[What are patients' attitudes towards generic drugs? The example of metformin]

The success of cost containment with generic drugs is based on consumer's willingness to accept substitution. This investigation reveals 3 major themes that can explain attitudes of patients towards generics: 1) personal beliefs and knowledge (coming from the media issues, family, friends) are fragmented and sometimes erroneous, with a background of suspicion on the quality of the generics; 2) relation with the prescriber (indirectly pharmacist) is central to build up patient's trust; suspicious professionals generate an anxious patient; 3) previous experience from the consumer with generics. Starting from patients' experiences and beliefs allows to anticipate their resistance to the generic and to adapt drug prescription choices.

Comparison between two generic questionnaires to assess satisfaction with medication in chronic diseases

Objective

The objective of this work was to compare two generic questionnaires assessing patients’ satisfaction with medication. In addition we tested whether satisfaction can predict adherence to medication regimens in patients with chronic diseases, and which dimensions of satisfaction are most involved.

Methods

This prospective, observational study was conducted over one year in a heterogeneous population of patients with various chronic diseases. Satisfaction with medication was assessed by using the TSQM® vII and the SatMed-Q® questionnaires, and adherence to treatment was assessed with the Morisky-Green questionnaire. Clinical pharmacists interviewed patients to collect clinical, demographic and therapeutic data.

Results

190 patients were enrolled. Both questionnaires showed excellent reliability and correlation was high (R = 0.70; p<0.001). Adherence was correlated with satisfaction with medication whether assessed with the SatMed-Q® (R = 0.23; p = 0.002) or the TSQM® (R = 0.17; p = 0.02). Among different dimensions of satisfaction, convenience of use and side effects are prominent predictors of adherence.

Conclusion

Adherence is related to the patient’s satisfaction with medication whether assessed with the TSQM® vII or the SatMed-Q®. Therefore, these simple questionnaires could be used as predictive tools to identify patients whos’ adherence needs to be improved.

Computerized physician order entry system combined with on-ward pharmacist: analysis of pharmacists' interventions

RATIONALE, AIMS AND OBJECTIVES

To analyse pharmacists' interventions in a setting where a computerized physician order entry system (CPOE) is in use and a pharmacist works on the ward.

METHOD

A prospective cohort study was conducted in seven wards of a French teaching hospital using CPOE along with the presence of a full-time on-ward pharmacy resident. We documented the characteristics of pharmacists' interventions communicated to physicians during the medication order validation process whenever a drug-related problem was identified. Independent predictors of the physician's acceptance of the pharmacist's intervention were assessed using multiple logistic regression analysis.

RESULTS

The 448 pharmacists' interventions concerned: non-conformity to guidelines or contraindications (22%), too high doses (19%), drug interactions (15%) and improper administration (15%). The interventions consisted of changes in drug choice (41%), dose adjustment (23%), drug monitoring (19%) and optimization of administration (17%). Interventions were communicated via the CPOE in 57% of cases and 43% orally. The rate of physicians' acceptance was 79.2%. In multivariate analysis, acceptance was significantly associated with the physician's status [higher for residents vs. seniors: OR = 7.23, CI 95 (2.37-22.10), P < 0.01], method of communication [higher for oral vs. computer communication: OR = 12.5, CI 95 (4.16-37.57), P < 0.01] and type of recommendation [higher for drug monitoring vs. drug choice recommendations: OR = 10.32, CI 95 (3.20-33.29), P < 0.01].

CONCLUSIONS

When a clinical pharmacist is present on a ward in which a CPOE is in use, the pharmacists' interventions are well accepted by physicians. Specific predictors of the acceptance by physicians emerge, but further research as to the impact of CPOE on pharmacist-physician communication is needed.

Overdosed prescription of paracetamol (acetaminophen) in a teaching hospital

INTRODUCTION

Paracetamol is the most commonly used analgesic and antipyretic. Reviews of hospital use of paracetamol are scarce. Little is known about the appropriateness of the dose of paracetamol prescribed for hospitalized adults. The aim of this study was to report on the nature and the frequency of the overdosed prescription of paracetamol observed in adult patients over a 4.5-year period in a teaching hospital.

