[Treatments for SARS-CoV2 infection: a retrospective study of drug-drug interactions and safety]

Objectifs

Réaliser un état des lieux des associations à risque d’interactions médicamenteuses (IAM) rencontrées et des événements indésirables (EI) médicamenteux survenus chez les patients traités pour une infection à SARS-CoV-2 lors de la première vague épidémique au Centre Hospitalier Universitaire de Tenon.

Méthodes

Une analyse rétrospective de l’ensemble des patients ayant reçu un médicament utilisé dans le SARS-CoV-2 (Azithromycine, Hydroxychloroquine et/ou Lopinavir/ritonavir) a été conduite sur la période du 15 mars 2020 au 17 avril 2020. Pour chaque patient, la recherche d’associations médicamenteuses à risque d’IAM en lien avec les médicaments utilisés dans le SARS-CoV-2 et la survenue d’EI a été faite rétrospectivement dans les dossiers médicaux. Chaque événement indésirable identifié a été analysé par le Centre régional de pharmacovigilance (CRPV) afin de déterminer l’imputabilité des médicaments.

Résultats

L’analyse des prescriptions de 312 patients a retrouvé 157 associations à risque d’IAM chez 110 patients, soit 35,3 % des patients de la cohorte. De plus, 26 événements indésirables ont été observés chez ces patients. Après analyse de l’imputabilité médicamenteuse, le CRPV a identifié 10 EI liés aux médicaments, soit un taux d’iatrogénie de 3,2 %. Seuls 2 de ces cas impliquaient une IAM avec les médicaments utilisés dans le SARS-CoV-2.

Conclusions

Notre étude a montré un taux faible d’EI liés aux médicaments utilisés dans le SARS-CoV-2. Malgré un nombre important d’associations à risque d’IAM identifiées, seul 0,6 % des patients ont présenté un EI lié à une IAM.

Daily multidisciplinary COVID-19 meeting: Experiences from a French university hospital

Objectives

In March 2020, the World Health Organization declared the coronavirus disease 2019 (COVID-19) a pandemic. In absence of official recommendations, implementing daily multidisciplinary team (MDT) COVID-19 meetings was urgently needed. Our aim was to describe our initial institutional standard operating procedures for implementing these meetings, and their impact on daily practice.

Methods

All consecutive patients who were hospitalized in our institution due to COVID 19, from March 31 to April 15, 2020, were included. Criteria to be presented at MDT meetings were defined as a proven COVID-19 by PCR or strongly suspected on CT scan, requiring hospitalization and treatment not included in the standard of care. Three investigators identified the patients who met the predefined criteria and compared the treatment and outcomes of patients with predefined criteria that were presented during MDT meeting with those not presented during MDT meeting. COVID-19 MDT meeting implementation and adhesion were also assessed by a hospital medical staff survey.

Results

In all, 318 patients with confirmed or suspected COVID-19 were examined in our hospital. Of these, 230 (87%) were hospitalized in a COVID-19 unit, 91 (40%) of whom met predefined MDT meeting criteria. Fifty (55%) patients were presented at a MDT meeting versus 41 (45%) were not. Complementary exploration and inclusion in the CorImmuno cohort were higher in MDT meeting group (respectively 35 vs. 15%, P = 0.03 and 80 versus 49%, P = 0.0007). Prescription of hydrocortisone hemisuccinate was higher in group of patients not presented during MDT meeting (24 vs. 51%, P = 0.007). Almost half of the patients fulfilling the inclusion criteria were not presented at MDT meeting, which can be partly explained by technical software issues.

Conclusions

Multidisciplinary COVID-19 meetings helped implementing a single standard of care, avoided using treatments that were untested or currently being tested, and facilitated the inclusion of patients in prospective cohorts and therapeutic trials.

[Evaluation of clinical practice in pulmonary oncology: a review of the literature]

INTRODUCTION

Evaluation of clinical practice in pulmonary oncology aims to improve both the quality of care and the control of costs.

REVIEW OF THE LITERATURE

A Medline search of the literature allowed analysis of the published studies of the evaluation of clinical practice. They showed that though 82-95% of patients with small cell bronchial carcinoma were treated with a combination of etoposide and cisplatin, less than half of the patients with non-small cell cancer received treatment.

VIEWPOINT

Various factors such as age, comorbidity, race, socio-economic status and gender affect the treatment decisions. There is also a discrepancy between the trial data and clinical practice that could be explained by two factors. On one hand advances are not always adopted by doctors and on the other hand the patient populations treated may sometimes be different from those in the trials.

CONCLUSION

Though the number of published studies is still low an increase is to be expected on account of the publication of new regulations concerning the evaluation of clinical practice and the appropriate use of drugs.

The relationship between introduction of American society of clinical oncology guidelines and the use of colony-stimulating factors in clinical practice in a Paris university hospital

BACKGROUND

Clinical practice guidelines are issued periodically by professional medical societies or committees to assist practitioners in clinical decision making. However, it is unclear whether such guidelines have any lasting impact on clinical practice.

OBJECTIVE

The purpose of this study was to assess the impact of the American Society of Clinical Oncology (ASCO) guidelines regarding use of hematopoietic colony-stimulating factors (CSF) on cancer care in a university hospital in Paris.

