Clinical pharmacy as a guarantee of safety in times of crisis: evolution and relevance of the continued presence of clinical pharmacists in frontline medical units during the first wave of COVID-19

BackgroundThe COVID-19 pandemic has had a major impact on the organisation of health services worldwide. In the first wave, many therapeutic options were explored, exposing patients to significant iatrogenic risk. In a context in which patient management was not well defined by clear recommendations and in which healthcare professionals were under great stress, was it still relevant to maintain pharmaceutical care or did it bring an additional factor of disorganisation?

OBJECTIVE

The aim of our study was to compare the relevance of pharmaceutical care practices before and during the COVID-19 crisis.

METHODS

A retrospective, comparative, observational analysis was conducted in two medical units in a French university hospital that were receiving patients with COVID-19 and benefiting from pharmaceutical care prior to the crisis. This study compared clinical pharmacy performance between two 1.5-month periods before and during the COVID-19 crisis. Performance was assessed according to the CLEO scale, rating the clinical, economic and organisational impacts of the accepted pharmaceutical interventions (PIs) performed in these units.

RESULTS

Of the 675 accepted PIs carried out in the two medical units over the entire study period, PIs performed during the COVID-19 period had a greater significant clinical impact (72% vs 56%, p˂0.0001), a more positive economic impact (38% vs 23%, p˂0.0001) and a more favourable organisational impact (52% vs 20%, p˂0.0001) than those performed prior to the COVID-19 period.

CONCLUSIONS

The health crisis generated important changes in care practices. Our study demonstrates the sustained relevance of pharmaceutical care during a health crisis. This local experience confirms the major interest in improving the integration of pharmaceutical expertise within French healthcare teams.

Successful Training of Patients to Intervene in Health Education and Clinical Research at Grenoble Patient School

The primary goal of patient and public involvement (PPI) in healthcare is to improve individual and population health outcomes. This study reports on the successful training of patients to be involved in patient education as peers and clinical research at Grenoble Patients' School (GPS). GPS was founded by patients as an independent association to train patients to the above objectives tasks. The training team was multi-professional and included expert PPI who were part of the professional team. Medical faculty members and 45 patients, 59% females, 52 ± 6.4 years old, trained between 2016 and 2017, showed high satisfaction at the end of the training courses. Almost all the trained patients were involved as peer educators and 4 were involved in clinical research projects at different stages under the guidance of medical teams. Patient involvement at GPS provided strong benefits to trainees and had some impact on education and obtaining research grants. The outcome of this patient training program resulted in the creation of a Patients' Department within the Medical and Pharmacy Schools at the Université Grenoble Alpes in 2020, https://medecine.univ-grenoble-alpes.fr/departements/departement-universitaire-des-patients/.

[Educational needs and implantable medical devices: how to meet the expectations of patients with coronary stents and heart valves?]

At the Grenoble Alpes University Hospital Center, patients with cardiovascular disease have the opportunity to participate in a therapeutic education program in the cardiac rehabilitation department. The objective of this study is to analyze the educational needs of patients with coronary stents and heart valve prostheses. Using an exploratory qualitative method, semi-structured research interviews were conducted with 22 patients and an inductive thematic analysis was performed. We found that emergency surgery does not facilitate the assimilation of information in comparison with a scheduled procedure. The image of the "repaired heart" creates a cognitive conflict with the chronicity imposed by secondary preventive monitoring, a particularity of the implantable medical device. Patients feel that the information they receive is sometimes too voluminous and not adapted to their current needs. Thus, we propose an individualized support model based on the respect of temporality and on the psycho-behavioral functioning of the patient.

CLEO: a multidimensional tool to assess clinical, economic and organisational impacts of pharmacists' interventions

OBJECTIVES

Clinical pharmacists' interventions (PIs) are an important element in ensuring good pharmaceutical care. We aimed to develop and validate a comprehensive multidimensional tool for assessing the potential impact of PIs for daily practice of medication review.

METHODS

Experts of the French Society of Clinical Pharmacy (SFPC) developed the CLinical, Economic and Organisational (CLEO) tool, consisting of three independent dimensions concerning clinical, economic and organisational impact. They were asked to analyse 30 scenarios of PIs, and re-rated 10 PIs with a washout of 1 month (internal validation). Then, seven external experts not involved in the development of the tool rated 60 scenarios collected when using the CLEO in daily practice. Inter- and intra-rater reliabilities were determined by calculation of the intra-class correlation (ICC_A,1). Users' satisfaction and acceptability of the tool were assessed on a 7-level Likert scale with a 17-item questionnaire.

