Enhancing Drug Management, Cost Savings, and Staff Satisfaction in Anesthesiology: A Quality Improvement Project in a Chinese Tertiary Hospital

INTRODUCTION

In alignment with China's national directive for improved drug management in anesthesiology, the Affiliated Hospital of Qingdao University initiated a quality improvement project, aiming to tackle the prevailing challenges of inefficiencies in drug administration, escalating drug costs, and the notable communication gap between pharmacists and anesthesiologists.

METHODS

We employed a Plan-Do-Study-Act methodology to establish a pharmacy team and execute a multidimensional pharmaceutical intervention. The interventions included the formulation of standard procedures, guidelines and regulations, assistance from an information system (including automatic dispensing cabinets and prospective prescription review system), communication feedback (via WeChat groups), and education for anesthesiology staff. The intervention spanned from April to September 2023, focusing on optimizing medication management, achieving cost savings, and enhancing the satisfaction of anesthesia team members, with an additional observation from October to December 2023.

RESULTS

Following the interventions, improvements were observed in drug management practices. These enhancements included increased compliance with accounting procedures, more rigorous registration of controlled substances, and more effective disposal of liquid residues. There was no adverse events related to high-alert medications or look-alike drug usage errors. The introduction of automatic dispensing cabinets and a prospective prescription review system markedly improved work efficiency. The utilization of a WeChat group facilitated effective communication about unreasonable prescriptions and drug-related issues. Among the 29,061 patients who underwent surgery both before and after the interventions, significant reductions were observed both in the drug proportion and the per capita drug costs (P = 0.03, P = 0.014, respectively). The per capita drug cost decreased by 20.82%, from ¥723.43 to ¥572.78, consistently remaining below ¥600 throughout the 9-month observation period. The per capita cost of monitoring drugs including dezocine, butorphanol, haemocoagulase agkistrodon, penehyclidine, and ulinastatin experienced a significant reduction (P < 0.05). Additionally, in the satisfaction questionnaires returned, a remarkable 94.44% of anesthesiology staff expressed high satisfaction with the comprehensive pharmaceutical interventions.

CONCLUSION

The quality improvement project has yielded remarkable positive outcomes, serving as a model worthy of reference and replication in similar healthcare settings.

Development and partial validation of Be-CLIPSS: a classification system for hospital clinical pharmacy activities

BACKGROUND

Documentation of drug related problems (DRPs) and pharmaceutical interventions (PIs) is essential for an objective evaluation of the pharmacist's contribution to pharmacotherapy. However, in Belgium, a nationally used classification system is not available, prohibiting structured and uniform documentation of DRPs and PIs.

AIM

To develop and validate a national classification system for in-hospital clinical pharmacy activities, based on literature and field experience, specifically intended for routine registration.

METHOD

Based on a literature review, a survey among Belgian hospital pharmacists and a stakeholder focus group, a first version of Be-CLIPSS (Belgian CLInical Pharmacy claSsification System) was developed. Inter-rater reliability of the DRPs and PIs was assessed. Additionally, its usability was reviewed. The system was further refined, followed by a second validation.

RESULTS

Both the survey and focus group discussion revealed little use of validated DRP and PI classification systems in Belgium, although these were considered highly desirable if practical and minimally time-consuming. The final classification system encompassed seven clinical pharmacy activities, grouped into four activity classes. The inter-rater reliability for the second activity class was substantial for the DRPs (κ = 0.737) and almost perfect for the PIs (κ = 0.872). The interpretability (86.4%), user-friendliness (61.4%), user satisfaction (84.1%), interest for use in daily practice (68.2%) and difficulty in correctly classifying the DRP and PI (31.8%) were assessed.

CONCLUSION

Be-CLIPSS, a newly developed and partially validated classification system for DRPs and PIs, was found to be user-friendly, with a good interpretability and user satisfaction, resulting in a high interest for use in daily practice.

