not want to spend their time on that”, he says.  However, pharmacists were keen to undertake this work.  The results showed that in the intervention group 90% of patients tapered their opioid doses by at least 50% before surgery compared with17% in the usual care group. “As a researcher it’s very rare to see such large differences – 17% versus 90%”, says Dr Penm.

Although the pilot study was not powered to evaluate other outcomes, some of the emerging findings suggest important impacts.  Those patients whose opioid doses were tapered before surgery consumed fewer opioids in hospital and received smaller quantities of opioids at discharge.  In addition, the length of hospital stay was shorter (4 days versus 5.6 days) in the intervention group. Three months after the surgery those in the intervention group were much less likely to be taking opioids than those in the control group. They also had improved physical function and  improved overall body pain intensity. Dr Penm notes that “it’s not powered for that so we do have to be a bit cautious  – but these are very promising results”.

About Dr Shania Liu and Dr Jonathan Penm

Dr Shania Liu  BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FSHP, FHEA completed her PhD at the University of Sydney looking at a pharmacist-led opioid tapering program for patients undergoing total hip and knee arthroplasty. Currently, she is a post-doctoral research fellow working at the University of Alberta in Canada where she is leading two large randomised trials looking at pharmacist-partnered management of chronic conditions such as cardiovascular disease. She also  continues to be involved in the pharmacist-led opioid tapering work looking at the impacts of opioid tapering before hip and knee replacement surgery.

At the 2024 FIP Congress Dr Liu was awarded the International Pharmaceutical Federation Early Career in Pharmaceutical Practice Recognition Award. The purpose of the award is to recognise an outstanding early career pharmacist who has made important contributions to their field of practice at a national level, and who is emerging internationally.

Dr Jonathan Penm BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FFIP, FSHP, FPS, FHEA, FANZCAP (PainMgmt, Research) is a senior lecturer at the University of Sydney School of Pharmacy in Australia. He is involved in both teaching and research and is also affiliated with the Prince of Wales Hospital, where he is involved in research with the pain team. His area of interest is evaluating hospital pharmacy services to reduce patient harm and the need for hospital care.  He currently runs several randomised controlled trials and is the Principal Investigator for OpioidHALT II.

Read and watch the full series on our website or on YouTube.

The case for reducing opioid treatment slowly before total hip and knee replacements is compelling, according to Dr Jonathan Penm. Many patients with osteoarthritis are taking opioids but “we know opioids are not the most effective medicine for osteoarthritis, so we’ve got a cohort of people taking a medicine that doesn’t have much evidence, that’s not very effective and comes with a lot of side effects”, he explains. Reducing the opioid doses is unlikely to make pain any worse but it could reduce the risk of harms, he adds. He notes that there is little evidence for the effectiveness of opioid dose tapering.  One previous retrospective study had shown that patients who tapered their opioids before surgery might have better post-surgical outcomes. However, as the study was not randomised it was not known if there was something different about the patients who tapered their doses. “They might just be patients who would naturally taper who weren’t as sick and so they have better outcomes – and so we just didn’t know if these harms were reversible”, he says.

OpioidHALT – objectives and methods

The objective of OpioidHALT study was to examine the feasibility and effectiveness of a pharmacist-led intervention to taper opioid dosage before hip and knee replacement surgery, compared with usual care.  The intervention was delivered via a video or telephone consultation. “Pharmacists and patients met ‘one-on-one’ over a Zoom meeting or over a telephone call and discussed their pain management and opioid use before surgery – approximately three months before their joint replacement surgery – with the aim to gradually taper their opioid dose until the day of their surgery”, explains Dr Shania Liu.