RESULTS

For internal reliability, the inter-rater reliability for the CLEO tool was good for clinical dimensions (ICC_A,1=0.693), excellent for economic dimensions (ICC_A,1=0.815) and fair for organisational dimensions (ICC_A,1=0.421); and the intra-rater reliability was good for clinical dimensions (ICC_A,1=0.822), excellent for economic dimensions (ICC_A,1=0.918) and good for organisational dimensions (ICC_A,1=0.738). For external reliability, the inter-rater reliability was good for clinical dimensions (ICC_A,1=0.649), excellent for economic dimensions (ICC_A,1=0.814) and fair for organisational dimensions (ICC_A,1=0.500). CLEO was viewed as relevant (mean±SD 4.93±1.27), acceptable (4.81±1.78), practicable (5.56±1.45) and precise (5.38±1.47).

CONCLUSIONS

CLEO is a comprehensive tool assessing clinical, economic and organisational impacts of PIs which has been developed, validated and was reliable and feasible for use in routine clinical practice.

Effectiveness of a multicomponent pharmacist intervention at hospital discharge for drug-related problems: A cluster randomised cross-over trial

AIMS

The aim of this study was to assess whether a pharmacist intervention associating medication reconciliation at discharge with a link to the community pharmacist reduces drug-related problems (DRP) in adult patients during the 7 days after hospital discharge in 22 university or general hospitals in France.

METHODS

We conducted a cluster randomised cross-over superiority trial with hospital units as the cluster unit. The primary outcome was a composite of any kind of DRP (prescription/dispensation, patient error or gap due to no medication available) during the 7 days after discharge, assessed by phone with the patient and community pharmacist. Among secondary outcomes, we studied self-reported unplanned hospitalisations at day 35 after discharge and severe iatrogenic problems.

RESULTS

A total of 1092 patients were enrolled in 48 units (538 in the experimental periods and 554 in the control periods). Three patients refused to have their data analysed and were excluded from the analyses. As compared with usual care, the pharmacist intervention led to a lower proportion of patients with at least one DRP (44.0% vs 50.6%; odds ratio [OR] 0.77, 95% confidence interval [CI] 0.61-0.98) and severe iatrogenic problems (5.2% vs 8.7%; OR 0.57, 95% CI 0.35-0.93) but no significant difference in unplanned hospitalisations at day 35 (5.8% vs 4.5%; OR 1.46, 95% CI 0.91-2.35).

CONCLUSION

Medication reconciliation associated with communication between the hospital and community pharmacist may decrease patient exposure to DRP and severe iatrogenic problems but not unplanned hospitalisation. However, this intervention could be recommended in health policies to improve drug management.

Evaluation of a collaborative care program for pulmonary hypertension patients: a multicenter randomized trial

Background Pulmonary hypertension is a rare, chronic and life-threatening group of diseases. Recent advances in pulmonary hypertension management prolong survival and improve quality-of-life. However, highly complex drug therapy enhances the risk of drug-related problems. Objective To assess the impact of involving clinical pharmacists in the collaborative care of pulmonary hypertension patients. Setting Ten French University Hospital Pneumology departments, all members of the French Network for Pulmonary Hypertension. Methods This prospective multicenter randomized controlled trial included incident pulmonary hypertension patients who were followed-up for 18 months. Randomization using an adapted Zelen method allocated patients to collaborative care (n = 41) or usual care groups (n = 51). A collaborative care program involving clinical pharmacists was developed through a close partnership between with physicians, nurses and pharmacists. Besides usual care, the program includes regular one-to-one interviews between the pharmacist and the patient. These interviews had following objectives: to perform an exhaustive medication history review; to identify the patient' needs, knowledge and skills; to define educational objectives and to provide patients with relevant information when needed. Following each interview, a standardized report form containing the pharmacist's recommendations was provided to physicians and nurses and discussed collaboratively. An ancillary economic analysis was performed. Main outcome measure Number of drug-related problems and their outcomes. Results The number of drug-related problems was not significantly different between groups (1.6 ± 1.5 vs. 1.9 ± 2.4; p = 0.41). More problems were resolved in the collaborative care group than in the usual care group (86.5% vs. 66.7%, p = 0.01). Time to clinical worsening, therapeutic adherence, satisfaction or quality-of-life were not statistically different between groups. Collaborative care decreased costs of drug-related hospitalizations. Conclusion Including clinical pharmacists in the multidisciplinary care of hospitalized patients with pulmonary hypertension improved the outcome of drug-related problems and reduced the costs of related hospitalization. However, we observed no efficacy on medication errors, clinical outcomes or medication adherence. Clinical Trial Registration ClinicalTrials.gov Identifier NCT01038284.

Clinical, economic and organizational impact of pharmacist interventions on injectable antineoplastic prescriptions: a prospective observational study

Background

Pharmacists play a key role in ensuring the safe use of injectable antineoplastics, which are considered as high-alert medications. Pharmaceutical analysis of injectable antineoplastic prescriptions aims to detect and prevent drug related problems by proposing pharmacist interventions (PI). The impact of this activity for patients, healthcare facilities and other health professionals is not completely known. This study aimed at describing the clinical, economic, and organizational impacts of PIs performed by pharmacists in a chemotherapy preparation unit.