METHODS

Prescription analysis by pharmacists was performed once a week in six medical and three surgical departments and daily in a post-emergency unit. In cases of prescription error, the pharmacist notified the physician through an electronic alert when a computerized prescription order entry system was available or otherwise by face-to-face discussion. For each drug-related problem detected, the pharmacists recorded relevant details in a database.

RESULTS

From October 2006 to April 2011, 44,404 prescriptions were reviewed and 480 alerts related to the overdosed prescription of paracetamol were made (1% of analyzed prescriptions). The extent of errors of dosage was within the intervals [90-120 mg/kg/d] and greater than 120 mg/kg/d for 87 and 11 patients respectively, who were prescribed a single non-combination paracetamol containing product. Sixty alerts concerned co-prescription of at least two paracetamol containing products with similar frequency for computerized (1.4/1000) or handwritten (1.2/1000) prescriptions.

DISCUSSION

Prescriptions of paracetamol for hospitalized adults frequently exceed the recommended dosage.

CONCLUSION

These results highlight the need for increased awareness of unintentional paracetamol overdose and support the initiation of an educational program aimed at physicians and nurses.

[Influenza A/H1N1v 2009 during pregnancy and breastfeeding: which antiviral to choose?]

SUMMARY

Pregnant women are at increased risk of severe complications associated with H1N1 pandemic influenza. Fever and inflammatory syndrome associated with the infection may also be deleterious for the developing fetus. Therefore, early antiviral treatment is recommended. Oseltamivir and zanamivir are the two therapeutic options available indicated in the treatment of H1N1 influenza; however, limited data is published on their use during pregnancy and lactation. In this review, we will focus on the effects of H1N1 during pregnancy and on data safety of antivirals during pregnancy and lactation. Main health authorities recommendations for H1N1 influenza treatment of pregnant women will also be presented.

[Designing a tool to describe drug interactions and adverse events for learning and clinical routine]

Pharmacists play an important role in prescription analysis. They are involved in therapeutic drug monitoring, particularly for drugs with a narrow therapeutic index, prevention and management of drug interactions, and may be called in to identify side effects and adverse events related to drug therapy. For the polymedicated patient, the medical file, the list of prescribed drugs and the history of their administration may be insufficient to adequately assign the responsibility of a given adverse effect to one or more drugs. Graphical representations can sometimes be useful to describe and clarify a sequence of events. In addition, as part of their academic course, students have many occasions to hear about "side effects" and "drug interactions". However, in the academic setting, there are few opportunities to observe the evolution and the consequences of these events. In the course of their hospital training, these students are required to perform patient follow-up for pharmacotherapeutic or educational purposes and to comment case reports to physicians. The aim of this paper is to present a tool facilitating the graphic display of drug interaction consequences and side effects. This tool can be a useful aid for causality assessment. It structures the students' training course and helps them better understand the commentaries pharmacists provide for physicians. Further development of this tool should contribute to the prevention of adverse drug events.

[Treatment adherence as a social ability: a case of patients with schizophrenia]

Psychosocial rehabilitation programs are available for schizophrenic patients to develop social abilities. Taking into account deficits in drug compliance of such patients, psycho-educational programs have been developed to tackle patients' abilities to take their drugs. One year after discharge from psychiatric facilities however, only 50% of the psychotic patients are still compliant with their drug treatment. The aim of our paper is to describe concepts associated with drug adherence as a social ability, and to illustrate these concepts with a program designed for psychotic patients. First, we define the concept of social rehabilitation, second, we describe strategies available to enhance adherence to drug treatment, third, we present a psycho-educational program developed at St. Egrève Hospital, France. This program is centered on the patient's own capacities to become adherent. Individual in-patient consultations, developed by a team of 3 professionals (psychiatrist, pharmacist, nurse) are linked to indiviual follow-up at home. Their scope is to identify specific targets for the patient's self-efficacy to run his drug treatment in an autonomous way.