For this pilot study a single pharmacist based in the community conducted all the consultations. The pharmacist was trained using freely available, online resources. “We recently published a training package summarising these resources so any pharmacist can access them”, says Dr Liu. The pharmacist worked with each patient to  develop an opioid tapering plan that was evaluated for safety by a pain specialist. In addition, the GP was kept in the loop at all stages. Dr Liu emphasises the patient-centred nature of the consultations. “Patients could lead the level of opioid tapering that they wished. The opioid tapering rate, however, was guided by national guidelines on opioid tapering rates. So, this was, on average, 10 to 25% of the patient’s baseline opioid dose tapered per month – so quite gradual – and we did monitor for safety”, she says. Furthermore, patients were offered simple analgesics and non-pharmacological approaches to ensure that pain was managed whilst the opioid doses were being tapered.

About Dr Shania Liu and Dr Jonathan Penm

Dr Shania Liu  BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FSHP, FHEA completed her PhD at the University of Sydney looking at a pharmacist-led opioid tapering program for patients undergoing total hip and knee arthroplasty. Currently, she is a post-doctoral research fellow working at the University of Alberta in Canada where she is leading two large randomised trials looking at pharmacist-partnered management of chronic conditions such as cardiovascular disease. She also  continues to be involved in the pharmacist-led opioid tapering work looking at the impacts of opioid tapering before hip and knee replacement surgery.

At the 2024 FIP Congress Dr Liu was awarded the International Pharmaceutical Federation Early Career in Pharmaceutical Practice Recognition Award. The purpose of the award is to recognise an outstanding early career pharmacist who has made important contributions to their field of practice at a national level, and who is emerging internationally.

Dr Jonathan Penm BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FFIP, FSHP, FPS, FHEA, FANZCAP (PainMgmt, Research) is a senior lecturer at the University of Sydney School of Pharmacy in Australia. He is involved in both teaching and research and is also affiliated with the Prince of Wales Hospital, where he is involved in research with the pain team. His area of interest is evaluating hospital pharmacy services to reduce patient harm and the need for hospital care.  He currently runs several randomised controlled trials and is the Principal Investigator for OpioidHALT II.

Read and watch the full series on our website or on YouTube.

Dr Liu’s recent publication, A pilot multicentre randomised clinical trial to determine the effect of a pharmacist-partnered opioid tapering intervention before total hip or knee arthroplasty, reports the findings of the OpioidHALT study.

From left to right: Luis Lourenço, FIP professional secretary; Paul Sinclair, FIP president; Shania Liu

Picture courtesy of FIP

Patients who undergo total hip (THA) and total knee replacement surgery (TKA) suffer from end stage osteoarthritis with chronic pain. “We know from existing research that opioids are often no better than simple analgesics like paracetamol or acetaminophen or anti-inflammatory pain medicines for osteoarthritis-related pain – so these opioids are not providing any additional benefit and yet they carry the risk of additional side effects such as drowsiness and the risk of falls”, explains Dr Liu. Moreover, opioid use before surgery is linked to worse outcomes including slower recovery and persistent opioid use three months after surgery, she adds.

The OpioidHALT trial (Feasibility of responsible pre-operative opioid use for Hip and knee ArthropLasTy (OpioidHALT) pilot study) was designed to examine the feasibility and acceptability of an intervention to reduce opioid use before elective THA or TKA compared to usual practice. “Total hip and knee replacement surgeries are among the most common elective surgical procedures performed around the world with over 1 million of these procedures performed in the USA alone in 2021.  As we know, the population as a whole is aging so these procedures are expected to at least double in volume over the next decade”, explains Dr Liu

About Dr Shania Liu and Dr Jonathan Penm

Dr Shania Liu  BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FSHP, FHEA completed her PhD at the University of Sydney looking at a pharmacist-led opioid tapering program for patients undergoing total hip and knee arthroplasty. Currently, she is a post-doctoral research fellow working at the University of Alberta in Canada where she is leading two large randomised trials looking at pharmacist-partnered management of chronic conditions such as cardiovascular disease. She also  continues to be involved in the pharmacist-led opioid tapering work looking at the impacts of opioid tapering before hip and knee replacement surgery.

