Pharmacist vs physician management of e-visit requests for COVID-19 medication: A randomized clinical trial.

Abstract

Background: Electronic visits (e-visits), defined as structured asynchronous electronic messages between patients and clinicians requiring clinical decision-making, are being increasingly used to enhance access to outpatient health care services, but the primary care physicians who typically manage them face work overflow. Pharmacists have been proposed to manage e-visits that lead to prescription requests, but scant evidence exists about the effectiveness of this approach.

Objective: To compare pharmacist management of structured asynchronous e-visit requests for COVID-19 medication with physician management regarding quality of care, timeliness, and patient care experience.

Methods: This cluster-randomized clinical trial included adults from 17 medical facilities of Kaiser Permanente Northern California who made e-visits requesting COVID-19 medication (nirmatrelvir-ritonavir) from October 9 to December 11, 2023. In the Pharmacist Care group, a regional team of pharmacists managed e-visits for COVID-19 medication; in the Physician Care group, pools of adult and family medicine physicians managed these visits. The primary outcome was whether a patient with 1 or more potential serious drug-drug interactions received counseling via an electronic secure message. Secondary outcomes included prescribing rates, time to the prescription, and patient perceptions of care quality.

Results: Among the 1,753 eligible patients (mean age = 52.2 [SD = 15.9] years; 57.7% female), 642 received Pharmacist Care and 1,111 received Physician Care. The percentage of patients with a potential drug-drug interaction who were sent counseling messages by the clinician did not differ between the Pharmacist Care (76 of 79 [96.2%]) and Physician Care groups (193 of 201 [96.0%]) (risk difference [RD] = 0.18%; 95% CI = -4.8% to 5.2%). The pharmacist and physician groups had similar rates of prescribing (87.4% vs 84.4%; RD = 2.9; 95% CI = -0.4 to 6.3). Pharmacist Care compared with Physician Care had faster mean time from the initial e-visit submission to the resulting prescription (1.0 vs 2.5 hours; RD = -1.5; 95% CI = -1.9 to -1.2). Pharmacist Care took more clinician time per visit than Physician Care (10.7 vs 4.2 minutes), resulting in higher estimated cost ($11.40 vs $6.70). After the study period, the pharmacist team made protocol changes to improve workflow efficiency, and a follow-up analysis 12 months later found significant reductions in per-visit time (to 5.7 minutes) and estimated cost (to $6.03) under Pharmacist Care. Patient perceptions of care did not differ significantly between groups.

Conclusions: Pharmacist care and physician care for patient e-visits for COVID-19 medication both yielded high quality of care, with no significant group differences. Evaluation of pharmacist care may be warranted for other e-visits designed to facilitate medication prescribing.

Clinical trial: ClinicalTrials.gov NCT06096863.