Methods

A prospective 10-week study was conducted on PIs involving injectable antineoplastic prescriptions. Each PI was assessed by one of the four multidisciplinary expert committees using a multidimensional tool with three independent dimensions: clinical, economic and organizational. An ancillary quantitative evaluation of drug cost savings was conducted.

Results

Overall, 185 patients were included (mean age: 63.5 ± 13.7 years; 54.1% were male) and 237 PIs concerning 10.1% prescriptions were recorded. Twenty one PIs (8.9%) had major clinical impact (ie: prevented hospitalization or permanent disability), 49 PIs (20.7%) had moderate clinical impact (ie: prevented harm that would have required further monitoring/treatment), 62 PIs (26.2%) had minor clinical impact, 95 PIs (40.0%) had no clinical impact, and 9 PIs (3.8%) had a negative clinical impact. For one PI (0.4%) the clinical impact was not determined due to insufficient information. Regarding organizational impact, 67.5% PIs had a positive impact on patient management from the healthcare providers’ perspective. A positive economic impact was observed for 105 PIs (44.3%), leading to a saving in direct drug costs of 15,096 €; 38 PIs (16.0%) had a negative economic impact, increasing the direct drug cost by 11,878 €. Overall cost saving was 3218€.

Conclusions

PIs are associated with positive clinical, economic and organizational impacts. This study confirms the benefit of pharmacist analysis of injectable antineoplastic prescriptions for patient safety with an overall benefit to the healthcare system.

Does dissatisfaction with physicians lead patients to alternative practitioners?

OBJECTIVES

To test the dissatisfaction hypothesis by focusing on the use of CAM practitioners by low back pain patients. Moreover, we have distinguished between the complementary use and the alternative use of a CAM practitioner to medical care.

METHODS

We conducted a cross-sectional study of a sample of 2,056 adults living in metropolitan France.

RESULTS

The likelihood of the alternative use of a CAM practitioner decreased with increasing satisfaction with the general practitioner (OR: 0.990, 95% CI 0.984-0.996). The likelihood of the complementary use of a CAM practitioner (excluding osteopaths) decreased with increasing satisfaction with medical care (OR: 0.984, 95% CI 0.972-0.996).

CONCLUSIONS

Our results support the dissatisfaction hypothesis to explain the use of CAM practitioners for low back pain, whether this use is alternative or complementary to medical care. However, concerning the complementary use, our study shows that this hypothesis is invalid for osteopaths.

The ABC taxonomy for medication adherence translated into French and German

AIMS

We translated the ABC adherence taxonomy (i.e. 7 terms and their corresponding definitions) published by Vrijens et al. (2012) into French and German without changing the original meaning with the aim to promote a standardised taxonomy for medication adherence to French- and German-speaking researchers and clinicians.

METHODS

A Delphi survey was performed. To generate round 1, we identified French and German synonyms for the 7 adherence terms through a literature search in PubMed. Investigators translated the original English definitions into French and German. Panellists were members of ESPACOMP-the International Society for Patient Medication Adherence; experts suggested by ESPACOMP members and first authors of medication adherence publications in French and German. Google forms were used to create online questionnaires. Delphi rounds were performed until consensus was reached. The consensus was defined according to the acceptance rate as moderate consensus (50-75%), consensus (>75-95%), and strong consensus (>95%).

RESULTS

The literature search resulted in 4-6 (French) and 4-7 (German) items per English term. Delphi rounds were launched between November 2016 and April 2018. Three rounds sufficed to reach consensus on all terms and definitions from 26 French-speaking and 25 German-speaking panellists. Preferred terms for medication adherence are adhésion médicamenteuse (82%) in French and Medikamentenadhärenz (88%) in German.

CONCLUSION

The use of a common terminology for medication adherence with translations in French and German will contribute to standardise the vocabulary, to harmonise research projects and ultimately ease comparison of study results among researchers and clinicians.

Do compensatory health beliefs predict behavioural intention in a multiple health behaviour change context? Evidence in individuals with cardiovascular diseases?

Multiple health behaviour change (MHBC) represents one of the best ways to prevent reoccurrence of cardiovascular events. However, few individuals with cardiovascular diseases engage in this process. The present study examined the role of compensatory health beliefs (CHB; i.e., belief that a healthy behaviour compensates an unhealthy one) as a drag to engagement in this process. Some studies have shown that CHBs predict intention to engage in healthy behaviours, but no study has investigated CHBs in individuals who actually need to change multiple health behaviours. The goal was to better understand the role of CHBs in intentions formation process among individuals with cardiac diseases in an MHBC context. One hundred and four patients completed a questionnaire at the beginning of their cardiac rehabilitation program. Results showed that: (1) CHBs negatively predicted intentions (2) but only for participants with high self-efficacy or low risk perception; (3) CHBs predictions differed depending on the nature of the compensating behaviour, and were more predictive when medication intake was the compensating one. Findings only partially confirmed previous research conducted on healthy individuals who were not in an MHBC process, and emphasized the importance of considering CHBs for individuals in this process.