Documentation of drug related problems and their management in community pharmacy: Data evolution over six years

BACKGROUND

Documentation of pharmacists' activities, such as drug related problems (DRPs) management, is necessary to estimate fair remuneration but is rarely done in community pharmacies.

OBJECTIVE

To document and evaluate the evolution of DRPs prevalence and management over six years.

METHODS

Observational study carried out since 2016 in a community pharmacy. Documentation was made yearly for 21 days (depending on seasons, holidays and medical internship rotations) using the ClinPhADoc tool. Pharmacists documented: medication, DRP type, intervention, implied partner and time for DRP management. A subanalysis was made depending on the medical rotation.

RESULTS

A total of 171 437 prescriptions were received and 6 844 (4.0%) documented with 1 550 DRPs. Most frequent DRPs were procedural (n = 506, 32.6%), dosage/posology (n = 263, 17.0%) and drug-drug interaction (n = 153, 9.9%). Mean time dedicated to DRP management was 6.9 min, the longest time was for clinical DRPs (11.0 min, SD = 6.6). Most DRPs (n = 726, 44.6%) were managed by the pharmacist alone taking less working time than when involving other stakeholders (p < 0.01). Statistically significant differences were found in DRPs between the beginning and end of medical rotation (p < 0.05).

CONCLUSIONS

Documentation of DRP management allowed consistent results over the years. Patterns of DRPs can be used to develop inter-professional interventions to prevent DRPs.

Data extraction error in pharmaceutical versus non-pharmaceutical interventions for evidence synthesis: Study protocol for a crossover trial

Background

Data extraction is the foundation for research synthesis evidence, while data extraction errors frequently occur in the literature. An interesting phenomenon was observed that data extraction error tend to be more common in trials of pharmaceutical interventions compared to non-pharmaceutical ones. The elucidation of which would have implications for guidelines, practice, and policy.

Methods and analyses

We propose a crossover, multicenter, investigator-blinded trial to elucidate the potential variants on the data extraction error rates. Eligible 90 participants would be 2nd year or above post-graduate students (e.g., masters, doctoral program). Participants will be randomized to one of the two groups to complete pre-defined data extraction tasks: 1) group A will contain 10 randomized controlled trials (RCTs) of pharmaceutical interventions; 2) group B will contain 10 RCTs of non-pharmaceutical interventions. Participants who finish the data extraction would then be assigned to the alternative group for another round of data extraction after a 30 min washout period. Finally, those participants assigned to A or B group will be further 1:1 randomly matched based on a random-sequenced number for the double-checking process on the extracted data. The primary outcome will be the data extract error rates of the pharmaceutical intervention group and non-pharmaceutical group, before the double-checking process, in terms of the cell level, study level, and participant level. The secondary outcome will be the data error rates of the pharmaceutical intervention group and non-pharmaceutical group after the double-checking process, again, in terms of the cell level, study level, and participant level. A generalized linear mixed effects model (based on the above three levels) will be used to estimate the potential differences in the error rates, with a log link function for binomial data. Subgroup analyses will account for the experience of individuals on systematic reviews and the time used for the data extraction.

Discussion

This trial will provide useful evidence for further systematic review of data extraction practices, improved data extraction strategies, and better guidelines.

Trial registration

Chinese Clinical Trial Register Center (Identifier: ChiCTR2200062206).

Effect of clinical pharmacists participating in nutritional therapy for patients with acute cerebral infarction complicated with dysphagia

Objective

To explore the effect of clinical pharmacists participating in nutritional therapy for patients with acute cerebral infarction (ACI) complicated with dysphagia.

Methods

This is a Clinical comparative study. A total of 82 patients with ACI complicated with dysphagia treated in Baoding No.1 Central Hospital from May 2021 to February 2022 were included as subjects. They were divided into control group (n= 40, without clinical pharmacists) and experimental group (n= 42, with clinical pharmacists) using a random number table. The effect of nutritional therapy and the incidence of adverse reactions were compared between the two groups.

