Results
Of 517 eConsults received from April 1, 2016 to March 31, 2017, 285 (55.1%) met inclusion criteria (Figure). Using a random number generator, 100 eConsults were further reviewed for outcomes of interest.
In this cohort, the mean age was 61 years, 87% were male, and 80% were White individuals. Most patients (83%) had ≥ 1 mental health comorbidity, and 53% had ≥ 2, with depressive symptoms, tobacco use, and/or posttraumatic stress disorder the most common diagnoses (Table 1). Eighty-seven percent of eConsults were for opioid tapers and the remaining 13% were for opioid pharmacotherapy.
The median pain score at time of consult was 6 on a 10-point scale, with no change at 6 months postconsult. However, 41% of patients overall had a median 3.3-point drop in pain score, 17% had no change in pain score, and 42% had a median 2.6-point increase in pain score.
At time of consult, 24% of patients had an opioid and benzodiazepine prescribed concurrently. At the time of the initial request, the mean MEDD was 177.5 mg (median, 165; range, 0-577.5). At 6 months postconsult, the average MEDD was 71 mg (median, 90; range, 0-450) for a mean 44% MEDD decrease. Eighteen percent of patients had no change in MEDD, and 5% had an increase.
One concern was the number of patients whose pain management regimen consisted of either opioids as monotherapy or a combination of opioids and skeletal muscle relaxants (SMRs), which can increase the opioid overdose risk and are not indicated for long-term use (except for baclofen for spasticity). Thirty-five percent of patients were taking either opioid monotherapy or opioids and SMRs for chronic pain management at time of consult and 28% were taking opioid monotherapy or opioids and SMRs 6 months postconsult.
Electronic Consults
Table 2 describes the reasons eConsults were requested. The most common reason was to taper the dose to be in compliance with the CDC 2016 guideline recommendation of MEDD < 90 mg, which was later increased to 100 mg by the VA/DoD guideline.
On average, eConsults were completed within a mean of 11.5 days of the PCP request, including nights and weekends. The CPS spent a mean 66.8 minutes to complete each eConsult. Once the eConsult was completed, PCPs took a mean of 9 days to initiate the primary recommendation. This 9-day average does not include 11 eConsults with no accepted recommendations and 11 eConsults for which the PCP implemented the primary recommendation before the CPS completed the consult, most likely due to a phone call or direct contact with the CPS at the time the eConsult was ordered.
A mean 3.5 actionable recommendations were made by the CPS and a mean 1.6 recommendations were implemented within 6 months by the PCP. At least 1 recommendation was accepted/implemented for 89% of patients, with a mean 55% recommendations that were accepted/implemented. Eleven percent of the eConsult final recommendations were not accepted by PCPs and clear documentation of the reasons were not provided.