A successful antibiotic treatment by a new administration route: a case report of a subcutaneous administration of ceftazidime and tobramycin

When intramuscular or intravenous administrations of parenteral drugs are not possible, the use of other routes (e.g., subcutaneous route) should be considered. We report a patient with Duchenne muscular dystrophy, who was hospitalized for acute pneumonia due to antibiotic-resistant strains of bacteria. Our patient was successfully recovered with antimicrobial therapy by subcutaneous administration of ceftazidime and tobramycin, for which no safety and efficacy data are available in humans. To the best of our knowledge, this case is the first supporting the subcutaneous administration safety and potential efficacy of both ceftazidime and tobramycin in humans.

[Involvement of hospital pharmacy technician for expanding medication reconciliation process in France: Actors' willingness and opinions]

OBJECTIVES

Medication reconciliation is widely promoted by international health authorities. Its expansion requires human resources, which are limited and unequally distributed among health care facilities. Recent international studies support the involvement of pharmacy technician in the medication reconciliation process but his role remains unstructured in France. We aimed to assess pharmacy technicians' opinions and willingness to be involved in the medication reconciliation process expansion and to identify the levers and barriers of the project.

METHODS

A field study was conducted among health facilities of our territory hospital group. Semi-structured interviews were carried out with different pharmacy technicians. Data were analyzed using a qualitative thematic analysis approach.

RESULTS

Overall, 12 pharmacy technicians from 5 hospitals were interviewed and almost all assumed their rightful place in the medication reconciliation process (n=11), with a view to revaluating tasks. For all pharmacy technicians, the main barriers to participate in medication reconciliation were the lack of time and training. The spread of a "patient culture", the supervision by pharmacists, the desire to be part of the care team in the ward and additional training requests were major levers of change.

CONCLUSIONS

Pharmacy technicians' role in expanding medication reconciliation process is legitimate and must be standardized in France. The deployment of the project requires to be formalized within a territory and should consider and develop local organisations.

Predictive factors of complementary and alternative medicine use in the general population in Europe: A systematic review

AIM

To identify predictive factors of CAM use in the general population in Europe.

METHODS

We performed a systematic review to summarize and analyse the published data on factors predictive of CAM use by the general population in Europe. The Cumulative Index to Nursing and Allied Health Literature, Google Scholar, PsycInfo, PubMed and the Web of Science databases were systematically searched up to August 2, 2018. We selected observational studies (case-control, cohort and cross-sectional) of adults conducted in Europe. Risk of bias was determined using the ROBINS-I tool recommended by the Cochrane Group.

RESULTS

Over six thousand articles were identified of which 49 met our inclusion criteria. Twenty three studies investigated the consultation of CAM practitioners, five looked at the use of CAM products, one concerned CAM practices and twenty studied combinations of these. Female gender and self-reported chronic disease are predictive factors of CAM practitioner use. In contrast, marital status is not a predictive factor for consulting a CAM practitioner. Female gender is also a predictive factor of CAM product use. For all other factors investigated, no clear conclusions could be drawn.

CONCLUSION

We found no clear specificity of the use of CAM practitioners versus conventional health practitioners. Other directions of public health research should be explored, rather than assuming that there is specificity.

[We have to stop talking about "non compliant" patients but rather about patients with difficulties of medication adherence]

Medication adherence can be defined as the link between "what the patient implements" and "what the patient and his doctor have decided together after negotiating without constrains". This definition should be put into perspective with the chronology of the disease and the way the patient experiences it. Counselling actions should always be adapted to the situation and negotiated with the patient, all along the process of care. This article proposes a model for this process and offers options pour tailored counselling. Key elements for pharmacist's practice are: simplify the prescription; communicate with the patient according to his stage of acceptation of the disease; get adequate training for motivational interviewing.

Description and analysis of hospital pharmacies in Madagascar

OBJECTIVE

Madagascar's health care system has operated without formal hospital pharmacies for more than two decades. The gradual integration of pharmacists in public hospitals since 2012 will allow the structuring of this field. This study was conducted to characterize the current situation regarding all aspects relating to the general functioning of hospital pharmacies and the services provided.

METHODS

This qualitative research used semi-structured interviews. Interviewees' perceptions about the general organization and functioning of hospital pharmacies and details on services provided were collected. The 16 interviewees were Ministry of Health staff members involved in hospital pharmacy, hospital directors, medical staff members and hospital pharmacy managers. Interviews were recorded, translated into French if conducted in Malagasy, and fully transcribed. Verbatim transcripts were coded according to the themes of hospital pharmacy and topical content analysis was performed.

RESULTS

The principal issue perceived by interviewees was the heterogeneity of the system in terms of technical and financing management, with a main impact on the restocking of pharmaceutical products. The drug supply chain is not under control: no internal procedure has been established for the selection of pharmaceutical products, the quantification of needs is complex, stock management is difficult to supervise, a standard prescription protocol is lacking, dispensing is performed by unqualified staff, no pharmaceutical preparation is manufactured in the hospitals and administration occurs without pharmaceutical support.