Drug-related problems in medical wards with a computerized physician order entry system

OBJECTIVE

Identification and estimation, by clinical pharmacists participating in routine medical rounds, of drug-related problems (DRPs), arising despite the use of a computerized physician order entry (CPOE) system.

METHODS

An 18-month prospective study of DRPs through a CPOE was conducted by seven clinical pharmacists participating in ward activity. DRPs were identified by two independent pharmacists using a structured order review (French Society of Clinical Pharmacy instrument).

RESULTS

A total of 29 016 medication orders relating to 8152 patients were analysed, and 2669 DRPs, involving 1564 patients (56% female; mean age 72.6 years), were identified representing 33 DRPs per 100 admissions. The most commonly identified DRPs were non-conformity to guidelines or contra-indication (29.5%), improper administration (19.6%), drug interaction (16.7%) and overdosage (12.8%). There were 429 different drugs associated with these DRPs. Cardiovascular drugs were the most frequently implicated (22.2%), followed by antibiotics/anti-infectives (13.3%) and analgesics/antiinflammatory drugs (11.3%). Different types of DRPs were closely associated with specific classes of drugs.

CONCLUSIONS

Drug-related problems are common even after implementation of CPOE. In this context, routine participation of clinical pharmacists in clinical medical rounds may facilitate identification of DRPs. Pharmacists should be able to enhance patient safety through such involvement.

[Hemorrhagic complications of anti-vitamin K]

Adverse events related to oral anticoagulants represent a major public health problem. Hemorrhagic episodes are the most frequent complications and can be life-threatening. A 10 month prospective survey on all cases treated with anti-vitamin K (AVK), and admitted to emergency room of CHU Grenoble, was conducted to identify the hemorrhagic adverse drug events (HADE). The evaluation support was a directive questionnaire and consisted of 3 parts: patient characteristics, patient's medicated treatment and the hemorrhagic event. 216 patients treated with AVK were identified and 68 of them presented a hemorrhagic adverse drug event. 60 patients older than 65 years out of 158, presented HADE (38%); versus 8 patients < or = 65 years out of 58 (RR = 2.75; p = 0.0007). Among the patients who have their INR > or = 5, 79% developed HADE versus 16% in the group who had their INR < 5 (< 0.0001). In the group of patients who had a change in drug therapy within the 7 days preceding their admission, 47% developed HADE versus 25% of patients whose treatment was not modified: Anti-microbial agents were the drug most frequently involved. The patient's knowledge of INR value and signs of excess AVK were significant. Concerning missed dose, 48 patients declared taking the missed dose with the next dose or when they remembered: 35% of them developed HADE (p = 0.49).

[Economic impact of pharmacist's interventions: illustration in a rheumatology ward]

BACKGROUND AND OBJECTIVE

Drug-related problems represent a major problem for public health. Beyond the health consequences, we have to take into account the cost of these events. Clinical pharmacy services represent a way to tackle this problem. The objective of this study was to perform a cost minimization study on clinical Pharmacist intervention (CPI) in a Rheumatology ward from a General hospital.

METHODS

During 16 months, CPIs developed in this unit were codified through an instrument proposed by the French Society of Clinica Pharmacy, and avoided costs on Drug acquisition, Medica Devices and working time of nurses were estimated.

RESULTS

610 pharmaceutical interventions were listed during 64 weeks. Among these interventions, 155 resulted in directs savings. 5,940 euro were saved over the period of data collection for an investment of 10,560 euro for pharmacist time. 90% of avoided costs were in these four categories: intravenous to oral administration conversion (44%); overdose (21%); drugs used without any indication (17%) and prescription duration too long (11%).

CONCLUSIONS

The mode is based on the rate of acceptance by the physicians of pharmacist recommendations and the impact time (average length of stay). CPI prevents unnecessary costs but should be followed by other partnerships pharmacy-care units to generate benefits in the current economic context.