At the 2024 FIP Congress Dr Liu was awarded the International Pharmaceutical Federation Early Career in Pharmaceutical Practice Recognition Award. The purpose of the award is to recognise an outstanding early career pharmacist who has made important contributions to their field of practice at a national level, and who is emerging internationally.

Dr Jonathan Penm BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FFIP, FSHP, FPS, FHEA, FANZCAP (PainMgmt, Research) is a senior lecturer at the University of Sydney School of Pharmacy in Australia. He is involved in both teaching and research and is also affiliated with the Prince of Wales Hospital, where he is involved in research with the pain team. His area of interest is evaluating hospital pharmacy services to reduce patient harm and the need for hospital care.  He currently runs several randomised controlled trials and is the Principal Investigator for OpioidHALT II.

Read and watch the full series on our website or on YouTube.

Why community pharmacists need skills in differential diagnosis

By 2026 all pharmacy graduates will have an independent prescribing qualification and there will be a increasing emphasis on clinical activities in community pharmacy.  Professor Rutter’s new book uses a case-study format and emphasises the importance of clinical reasoning to reach a diagnosis.

The WWHAM mnemonic is no longer adequate to guide consultations, he explains.

WWHAM stands for:

• Who: Who is the medicine for?
• What: What are the symptoms?
• How long: How long have the symptoms been present?
• Action: What action has been taken?
• Medication: Are you taking any other medication?

How clinical reasoning underpins effective consultations

Professor Rutter’s new book follows a case study format because this is an effective way to “contextualise facts and figures and knowledge into something more ‘real life’”, he says. For example, a symptom such as cough would be approached very differently in a 75-year-old man from a 5-year-old child. The objective of the consultation is to sift out from the list of possible causes of cough those that are most likely in the patient in question. Clinical reasoning is flexible and responsive and allows the practitioner to take a long list of conditions and narrow it down into a smaller number of possibilities in a logical way.

Clinical reasoning – the challenge of moving from novice to expert

The Pharmacy First scheme allows the pharmacist access to medicines which otherwise would be prescription only medicines (POMs), in specific situations. Clinical reasoning is important in establishing a diagnosis which is the first step in the Pharmacy First service.  Professor Rutter envisages that the Pharmacy First service will be extended in future as part of the movement to make pharmacy a more clinical profession. This will call for more expertise in clinical reasoning and feedback on pharmacists’ performance will be essential to raise their “ceiling of competence”, he explains.

In future, community pharmacists’ clinical role will be extended further and the traditional dispensing role will diminish. In addition, “I think the digital side of pharmacy will increase and that will hopefully allow greater communication between pharmacy and general practice services so they’re better integrated”, he says.

About Paul Rutter

Paul Rutter is  Professor of Pharmacy Practice at Portsmouth University. His main area of interest is differential diagnosis of minor conditions for pharmacists and his academic teaching deals mainly with this topic. He is the author of the textbook, Symptoms, Diagnosis and Treatment in Community Pharmacy, now in its fifth edition. His new book, Differential diagnosis for non-medical prescribers, nurses and pharmacists: A case-based approach, was published in August 2024.

Read and watch the full series on our website or on YouTube.

Link to Pharmacy First 

The Pharmacy First scheme allows the pharmacist access to medicines which otherwise would be prescription only medicines (POMs), in specific situations. This is expected to relieve some pressure on GP services. However, “You’ve still got to make that diagnosis, you’ve still got to get to the point that you are confident that you are dealing with condition X and then you can use the Pharmacy First service to supply the appropriate medicine”, says Professor Rutter. The pharmacist is still responsible for making the diagnosis and the new book “will  help pharmacists establish the diagnosis with more confidence and more accuracy”, he adds.

Clinical Reasoning and Artificial Intelligence

Clinical reasoning and decision making is now creeping in to the undergraduate pharmacy curriculum as independent prescribing is becoming embedded. It is already a feature of post-graduate independent prescribing courses.