CONCLUSIONS

Progressive structuring of efficient hospital pharmacy services using the Basel statements for the future of hospital pharmacy is urgently needed to improve health care in Madagascar.

Theory-Based Interventions Combining Mental Simulation and Planning Techniques to Improve Physical Activity: Null Results from Two Randomized Controlled Trials

Interventions to assist individuals in initiating and maintaining regular participation in physical activity are not always effective. Psychological and behavioral theories advocate the importance of both motivation and volition in interventions to change health behavior. Interventions adopting self-regulation strategies that foster motivational and volitional components may, therefore, have utility in promoting regular physical activity participation. We tested the efficacy of an intervention adopting motivational (mental simulation) and volitional (implementation intentions) components to promote a regular physical activity in two studies. Study 1 adopted a cluster randomized design in which participants (n = 92) were allocated to one of three conditions: mental simulation plus implementation intention, implementation intention only, or control. Study 2 adopted a 2 (mental simulation vs. no mental simulation) × 2 (implementation intention vs. no implementation intention) randomized controlled design in which fitness center attendees (n = 184) were randomly allocated one of four conditions: mental simulation only, implementation intention only, combined, or control. Physical activity behavior was measured by self-report (Study 1) or fitness center attendance (Study 2) at 4- (Studies 1 and 2) and 19- (Study 2 only) week follow-up periods. Findings revealed no statistically significant main or interactive effects of the mental simulation and implementation intention conditions on physical activity outcomes in either study. Findings are in contrast to previous research which has found pervasive effects for both intervention strategies. Findings are discussed in light of study limitations including the relatively small sample sizes, particularly for Study 1, deviations in the operationalization of the intervention components from previous research and the lack of a prompt for a goal intention. Future research should focus on ensuring uniformity in the format of the intervention components, test the effects of each component alone and in combination using standardized measures across multiple samples, and systematically explore effects of candidate moderators.

A Randomised Controlled Trial to Test the Effectiveness of Planning Strategies to Improve Medication Adherence in Patients with Cardiovascular Disease

BACKGROUND

Low levels of adherence to medication prescribed to treat and manage chronic disease may lead to maladaptive health outcomes. Theory-based, easy-to-administer interventions that promote patients' effective self-regulation of their medication-taking behaviour are needed if adherence is to be maximised. We tested the effectiveness of an intervention adopting planning techniques to promote medication adherence.

METHODS

Outpatients with cardiovascular disease (N = 71) were allocated to either an experimental condition, in which participants were asked to form implementation intentions and coping plans related to their treatment, or to a no-planning control condition, in which participants received no treatment. Patients also completed self-report measures of medication adherence, self-efficacy, and beliefs in medication necessity and concerns. Measures were administered at baseline and at 6-week follow-up.

RESULTS

Results revealed no overall main effect for the intervention on medication adherence. Post-hoc moderator analyses revealed that the intervention was effective in patients with lower necessity beliefs compared to those with higher necessity beliefs.

CONCLUSION

While current findings have promise in demonstrating the conditional effects of planning interventions, there is a need to replicate these findings by manipulating planning and beliefs independently and testing their direct and interactive effects on medication adherence.

Reduced variability and execution time to reach a target with a needle GPS system: Comparison between physicians, residents and nurse anaesthetists

Ultrasound (US) guided needle positioning is safer than anatomical landmark techniques for central venous access. Hand-eye coordination and execution time depend on the professional's ability, previous training and personal skills. Needle guidance positioning systems (GPS) may theoretically reduce execution time and facilitate needle positioning in specific targets, thus improving patient comfort and safety. Three groups of healthcare professionals (41 anaesthesiologists and intensivists, 41 residents in anaesthesiology and intensive care, 39 nurse anaesthetists) were included and required to perform 3 tasks (positioning the tip of a needle in three different targets in a silicon phantom) by using successively a conventional US-guided needle positioning and a needle GPS. We measured execution times to perform the tasks, hand-eye coordination and the number of repositioning occurrences or errors in handling the needle or the probe. Without the GPS system, we observed a significant inter-individual difference for execution time (P<0.05), hand-eye coordination and the number of errors/needle repositioning between physicians, residents and nurse anaesthetists. US training and video gaming were found to be independent factors associated with a shorter execution time. Use of GPS attenuated the inter-individual and group variability. We observed a reduced execution time and improved hand-eye coordination in all groups as compared to US without GPS. Neither US training, video gaming nor demographic personal or professional factors were found to be significantly associated with reduced execution time when GPS was used. US associated with GPS systems may improve safety and decrease execution time by reducing inter-individual variability between professionals for needle-handling procedures.