METHODS

The study was performed at Hĵpital Tenon, an 830-bed university hospital in Paris, in 1996 and 1997, both before and after the ASCO guidelines were implemented. The guidelines were first disseminated as a continuing medical education program and then actively implemented using a CSF prescription order form summarizing the guidelines. This form had to be used during the patient consultation and was sent to the Hĵpital Tenon pharmacy for CSF dispensation. Even if CSF use did not comply with the ASCO guidelines, the pharmacy filled the prescription. Seven other university hospitals in Paris, where the ASCO guidelines were not actively implemented, comprised the control group. The main outcome measure was the proportion of prescriptions in compliance with the 1996 update of the ASCO guidelines. Secondary outcome measures were the proportions of prescriptions in compliance with ASCO guidelines regarding primary prophylactic, secondary prophylactic, and therapeutic CSF administration.

RESULTS

Before implementation of the ASCO guidelines, CSF use in compliance with the guidelines was 39% (41/105) at the study site and 31% (16/51) at the control sites (P > 0.05). Six months after dissemination and implementation of the guidelines, the proportion of CSF prescriptions complying with ASCO guidelines increased significantly versus baseline (P = 0.003) in the study group, to 61% (50/82). However, even after the guidelines were implemented, compliance with guidelines on primary prophylactic CSF administration did not change significantly versus before implementation in the study group (12% [5/41] before implementation vs 6% [2/33] after implementation; P > 0.05).

CONCLUSIONS

The results suggest an association between the active implementation strategy (continuing medical education and CSF prescription reminder form) and physician compliance with the ASCO guidelines. Implementation of the ASCO guidelines appears to have had some impact on medical practice.

Multicenter study of the impact of prescription guidelines on the use of colony stimulating factors

The aim of this work was to assess the impact of circulating guidelines for correct prescription practices of colony stimulating factors (CSF). Two hospital groups were compared, a 'guidelines' group (seven teaching hospitals) that circulated the guidelines and a control group (eight teaching hospitals) that did not. In addition, two periods were compared before and after distribution of the guidelines: from 17 February to 2 March 1996 and from 17 February to 2 March 1997. The assessment involved compliance with the guidelines for the following parameters: indications, dose regimen, time to start of CSF therapy and duration of CSF therapy between the control and guideline groups and also between the two periods. The population included 404 patients analyzed (209 in 1996 and 195 in 1997) for the indication of post-chemotherapy neutropenia. Total compliance in the first period (all four items) was 44.2% in the control group and 50.8% in the guideline group (nonsignificant), and during the second period was 31.9 and 59.6% in the two groups (p<0.001). During the first period, the differences in compliance with the guidelines for indication, dose regimen, time to start of treatment and duration between the groups were not significant. In the second period, this difference became significant and in favor of the guideline group for dose regimen (p = 0.009) and treatment duration (p = 0.02). The results of this study show the need to continuously define prescription reference systems according to available data, and to circulate them widely to improve the quality of health care and to control expenses.

Impact of ASCO guidelines for the use of hematopoietic colony stimulating factors (CSFs): survey results of fifteen Paris university hospitals

To assess whether physicians comply with American Society of Clinical Oncology (ASCO) guidelines for the use of CSFs, a prospective survey was performed in 15 Paris university hospitals involved in cancer treatment in 1997. If 45% of the prescriptions complied with the guidelines, primary prophylactic administration, which represented 52% of cases, did not comply with ASCO guidelines. These results suggested that primary prophylactic administration was one major clinical situation in which physicians could benefit from guidance to use a CSFs and that criteria defined by ASCO to allow primary prophylactic administration were not applied in clinical practice.

Impact of guidelines implemented in a paris university hospital: application to the use of antiemetics by cancer patients

AIMS

To assess the impact with time of guidelines on antiemetic use in an 850-bed Paris university hospital with a high proportion of cancer patients.

METHODS

Guidelines on the use of antiemetics available in cancer chemotherapy were drafted according to the Delphi technique. Their implementation was based upon a patient-specific antiemetic prescription form. To assess the impact of guideline implementation over time, discrepancies between current practice and the guidelines were compared before guideline implementation (between March and August 1995) and after implementation (between March and August 1997, and March and August 1998).

RESULTS

Before the Delphi panel's guidelines were implemented, 5-HT3 antagonists were inappropriately administered in 70% of cases. After guideline implementation, this proportion dropped significantly (P<0.0001, Fisher's exact test) to 22% between March and August 1997 and 28% between March and August 1998.

CONCLUSIONS

Implementation of guidelines seems to have resulted in significant changes with time, although a causal relationship has not been demonstrated. The development of guidelines by our hospital's multidisciplinary working group helped the various consultants to adjust medical practices to take account of these changes.

Clinical practice guidelines for the use of albumin: results of a drug use evaluation in a Paris hospital. Tenon Hospital Paris

Clinical practice guidelines on the prescription of albumin were instituted in our hospital according to a method which combined a review of the medical literature with experts points of view. Their broadcasting was based upon a daily patient-specific decision support which was well-documented by the prescribing physician. The method for assessing the impact was a six month analysis of the discrepancies between recommendations and clinical practice. Results were a better compliance with guidelines (25.5% before and 59% after developing recommendations), a decrease 70% in grams of albumin prescribed and in use of an increase synthetic colloids, and a savings of $57,208 per year.

Clinical practice guidelines for the use of albumin: results of a drug use evaluation in a Paris hospital. Tenon Hospital Paris

Clinical practice guidelines on the prescription of albumin were instituted in our hospital according to a method which combined a review of the medical literature with experts points of view. Their broadcasting was based upon a daily patient-specific decision support which was well-documented by the prescribing physician. The method for assessing the impact was a six month analysis of the discrepancies between recommendations and clinical practice. Results were a better compliance with guidelines (25.5% before and 59% after developing recommendations), a decrease 70% in grams of albumin prescribed and in use of an increase synthetic colloids, and a savings of $57,208 per year.