In future, artificial intelligence (AI) will undoubtedly play a role in teaching and delivery of services but is unlikely to take over clinical reasoning activities, says Professor Rutter. “Clinical reasoning is fundamentally a thinking and cognitive process that you have to do yourself. So, I think AI will be used to create test cases to give students opportunities to practice this clinical reasoning in a safe environment where they can build up their experience. I think it will augment and supplement how we teach clinical reasoning but the actual process of how you do clinical reasoning has still got to be thought through by the student themselves – so I don’t think AI will ever replace that”, he explains.

Clinical reasoning: from novice to expert

Professor Rutter envisages that the Pharmacy First service will be extended as part of the movement to make pharmacy a more clinical profession. Inevitably, the ways in which pharmacists arrive at a differential diagnosis will come under scrutiny, particularly from GPs who will have been taught clinical reasoning as part of the way they make a diagnosis. When they see that pharmacists are approaching the activity in the same way that they themselves would, it should give pharmacists more credibility and enable GPs to have more confidence in what they do, he says.

Clinical reasoning is, in some ways, a new activity for community pharmacists and it will take time for them to become experts. The development of expertise depends on experience – the more cases of a similar condition that a practitioner sees, the more his or her understanding of the way the condition presents develops. “The biggest challenge for pharmacists is how do you get that feedback …  to know you’re doing a good job”, says Professor Rutter.  If the diagnosis is uncertain then, as a community pharmacist , he would refer the patient to the GP but then rarely receives any feedback. “Most times in community pharmacy you don’t get feedback from the patient or the doctor to tell you whether you were right or wrong. Now for us to become good at clinical reasoning and more expert that loop needs to be closed. I think it’s important that pharmacists try to talk to their GPs when they’re making these referrals to say, “Well, I’m referring this case to you because I think it might be this but I’m not sure. I’d really appreciate it if you could tell me what you think so that I can improve for next time”, and by doing that you’re able to raise your ceiling of competence. …. [If] you get feedback on cases, over time your ceiling of competence goes up and up and up and you’re able to treat more and more patients”, he explains.

Vision for the future

In 10 years’ time, Professor Rutter foresees that community pharmacists’ clinical role will be extended further and most pharmacists will be independent prescribers. Dispensing in community pharmacies will be limited to items required immediately  and much will be done remotely with medicines delivered by post. Pharmacists will the be free to concentrate their efforts on management of long-term conditions for stable patients. “Many of the roles that GPs currently perform I think will be performed in a pharmacy and patients will be directed to the pharmacy more and more rather than the GP. So, I only see the clinical side of pharmacy growing and the traditional kind of dispensing side of pharmacy disappearing. I think we will, at that point, in 10 years’ time, be a very clinical, patient-facing profession. I think the digital side of pharmacy will increase and that will hopefully allow greater communication between pharmacy and general practice services so they’re better integrated”, he says.

About Paul Rutter

Paul Rutter is  Professor of Pharmacy Practice at Portsmouth University. His main area of interest is differential diagnosis of minor conditions for pharmacists and his academic teaching deals mainly with this topic. He is the author of the textbook, Symptoms, Diagnosis and Treatment in Community Pharmacy, now in its fifth edition. His new book, Differential diagnosis for non-medical prescribers, nurses and pharmacists: A case-based approach, was published in August 2024.

Read and watch the full series on our website or on YouTube.

Professor Rutter’s new book follows a case study format because this is an effective way to “contextualise facts and figures and knowledge into something more ‘real life’”, he says. For example, a symptom such as cough would be approached very differently in a 75-year-old man from a 5-year-old child.

Clinical reasoning plays a critical role here. “It’s about bringing forward to the conscious level your thinking. So, it’s about testing a hypothesis,  it’s about thinking “Well, if I’ve got a 5-year-old child with a cough, what’s the likely diagnosis?” and then testing that hypothesis by asking those questions which are pertinent at that time in the conversation. And the type of question will change depending on the context and it will depend on the response of the patient as to what question you would then ask next”, he explains.  “Clinical reasoning is very flexible it responds to what the patient says and you as the clinician are directed to ask your next question based on the information that’s been provided by the patient”, he adds. Each clinician might use a different series of questions for a given problem, depending on their experiences and the way in which they process the information from the patient, but should arrive at the same endpoint.

