[Quality of treatment after myocardial infarction: impact of hospital guidelines]

After myocardial infarction (MI), international societies of cardiology recommend an optimal treatment associating four classes of drugs, known as BASI combination (beta-blocker, antiplatelets, statin and inhibitor of the angiotensin converting enzyme). This study shows that the implementation of locally adapted guidelines in a regional hospital (CHCVs, Sion) significantly improve the treatment quality after MI, with a 10% increase of the BASI combination at discharge. Detailed results are discussed. Finally, we provide a table summarizing the optimal treatment strategy with drug examples including doses, which will be helpful to both general practitioners and specialists.

Clinical and economic outcomes of pharmaceutical services related to antibiotic use: a literature review

AIM OF THE REVIEW

To identify and review the clinical and economic impact of pharmacists' interventions on antibiotic use.

METHOD

A literature search was conducted on Medline (1966-2003) to identify original articles measuring the impact of pharmacists' interventions on antimicrobial therapy at patient's or prescriber's level.

RESULTS

Forty-three articles were included: 20 uncontrolled before-after studies, four controlled before-after studies, five controlled trials, 12 randomized controlled trials and two interrupted time series (ITS). The described interventions were grouped into four categories: patient-specific recommendations (pharmacists' interventions concerning patient-specific drug therapy), implementation of policies, education, and therapeutic drug monitoring. These interventions were often combined to provide a multifaceted intervention, making it difficult to isolate the impact of one specific intervention. Measured outcomes were: appropriateness of prescribing (evaluated in 17 studies, 16 showing significant improvement), costs (analysed in 22 studies, nine showing a statistically significant reduction in costs after or with the intervention), and length of hospital stay (mixed results). Other measured outcomes were: drug use, prescriptions, length of treatment, dose intervals, switch to oral route, mortality rate, and treatment failure.

CONCLUSION

Over the years, the number of studies and quality of methodology has increased. The most frequently observed outcomes with a positive impact were appropriateness of prescribing and cost savings. The vast majority of studies used multiple interventions, in conjunction with pharmacists' recommendations to physicians. Coupled with the use of practice guidelines or educational strategies, these interventions demonstrated a positive impact on economic or clinical outcomes. However, the data are still sparse and sometimes contradictory; therefore, further studies with randomized controlled designs are needed.

Hospital pharmacists' reinforcement of guidelines for switching from parenteral to oral antibiotics: a pilot study

OBJECTIVE

The cost of antibiotics in hospitals may be reduced by streamlining, and, particularly, by early switching from the intravenous (i.v.) to the oral route of administration. The aim of the study was to evaluate the feasibility and impact of guidelines for switching, reinforced by pharmacists.

METHOD

Patients admitted to internal medicine wards and treated with i.v. antibiotics for various infections were included for six weeks before (group A) and six weeks after (group B) the intervention. Differences in patient characteristics and their outcomes were sought between the two groups.

RESULTS

The 26 patients in group B stayed longer in hospital than the 29 in group A (13.3 vs. 9.7 days; P = 0.05). They also tended to need more time to reach the pre-defined criteria for switching (3.6 vs. 2.4 days; P = 0.09). From that point on, they were switched more rapidly to oral antibiotics (1.5 vs. 3.2 days; P = 0.02), which resulted in a trend toward a lower treatment cost until their discharge (44 vs. 92 euros; P = 0.08). No difference was found between the 2 groups for the duration of the i.v. therapy, or the total in-hospital cost of antibiotics.

CONCLUSION

Pharmacists may help implement and reinforce guidelines for switching to oral antibiotics. The evaluation of such interventions implies the choice of appropriate outcomes and the awareness of confounding factors.