[Identification of knowledge deficits of pharmacy students at the beginning of the fifth year of pharmacy practice experience: Proposals to change the content of academic programs]

INTRODUCTION

In France, community pharmacy students performed a hospital pharmacy practice experience during the 5th year of the university curriculum. The purpose of a part of the content of the academic teaching program delivered before this practice experience is to prepare the students for their future hospital activities. It should enable them for the practical use of knowledge in order to improve pharmacotherapy, laboratory diagnosis and monitoring of patients' care. The aim of this study was to show if there are gaps in this program.

METHODS

Fourteen students performing their clerkship in a teaching hospital were invited to highlight these gaps when they were gradually immersed in the pharmaceutical care. They did so under the careful observation of hospital pharmacist preceptors. These practitioners referred to professional guidelines, documentary tools used in daily clinical practice and publications supporting their pharmaceutical care practices.

RESULTS

Shortcomings and gaps identified were: how to communicate with other healthcare professionals and the content of verbal exchanges, how to conduct a patient-centered consultation, documentation tools required for relevant pharmacist' interventions, codification of pharmacist's interventions, risks related to drug packaging and benefit risk assessment of health information technologies.

DISCUSSION

These gaps represent a handicap by delaying the process that led to move from student to healthcare professional. Hospital pharmacist preceptors have to fill in these gaps before engaging students in pharmaceutical care.

CONCLUSION

These results invite to revise partly the content of the academic teaching program delivered before the 5th year hospital pharmacy practice experience.

Why Do Patients with Chronic Inflammatory Rheumatic Diseases Discontinue Their Biologics? An Assessment of Patients’ Adherence Using a Self-report Questionnaire

Objective.

Concerns have been raised about nonadherence behavior among patients with chronic inflammatory rheumatic diseases (CIRD) receiving biologics. This nonadherence may be caused by various factors. The main objective was to explain why patients discontinue their biologics of their own accord.

Methods.

A quantitative and descriptive study was performed using a self-report questionnaire that was sent through the Internet to members of different patient associations. Sociodemographic data, medical and therapeutic history, management of biologic administration, previous experiences, and patients’ beliefs and perceptions about treatment efficacy and side effects were studied to explain self-discontinuation (SD).

Results.

A total of 581 patients answered the questionnaire between June 16, 2012, and July 4, 2012, including patients with ankylosing spondylitis (351/581, 60.4%), rheumatoid arthritis (196/581, 33.7%), psoriatic arthritis (30/581, 5.2%), and other CIRD (4/581, 0.7%). More than 1000 different biologics were described by the 581 patients, with a median of 2 lines per patient. Eighty-six patients discontinued their biologics of their own accord (14.8%). In a multivariate analysis, factors that were significantly related to SD were low level of pain, more than 1 line of biologics tried, self-administration of biologics, negative beliefs about the treatment, and a lack of medical and social support.

Conclusion.

Five predictive factors of this SD were identified, which should be assessed in routine with patients with CIRD receiving biologic treatment: pain, treatment history, self-administration of injections, negative beliefs about treatment, and a lack of perceived medical and social support.

[Therapeutic Drug Management for Transplanted Women with a Planned Pregnancy: About Two Cases of Lung and Heart-lung Transplantation]

Advances in lung transplantation allow the women of childbearing age to consider becoming mothers. When planning to become pregnant, a therapeutic drug management of immunosuppressive drugs and associated therapies is required. It must take into account teratogenic and fetotoxic drugs, as well as pharmacokinetic changes encountered during pregnancy. Increasingly data are currently available on the management of immunosuppressive drugs and associated therapies during pregnancy. We report the case management of drug therapy before and during pregnancy in two patients after a lung or heart-lung transplantation. To prevent the emergence of complications for mother and child, a literature review has been necessary to manage drug therapies of each patient.

[In vitro study of the flow duration of antibiotics solutions prepared in elastomeric infusion devices: effect of cold storage for 3 to 7days]

INTRODUCTION

Within the cystic fibrosis patients' home care, EMERAA network ("Together against Cystic fibrosis in Rhone-Alpes and Auvergne") organizes parenteral antibiotics cures at home prepared in elastomeric infusion devices by hospital pharmacies. However, patients and nurses found that the durations of infusion with these devices were often longer than the nominal duration of infusion indicated by their manufacturer. This study aimed to identify the potential different causes in relation to these discordances.

MATERIAL AND METHODS

Three hundred and ninety devices of two different manufacturers are tested in different experimental conditions: three antibiotics each at two different doses, duration of cold storage (three days or seven days) or immediate tests without cold storage, preparation and storage of the solution in the device (protocol Device) or transfer in the device just before measurement (protocol Pocket).

RESULTS

All tests highlighted a longer flow duration for devices prepared according to the protocol Device versus the protocol Pocket (P=0.004). Flow duration is increased in the case of high doses of antibiotics with high viscosity such as piperacilline/tazobactam.

DISCUSSION

The results of this in vitro study showed the impact of: (1) the time between the filling of the device and the flow of the solution; (2) cold storage of elastomeric infusion devices; (3) concentration of antibiotics and therefore the viscosity of the solution to infuse.