Returning to the examples above – a 5-year-old child who’s had a cough for a couple of weeks and a 75-year- old man who’s had a cough for three weeks – would call for slightly different questions. Whereas asking about the number of cigarettes smoked daily might be routine for an adult, it would not be appropriate for a 5-year-old child. The objective of the consultation is to sift out from the list of possible causes of cough those that are most likely in the patient in question. Clinical reasoning “allows you to take that long list of conditions and narrow it down into a smaller number of possible conditions which you then can test as to what is it likely to be. So, you might have 20 conditions which cause cough but straight away by the person that you’re talking to and the context that they present in – i.e. how long they’ve had it or things like that – you can go down from say 20 conditions to two or three or four quite quickly, but then you’re very targeted in the questions that you ask”, says Professor Rutter.

About Paul Rutter

Paul Rutter is  Professor of Pharmacy Practice at Portsmouth University. His main area of interest is differential diagnosis of minor conditions for pharmacists and his academic teaching deals mainly with this topic. He is the author of the textbook, Symptoms, Diagnosis and Treatment in Community Pharmacy, now in its fifth edition. His new book, Differential diagnosis for non-medical prescribers, nurses and pharmacists: A case-based approach, was published in August 2024.

Read and watch the full series on our website or on YouTube.

Professor Rutter’s main area of interest is differential diagnosis of minor conditions for pharmacists. His own career started in community pharmacy where he says he “really enjoyed interacting with patients”. He became a teacher/practitioner with Boots the Chemist and found that he also enjoyed teaching. He gained a PhD and started his academic career at Portsmouth University. After spells at Wolverhampton University and the University of Central Lancashire he returned to Portsmouth to take up the post of Professor of  Pharmacy Practice.

Professor Rutter is probably best known for his book on symptoms diagnosis and treatment in Community Pharmacy, now in its fifth edition. His new book, Differential diagnosis for non-medical prescribers, nurses and pharmacists: A case-based approach, is intended to fill a gap that is not covered by the earlier book.  As the scope of practice for community pharmacists expands, skills in differential diagnosis of signs and symptoms will become increasingly important, he says. “We all know that we’re going to have a prescribing workforce – by 2026 all [pharmacy] graduates will have that IP (independent prescribing) qualification and this book is trying to address that extended role for pharmacy”, he explains. The book uses a case-study format and emphasises the importance of clinical reasoning to reach a diagnosis.

Hitherto, pharmacists have relied on the WWHAM (or 2-WHAM) mnemonic to guide consultations. WWHAM stands for:

• Who: Who is the medicine for?
• What: What are the symptoms?
• How long: How long have the symptoms been present?
• Action: What action has been taken?
• Medication: Are you taking any other medication?

Although WWHAM elicits some information from patients it is not a good diagnostic tool. “If you think about the questions that it asks, at least two of those five questions are more to do with management and treatment planning rather than the diagnosis so it doesn’t actually ask many questions to establish the differential diagnosis”, says Professor Rutter. The role of pharmacy in the community has now developed further. “Because we are now being expected to do a lot more in pharmacy, we need to adopt new ways of thinking and new ways of getting information from the patient – and that’s where clinical reasoning comes in”, he explains. The new book is focused on the use of clinical reasoning in order to establish a differential diagnosis, he adds.

WWHAM still has a  place – ideally it is a tool that should be used by pharmacy counter assistants to obtain basic information that can be given to a  pharmacist prior to a consultation, says Professor Rutter.

About Paul Rutter

Paul Rutter is  Professor of Pharmacy Practice at Portsmouth University. His main area of interest is differential diagnosis of minor conditions for pharmacists and his academic teaching deals mainly with this topic. He is the author of the textbook, Symptoms, Diagnosis and Treatment in Community Pharmacy, now in its fifth edition. His new book, Differential diagnosis for non-medical prescribers, nurses and pharmacists: A case-based approach, was published in August 2024.