Results

In the experimental group, PALB and ALB were both higher than those in the control group on the seven and 14-day after treatment (p< 0.05), while HB was higher than that in the control group only on the 14-day after treatment (p< 0.05). After treatment for 14-day, MAMC and TSF in the experimental group were higher than those in the control group (p< 0.05), while NIHSS score was lower than that in the control group (p< 0.05). The incidence of adverse events in the experimental group was lower than that in the control group (p< 0.05).

Conclusion

Pharmaceutical intervention in nutritional therapy for patients with ACI complicated with dysphagia has positive significance in further improving the nutritional status and nutritional indexes, enhancing the efficacy of drug treatment and reducing the risk of adverse events, and is worthy of promotion.

N-acetyl-L-leucine for Niemann-Pick type C: a multinational double-blind randomized placebo-controlled crossover study

BACKGROUND

Niemann-Pick disease type C (NPC) is a rare autosomal recessive neurodegenerative lysosomal disease characterized by multiple symptoms such as progressive cerebellar ataxia and cognitive decline. The modified amino acid N-acetyl-leucine has been associated with positive symptomatic and neuroprotective, disease-modifying effects in various studies, including animal models of NPC, observational clinical case studies, and a multinational, rater-blinded phase IIb clinical trial. Here, we describe the development of a study protocol (Sponsor Code "IB1001-301") for the chronic treatment of symptoms in adult and pediatric patients with NPC.

METHODS

This multinational double-blind randomized placebo-controlled crossover phase III study will enroll patients with a genetically confirmed diagnosis of NPC patients aged 4 years and older across 16 trial sites. Patients are assessed during a baseline period and then randomized (1:1) to one of two treatment sequences: IB1001 followed by placebo or vice versa. Each sequence consists of a 12-week treatment period. The primary efficacy endpoint is based on the Scale for the Assessment and Rating of Ataxia, and secondary outcomes include cerebellar functional rating scales, clinical global impression, and quality of life assessments.

DISCUSSION

Pre-clinical as well as observational and phase IIb clinical trials have previously demonstrated that IB1001 rapidly improved symptoms, functioning, and quality of life for pediatric and adult NPC patients and is safe and well tolerated. In this placebo-controlled cross-over trial, the risk/benefit profile of IB1001 for NPC will be evaluated. It will also give information about the applicability of IB1001 as a therapeutic paradigm for other rare and common neurological disorders.

TRIAL REGISTRATIONS

The trial (IB1001-301) has been registered at www.

CLINICALTRIALS

gov (NCT05163288) and www.clinicaltrialsregister.eu (EudraCT: 2021-005356-10). Registered on 20 December 2021.

Pharmaceutical intervention for adverse events improves quality of life in patients with cancer undergoing outpatient chemotherapy

Background

The effect of pharmaceutical intervention to treat adverse events on quality of life (QOL) in outpatients receiving cancer chemotherapy is unclear. We investigated whether pharmaceutical intervention provided by pharmacists in collaboration with physicians improves QOL with outpatient cancer chemotherapy.

Methods

We conducted a single-center retrospective descriptive study of pharmaceutical intervention for patients receiving outpatient cancer chemotherapy at Gifu University Hospital between September 2017 and July 2020. We assessed patient QOL using the Japanese version of the EuroQol 5 Dimension5 Level (EQ-5D-5L). Adverse events were graded using the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. We compared the EQ-5D-5L utility value and incidence of grade 2 or higher adverse events before and after pharmaceutical intervention.