CONCLUSION

It is therefore essential that health care teams are aware of factors, which may lead to longer infusion durations with these infusion devices. When the additional time for infusion remain acceptable, it should be necessary to inform the patient and to relativize these lengthening compared to many benefits that these devices provide for home care.

Physicians and community pharmacists collaboration in primary care: A review of specific models

BACKGROUND

Since 2008, French healthcare reform encourages community pharmacists (CP) to develop collaborative care with other health care providers through new cognitive pharmacy services.

OBJECTIVES

This review is aimed to identify theoretical models that have been developed to understand the physician-CP collaboration (PCPC) and to identify the associated determinants.

METHODS

English-written abstracts research was conducted on Pubmed/Medline, PsycINFO, Sociological Abstracts, and CINAHL from January 1990 to June 2013. Keywords were based on common terminology of inter-professional relations and community pharmacy.

RESULTS

Of the 1545 single articles identified, the final review was conducted on 16 articles. Four specific models of collaboration centered on PCPC were identified: (i) the Collaborative Working Relationship Model (CWR), (ii) the Conceptual model of GPCP collaboration, (iii) the CP Attitudes towards Collaboration with GPs Model (ATC-P), (iv) the GP Attitudes towards collaboration with CPs (ATC-GP). The analysis of these four PCPC models shows that their respective factors might cover the same concepts, especially for relational and interactional determinants. These key elements are: trust, interdependence, perceptions and expectations about the other HCP, skills, interest for collaborative practice, role definition and communication.

CONCLUSION

A meta-model for PCPC has been postulated. It can be used for qualitative exploration of PCPC, in a context of implementation of collaborative practice including CPs, in the primary care.

[Pharmacists' interventions conducted by hospital pharmacists on psychotropic drugs pharmacotherapy]

INTRODUCTION

The French Society of Clinical Pharmacy (SFPC) through the special interest group "standardization and optimization of clinical pharmacy activities" stated that the study of pharmacists' interventions (PIs) conducted during prescription analysis was a priority. The SFPC developed an internet website named Act-IP(®) (http://www.sfpc.eu/fr/) where French speaking pharmacists were able to document PIs using a normalized codification. The objective of this study was to analyze medication-related problems linked to psychotropic drugs in hospital and to investigate PIs performed during prescription analysis.

MATERIALS AND METHODS

This is a multicenter, retrospective, observational study using PIs involving psychotropic medications recorded between September 2006 and February 2009 on the Act-IP(®) website.

RESULTS

Four thousand six hundred and twenty PIs recorded by 165 pharmacists in 57 hospitals were related to psychotropic drugs. Patients concerned by these drug-related problems were 64 years old on average. Seven categories of medication-related problems represented more than 69% of PIs (1.1-Non Conformity of the drug choice compared to the formulary; 4.1 Supratherapeutic dose; 5.3 Therapeutic redundancy; 6.2 Drug interaction (all levels of severity); 7.0 Adverse drug reaction; 8.3 Inappropriate drug form; 8.5 Inappropriate timing of administration). The PIs related to 9.2 Patient's non compliance, 2.0 Untreated indication and 3.2 Length of the treatment too short were infrequent (less than 1%). The most common type of intervention was the dose adjustment. Almost 45% of these PIs involved Zopiclone or Zolpidem prescription in elderly patients. Seven hundred and nine drug interactions were identified by pharmacists. The most common type of drug interaction considered the risk of cardiac arrhythmias due to antipsychotic medications. One hundred and thirty-three PIs concerned adverse drug reaction. The most frequent adverse drug reactions were a fall (36 PIs), hemorrhage/bleeding (32 PIs), drowsiness (12 PIs) and extrapyramidal syndrome (12 PIs). Antidepressant drugs were the greatest pharmacological class concerning adverse drug reaction. The overall acceptance rate was 57%. Eight hundred and seventy-four PIs (19%) were refused and 1111 (24%) were non-assessable.

DISCUSSION

PIs avoids drug-related problems, such as the polyprescription of benzodiazepine or supratherapeutic dose. However, few PIs concern compliance to therapy or polyprescription of antipsychotic drugs. These two categories of medication-related problems are known to be an issue in mental health therapy. The lack of guidelines describing mental health pathology (such as the HAS guideline) is an obstacle for performing evidence-based PIs. The lack of information describing the context of the prescription is a limitation of this study. In order to improve their practice, pharmacists have to focus more on the context in which patients are evolving, and to take into account its entire situation based on Anglo-Saxon approaches. A second way is to identify clinical settings where PIs are useful and to describe PIs needed. Doctors and pharmacists should get together and talk about these clinical situations and PIs, because some may be misunderstood or disapproved by prescribers. This collaboration could take the form of a thesaurus combining clinical situation and PIs.

CONCLUSION

It appears important for pharmacists to show their daily involvement in the quality of medical care. This feedback on medication problems encountered and PIs proposed should help prescribers to identify clinical situations at risk. Nevertheless, this study also suggests that progress is possible. Dialogue must allow pharmacists and physicians to delete misunderstandings about their practices.