Read and watch the full series on our website or on YouTube.

Pulmonary embolism – what patients experience

The two most common forms of venous thromboembolism (VTE) are deep vein thrombosis (DVT) and pulmonary embolism (PE). In the UK, about 39 to 115 per 100,000 of the population each year will develop a PE and the mortality rate can be up to 30%. However, “what we’ve started to realise in recent times is that not all PEs are the same and actually there’s distinct groups within that bracket”, says Mr Power. Patients with high-risk (usually large) PEs are critically unwell and require hospital admission.  Patients with low-risk (usually small) PEs can often be managed as outpatients.

How are high and low-risk pulmonary embolisms diagnosed and managed?

A computed tomography pulmonary angiogram (CTPA) is now the first line diagnostic modality for suspected pulmonary embolism, explains Mr Power.  It allows clinicians to identify large and small pulmonary emboli.

In the past there were significant inconsistencies in the management of PE. For example, 50% of DVT patients in Swansea did not receive any follow-up.  The 2019 NCEPOD report of PE management identified similar inconsistencies nationwide. In 2020 the British Thoracic Society (BTS) published quality standards for outpatient PE management and the team in Swansea used this a prompt to review its own services and a catalyst to develop the new service.

How the pulmonary embolism pathway ensures consistent decision-making

The pulmonary embolism pathway has been designed to ensure acute risk assessment and appropriate follow up for all pulmonary embolism patients whether treated as inpatients or outpatients.

Routine risk assessment using the PE severity index (PESI) was introduced for all PE patients. In addition, seven-day and long-term follow-up was put in place. Steps were also taken to ensure that that those patients who initially required hospital admission later entered the same standardised follow-up pathway.

The Swansea model differs from others in that it covers the whole pathway in an integrated way rather than separating the acute phase and the follow-up phase. “So, we have this ideal pathway from day one to month three.  Patients will come into that pathway at different points but the idea is that eventually we reach the same point and because it’s the same group of clinicians doing it, we get the consistency. …. Every patient referred into the service – it doesn’t matter from which point – they will have that input and they’ll have that consistency of decision making”, says Mr Power.

What impact has the pulmonary embolism pathway had?

During the 12-month period September 2022 to the end of August of 2023 some 300 pulmonary embolism (PE) referrals were received. Of these, 89 were managed as ambulatory patients; the 30-day readmission rate was 4% and only 3% required referral to the respiratory team.

At the critical seven-day review, patients undergo a full clinical assessment. As this is done in the Same-Day Emergency Care (SDEC) unit there is immediate access to other specialists if the patient’s clinical status is declining.

One of the biggest challenges was tackling his own strongly-held view that further development of pharmacists’ advanced practice skills was required. A framework for practice has now been developed together with an extensive training programme. The advanced practice training ensures that “we actually add things on to our skills to make us better as prescribing clinicians within that area”, says Mr Power.

How to establish a sustainable pulmonary embolism service

A number of features have contributed to the success of the pharmacy-led outpatient PE pathway including a close working relationship with the doctors, the systematic delivery of seven-day follow-up and pharmacists’ acquisition of advanced practice skills.

Pharmacists now make all the decisions about duration of anticoagulation.  As a result, some registrars and other junior doctors have sat in on pharmacists’ clinics – an experience that Mr Power says has been mutually beneficial.

Anecdotal feedback from patients suggests that those who have gone through the ambulatory pathway tend to be less anxious. “Patients really do seem to respond really well to the service and are very appreciative of having that prompt follow-up”, says Mr Power.

The PE pathway “was the natural next step to ensure that we have a fully comprehensive VTE service which is addressing all of the most common presentations of VTE and offering a high-quality service …. that’s delivering good patient outcomes and is sustainable”, he says. The current arrangement is funded to provide 37.5 hours per week of VTE service, he adds.