Results

Our analysis included 151 patients who underwent 210 chemotherapy cycles. Pharmaceutical intervention significantly improved patients’ EQ-5D-5L utility values from 0.8197 to 0.8603 (P < 0.01). EQ-5D-5L utility values were significantly improved after pharmaceutical intervention for nausea and vomiting (pre-intervention 0.8145, post-intervention 0.8603, P = 0.016), peripheral neuropathy (pre-intervention 0.7798, post-intervention 0.7988, P = 0.032) and pain (pre-intervention 0.7625, post-intervention 0.8197, P = 0.035). Although not statistically significant, the incidence of grade 2 or higher adverse events, including nausea and vomiting, dermopathy, pain, oral mucositis, diarrhea and dysgeusia, tended to be lower post-intervention than pre-intervention.

Conclusions

Pharmaceutical intervention by pharmacists in collaboration with physicians may improve QOL in patients undergoing outpatient cancer chemotherapy.

[Clinical medication review in French community pharmacy: Interest of a new pharmaceutical service for detection of drug related problems]

OBJECTIVE

Using clinical medication reviews, analyze the most pharmaceuticals intervention generating treatments and the problems associated.

METHODS

Analysis of activity reports made by 6th year pharmaceutical students from the University of Bordeaux, class of 2017-2018.

RESULTS

76 % of clinical medication review have detected at least one drug related problem in the population of this study. Drug classes that most frequently lead to pharmaceutical interventions are nervous system drugs, alimentary tract and metabolisma drugs and cardiovascular system drugs. The most frequent drug related problems are an unjustified prescription, a contraindication or a non-compliance with the standards of care and posology issues.

CONCLUSIONS

The most at risk and pharmaceutical intervention generating drugs in this study are the same as described in the international literature. This shows that more precautions must be taken for their use in the elderly. Furthermore, this new pharmaceutical service is an efficient way to detect them.

Oral anticoagulants: Interventional pharmaceutical study with reminder of good practices, and iatrogenic impact

OBJECTIVES

Study of the impact of geriatricians' training on the improvement of their prescribing practices, and comparison of iatrogenesis between the two classes of oral anticoagulants.

MATERIAL AND METHODS

Before/after and here/there comparison between a trained prescribers group and a control group, before and after the pharmacist intervention, with comparison of the iatrogenesis of two oral anticoagulant classes. Patients in the acute and post-acute geriatric departments treated with a vitamin K antagonist or a direct oral anticoagulant were included. Criteria for Good practice were rated according to a scale of severity: calculation of a score and a percentage of compliance per patient, and then an average of the percentage of compliance (main criterion) within the populations to be compared. The proportion of iatrogenic elements between the two classes was compared. We used statistical tests (significance threshold of 5%).

RESULTS

Vitamin K antagonist: a decreasing trend in the control group (P=0.086) and an increasing trend in the trained group (P=0.183) was observed in prescription compliance before/after training. Direct oral anticoagulants: the compliance before/after decreased in the control group (P=0.005) and increased in the trained group (P=0.024). After training, compliance is higher among the group of trained prescribers for both vitamin K antagonist (P=0.018) and direct oral anticoagulant (P=0.003). The proportion of iatrogenic events in the two oral anticoagulants classes was not significantly different.

CONCLUSIONS

Interest of good practice reminders in the quality of oral anticoagulants prescriptions with no difference in safety of use between the two classes.

Allicin Reversed the Process of Frailty in Aging Male Fischer 344 Rats With Osteoporosis

The research and development of pharmaceutical intervention is insufficient for the frail older adults, especially in preclinical stage for the frail individuals with osteoporosis. Garlic exerts an antiosteoporotic effect and its vital component allicin could protect organisms against aging. The present study aimed to investigate the effect of long-term intragastric administration of allicin (low dose of 4 mg·kg⁻¹·d⁻¹; middle dose of 8 mg·kg⁻¹·d⁻¹; high dose of 16 mg·kg⁻¹·d⁻¹) on frailty with osteoporosis in aging male Fischer 344 rats. Frailty was assessed with a 27-item frailty index based on quantifying health-related deficits in adult male rats varied from 13 to 21 months and in control rats from 6 to 9 months. Osteoporosis was appraised by bone mineral density detected by dual-energy X-ray absorptiometry, biomechanical properties measured by a three-point bending test, and bone metabolic analysis using ELISA. Allicin could attenuate frailty index scores by reducing the accumulation of health deficits in aging male Fischer 344 rats. Meanwhile, allicin could protect against senile osteoporosis, and the underlying mechanism may involve in increasing low bone turnover through elevation of both bone formation and bone resorption, and subsequently lead to increase of bone mineral density, contributing to reversing deleterious bone biomechanical features associated with aging. The present study reveals firstly that long-term oral administration with allicin attenuated frailty with osteoporosis during the process of aging, which provides a preclinical evidence for intervention of frailty.