A prospective study of quality of life in 77 type 1 diabetic patients 12 months after a hospital therapeutic educational programme

AIM

The aim of therapeutic education includes improvement of quality of life (QOL). However, the majority of studies are focused on biomedical or behavioural markers only. We performed a prospective study to assess QOL in adult type 1 diabetic patients for one year following a hospital educational programme.

METHODS

During this prospective single-centre study, QOL was assessed by the DQOL questionnaire in 77 consecutive patients at baseline and three, six and 12 months after a three-day educational programme.

RESULTS

The rate of response was 72.7% (n=55) at three months and 67.5% (n=52) at one year. The overall DQOL score improved at three months from 65.6+/-10.1 to 70.1+/-10.4 (P<0.001), and at one year from 65.1+/-10.4 to 68.5+/-11.7 (P=0.001). Patients exhibited greater satisfaction (66.3+/-15 versus 75.3+/-14.1, P<0.001), a diminished impact of diabetes (61.2+/-10 versus 63.4+/-9.6, P=0.016) as well as of anxiety related to diabetes (67.6+/-18.6 versus 73.6+/-16.2, P=0.009) at three months. This significant improvement was maintained at one year. Improvement in DQOL score at three months was positively correlated with a reduction in HbA(1c) (7.6+/-1.4% versus 7.8+/-1.4%, P=0.032), (r=-0.293, P<0.037). Patients with serious hypoglycaemia before the programme appeared to derive greater benefit from therapeutic education (OR: 9.88, 95% CI: 1.094-89.20).

CONCLUSION

QOL assessed by DQOL improved after therapeutic education and during the following year. The improvement in DQOL score at three months correlated with a reduction in HbA(1c) levels and appeared to particularly benefit to those who had severe hypoglycaemia before the programme.

Assessment of Clinical Pharmacists' Interventions in French Hospitals: Results of a Multicenter Study

Background:

The development of clinical pharmacy activities in most European countries is underway; however, data on these activities are still poorly reported. Multicenter studies are necessary to standardize and demonstrate the value of clinical pharmacy activities in these countries.

Objective:

To document clinical pharmacists' daily routine interventions (Pls) to identify trends of intervention, drugs, and situations most frequently associated with drug-related problems (DRPs) and to estimate physicians' acceptance of PI.

Methods:

A prospective study of Pls was conducted in 6 French hospitals. The sample consisted of 300 randomized Pls par hospital, recorded during the medication order validation process when a DRP was identified. We recorded patients' demographic characteristics, drugs involved, wards, DRP description, pharmacists' recommendations, and whether or not the recommendations were accepted by the physicians.

Results:

A total of 38, 626 medication orders were analyzed by 28 clinical pharmacists, leading to 1800 Pls (4.66 Pls per 100 medication orders). Of the 1800 Pls, 25.9% targeted psychotropic drugs, 15.9% targeted antithrombotic drugs. 15.5% targeted digestive and metabolic drugs, and 15.0% targeted cardiovascular drugs. The most commonly identified DRPs were nonconformity to guidelines or contraindication (21.3%), followed by improper administration (20.6%), supratherapeutic dose (19.2%), and drug interaction (12.6%). Nearly half (42.2%) of the pharmacists' recommendations were related to drug choice (drug switch 22.2%, drug discontinuation 16.3%, addition of a new drug 3.7%) followed by dose adjustment (23.8%), optimization of administration (21, 9%; change of administration route 10.3%, administration modalities 11.6%), and need for drug monitoring (12.2%). The rate of physicians' acceptance was 73.4% (15.3% refusals, 11.3% not assessable).

Conclusions:

In French hospitals, pharmacists contribute to preventing DRPs during medication order validation. This study suggests that a few types of drugs and errors constitute a substantial proportion of Pls. Knowledge of the most frequent DRPs could significantly increase the efficiency of clinical Pls.