Trends in pharmacists' medication order review in French hospitals from 2006 to 2009: analysis of pharmacists' interventions from the Act-IP© website observatory

WHAT IS KNOWN AND OBJECTIVES

The French Society of Clinical Pharmacy has developed a website, named Act-IP©, enabling hospital pharmacists to document and analyse pharmacists' interventions (PIs) proposed during medication order review when a drug-related problem is detected. This study analyses PIs documented in Act-IP© and assesses factors associated with physicians' acceptance of PIs.

METHODS

PIs documented into Act-IP© over a 30-month period were analysed. Independent predictors of physicians' acceptance were assessed using multiple logistic regression.

RESULTS AND DISCUSSION

A total of 34,522 PIs were registered by 201 pharmacists working in 59 hospitals. PIs were mostly related to 'dose adjustment' (25%), 'drug discontinuation' (20%) and 'drug switch' (19%). Of the 43,343 medications involved, 28% targeted drugs acting on the central nervous system, 17% anti-infective drugs and 16% cardiovascular drugs. Sixty-eight per cent of PIs were accepted by physicians (15% refusals and 17% non-assessable). Physicians' acceptance was significantly associated with 1/ drug group: antineoplastics and immunomodulators (OR = 2.29, CI 95[1.94-2.69]), anti-infectives (OR = 1.19, CI 95 [1.11-1.28]); 2/ type of intervention: drug switch (OR = 1.54, CI 95 [1.43-1.65]), drug discontinuation (OR = 1.38, CI 95 [1.29-1.48]), administration modality optimization (OR = 1.19, CI 95 [1.11-1.29]), addition of a new drug (OR = 1.12, CI 95 [1.00-1.24]); 3/ ward specialty: paediatrics (OR = 1.83, CI 95 [1.24-2.70]) and intensive care (OR = 1.34, CI 95 [1.10-1.64]); 4/ level of pharmacist integration in the ward: higher when the pharmacist is regularly in the ward compared with occasionally (OR = 0.74, CI 95 [0.70-0.79]) or never (OR = 0.68, CI 95 [0.60-0.75]) present.

WHAT IS NEW AND CONCLUSION

This study highlights the role of routine pharmacist review of medication orders to prevent drug-related problems and gives new insights for a successful collaboration between physicians and pharmacists.

Pharmacists' interventions on intravenous to oral conversion for potassium

BACKGROUND

Guidelines recommend use of the oral route whenever possible to treat or prevent hypokalemia. Although a myriad of papers have been published regarding intravenous to oral (IV to PO) therapy conversion programs and about clinical pharmacy services provided in hospitals, little is known on the role of hospital pharmacists in promoting the oral route for potassium administration.

OBJECTIVE

The aim of this work was to describe the frequency of interventions related to IV to PO potassium therapy conversions performed by hospital pharmacists. Setting French hospitals recording pharmacist's interventions on the website tool of the French Society of Clinical Pharmacy.

METHODS

From the pharmacist's interventions (PI) dataset recorded we extracted all interventions related to potassium IV to PO conversion. We assessed the acceptance rate of these PI by prescribers. Additional free text information in the dataset was analysed.

MAIN OUTCOME MEASURES

IV to PO potassium therapy conversions related to potassium chloride.

RESULTS

From January 2007 to December 2010, 87 hospitals recorded 1,868 PIs concerning IV to PO therapy conversion. Among these, 16 (<1 %) concerned potassium chloride. They were recorded by four hospitals (4.6 %) with respectively 12, 2, 1 and 1 PIs. Six PIs were accepted by physicians and the prescriptions were modified.

CONCLUSION

PIs to promote the administration of potassium by the oral route are extremely rare. Our results and scarce previously published data reveal that this field of practice remains almost unexplored. These findings highlight an important gap in the field of intravenous to oral therapy programs. This situation must be regarded as unsatisfactory and should lead to setting up more education and research programs.

Pharmacy education in Vietnam

Pharmacy education programs in Vietnam are complex and offer various career pathways. All include theory and laboratory modules in general, foundation, and pharmaceutical knowledge; placements in health facilities; and a final examination. The various pharmacy degree programs allow specialization in 1 or more of 5 main fields: (1) drug management and supply, (2) drug development and production, (3) pharmacology and clinical pharmacy, (4) traditional medicine and pharmacognosy, and (5) drug quality control, which are offered as main specialization options during the reformed undergraduate and postgraduate programs. However, pharmacy education in Vietnam in general remains product oriented and clinical pharmacy training has not received adequate attention. Only students who have obtained the bachelor of pharmacy degree, which requires a minimum of 5 years of study, are considered as fully qualified pharmacists. In contrast, an elementary diploma in pharmacy awarded after 1 year of pharmacy study permits entry into more junior pharmacy positions. Since the 2000s, there has been a surge in the number and types of schools offering pharmacy qualifications at various levels.