A master protocol to investigate a novel therapy acetyl-L-leucine for three ultra-rare neurodegenerative diseases: Niemann-Pick type C, the GM2 gangliosidoses, and ataxia telangiectasia

BACKGROUND

The lack of approved treatments for the majority of rare diseases is reflective of the unique challenges of orphan drug development. Novel methodologies, including new functionally relevant endpoints, are needed to render the development process more feasible and appropriate for these rare populations and thereby expedite the approval of promising treatments to address patients' high unmet medical need. Here, we describe the development of an innovative master protocol and primary outcome assessment to investigate the modified amino acid N-acetyl-L-leucine (Sponsor Code: IB1001) in three separate, multinational, phase II trials for three ultra-rare, autosomal-recessive, neurodegenerative disorders: Niemann-Pick disease type C (NPC), GM2 gangliosidoses (Tay-Sachs and Sandhoff disease; "GM2"), and ataxia telangiectasia (A-T).

METHODS/DESIGN

The innovative IB1001 master protocol and novel CI-CS primary endpoints were developed through a close collaboration between the Industry Sponsor, Key Opinion Leaders, representatives of the Patient Communities, and National Regulatory Authorities. As a result, the open-label, rater-blinded study design is considerate of the practical limitations of recruitment and retention of subjects in these ultra-orphan populations. The novel primary endpoint, the Clinical Impression of Change in Severity© (CI-CS), accommodates the heterogenous clinical presentation of NPC, GM2, and A-T: at screening, the principal investigator appoints for each patient a primary anchor test (either the 8-m walk test (8MWT) or 9-hole peg test of the dominant hand (9HPT-D)) based on his/her unique clinical symptoms. The anchor tests are videoed in a standardized manner at each visit to capture all aspects related to the patient's functional performance. The CI-CS assessment is ultimately performed by independent, blinded raters who compare videos of the primary anchor test from three periods: baseline, the end of treatment, and the end of a post-treatment washout. Blinded to the time point of each video, the raters make an objective comparison scored on a 7-point Likert scale of the change in the severity of the patient's neurological signs and symptoms from video A to video B. To investigate both the symptomatic and disease-modifying effects of treatment, N-acetyl-L-leucine is assessed during two treatment sequences: a 6-week parent study and 1-year extension phase.

DISCUSSION

The novel CI-CS assessment, developed through a collaboration of all stakeholders, is advantageous in that it better ensures the primary endpoint is functionally relevant for each patient, is able to capture small but meaningful clinical changes critical to the patients' quality of life (fine-motor skills; gait), and blinds the primary outcome assessment. The results of these three trials will inform whether N-acetyl-L-leucine is an effective treatment for NPC, GM2, and A-T and can also serve as a new therapeutic paradigm for the development of future treatments for other orphan diseases.

TRIAL REGISTRATION

The three trials (IB1001-201 for Niemann-Pick disease type C (NPC), IB1001-202 for GM2 gangliosidoses (Tay-Sachs and Sandhoff), IB1001-203 for ataxia telangiectasia (A-T)) have been registered at www.clinicaltrials.gov (NCT03759639; NCT03759665; NCT03759678), www.clinicaltrialsregister.eu (EudraCT: 2018-004331-71; 2018-004406-25; 2018-004407-39), and https://www.germanctr.de (DR KS-ID: DRKS00016567; DRKS00017539; DRKS00020511).