The main priority for the immediate future is to develop further the working framework and training process.  Mr Power hopes that in future this might form the basis of a national training framework for pharmacists and other health care professionals who wish to work in this area.

About Kieron Power

Kieron Power is Principal Pharmacist for Thrombosis and Anticoagulation in Swansea Bay University Health Board in South Wales.  His role comprises three elements:

• Thrombosis and Anticoagulation Lead for the health board – a governance role that involves leading on policy and guidance within the Health Board and performance monitoring for hospital-acquired thrombosis rates, venous thromboembolism risk assessments and general anticoagulation prescribing factors.
• Running a weekly thrombosis and anticoagulation specialist clinic on behalf of the consultant haematologists.
• Leading and running the pharmacist-led acute VTE service and follow-up service that operate within the health board

Read and watch the full series on our website or on YouTube.

One concern that is often voiced is the issue of whether junior doctors become de-skilled at some aspects of patient care because clinical pharmacists have taken them over. Mr Power acknowledges that junior doctors now make decisions about duration of anticoagulation less frequently than in the past, “because when we see patients to that three-month point, one of the key things that we do is decide, ‘how long are we going to anticoagulate this patient for?’ – and actually we are doing that almost exclusively within the Health Board”.  As a result, some registrars and other junior doctors have sat in on pharmacists’ clinics – an experience that Mr Power says has been mutually beneficial. “I’ve been very keen to learn from them in terms of their skill set, in terms of how they would approach certain aspects and they’ve been very keen to learn from me.  Again, I think that’s been a really positive experience, especially because we’re working at this advanced practice level, that we’re able to have a little bit of an idea sharing as well so that we’re continuously improving what we’re delivering to our patients”, he says.

Patients who have experienced a pulmonary embolism (PE) are very anxious. Anecdotal feedback from patients suggests that those who have gone through the ambulatory pathway tend to be less anxious. This may be because “they don’t really associate themselves as having an acute serious condition until they’re told following the CTPA (computed tomography pulmonary angiogram).  The patients who have far more traumatic events and are hospitalised have far greater levels of anxiety”, explains Mr Power. Prompt follow-up appears to a major factor contributing to  patient satisfaction. “We offer a dedicated clinic for VTE (venous thromboembolism), we have the knowledge of the condition, we’re able to sit down with the patient and have a discussion around the diagnosis to help them to understand how the recovery process works”, he says. “Patients really do seem to respond really well to the service and are very appreciative of having that prompt follow-up”, he adds.

Comprehensive VTE management

The outpatient PE pathway adds an extra dimension to the existing VTE service. Initially the service was primarily focused on the management of deep vein thromboses (DVTs) and cancer-associated thromboses.  The PE pathway “was the natural next step to ensure that we have a fully comprehensive VTE service which is addressing all of the most common presentations of VTE and offering a high-quality service …. that’s delivering good patient outcomes and is sustainable”, he says.

The current arrangement is funded to provide 37.5 hours per week of VTE service. The team is able to handle both new and follow-up patients and it receives referrals from the SDEC (Same-Day Emergency Care) unit where it is based and other Health Boards.

The main priority for the immediate future is the working framework and training process.  An 18-month competency-based training programme that includes much supervised and  semi-supervised practice has been developed. Mr Power hopes that in future this might form the basis of a national training framework for pharmacists and other health care professionals who wish to work in this area.

About Kieron Power

Kieron Power is Principal Pharmacist for Thrombosis and Anticoagulation in Swansea Bay University Health Board in South Wales.  His role comprises three elements:

• Thrombosis and Anticoagulation Lead for the health board – a governance role that involves leading on policy and guidance within the Health Board and performance monitoring for hospital-acquired thrombosis rates, venous thromboembolism risk assessments and general anticoagulation prescribing factors.
• Running a weekly thrombosis and anticoagulation specialist clinic on behalf of the consultant haematologists.
• Leading and running the pharmacist-led acute VTE service and follow-up service that operate within the health board

Read and watch the full series on our website or on YouTube.