Pharmacotherapeutic candidates for myopia: A review

This review provides insights into the mechanism underlying the pathogenesis of myopia and potential targets for clinical intervention. Although the etiology of myopia involves both environmental and genetic factors, recent evidence has suggested that the prevalence and severity of myopia appears to be affected more by environmental factors. Current pharmacotherapeutics are aimed at inhibiting environmentally induced changes in visual input and subsequent changes in signaling pathways during myopia pathogenesis and progression. Recent studies on animal models of myopia have revealed specific molecules potentially involved in the regulation of eye development. Among them, the dopamine receptor plays a critical role in controlling myopia. Subsequent studies have reported pharmacotherapeutic treatments to control myopia progression. In particular, atropine treatment yielded favorable outcomes and has been extensively used; however, current studies are aimed at optimizing its efficacy and confirming its safety. Furthermore, future studies are required to assess the efficacy of combinatorial use of low-dose atropine and contact lenses or orthokeratology.

[IMPACTCHIMIO: Development and multicentric validation of a tool for collecting pharmaceutical interventions carried out within chemotherapy reconstitution units]

OBJECTIVES

To develop and validate prospectively a specific tool for pharmaceutical interventions performed in centralized cytotoxic preparation units.

METHODS

A pharmaceutical intervention is defined as a type of intervention performed in relation to a problem encountered. ImpactChimio is derived from the Act-IP® (SFPC) tool. The initial version (version 1) was developed from the pharmaceutical interventions collected over 1 year by the pilot centre. Its validation was carried out by the Delphi method via a prospective multicentric collection to assess its robustness (real life pharmaceutical interventions) and reproducibility (50 pharmaceutical interventions classified by pharmacists naive or not to the tool and study of classification divergences).

RESULTS

The development of the tool (version 1) was based on the analysis of 412 pharmaceutical interventions. For its validation, 196 pharmaceutical interventions were provided by 6 centers for 5 months. The changes have been incorporated into the new versions of the tool (version 2 and version 3). Six naive and six non-naive pharmacists then tested reproducibility by reclassifying 50 selected pharmaceutical interventions into version 3. A total of 136 discrepancies (11.3 %) were found out of 1200 responses: 66 related to the problem encountered and 70 to the type of intervention. No statistically significant differences were found between naive and non-naive pharmacists.

CONCLUSIONS

ImpactChimio is the first pharmaceutical interventions' specific tool for centralized cytotoxic preparation units, developed and validated by a multicentric study using the Delphi method. It makes possible to enhance the value of the analysis activity and to identify training areas for the teams.

Results and lessons learnt from a randomized controlled trial: prophylactic treatment of vestibular migraine with metoprolol (PROVEMIG)

Background

Vestibular migraine (VM) is the most frequent cause of recurrent spontaneous attacks of vertigo causally related to migraine. The objective of the Prophylactic treatment of vestibular migraine with metoprolol (PROVEMIG) trial was to demonstrate that metoprolol succinate is superior to placebo in the prevention of episodic vertigo- and migraine-related symptoms in patients with VM.

Methods

This phase III, two-arm, parallel-group, double-blind, randomized placebo-controlled trial was designed to be conducted at tertiary referral centres at neurology and ear, nose and throat departments of eight German university hospitals. The planned sample size was a total of 266 patients to be allocated. Adults aged 18 years or above diagnosed with probable or definitive VM according to the Neuhauser criteria 2001 were randomly assigned 1:1 to 6 months blinded metoprolol (maintenance dosage of 95 mg daily) or placebo. The primary efficacy outcome was the self-reported number of vertiginous attacks per 30 days documented by means of a paper-based daily symptom diary. The pre-specified time period of primary interest was defined as months 4 to 6. Secondary outcomes included the patient-reported number of migraine days and vertigo days, the Dizziness Handicap Inventory, and clinical assessments. Adverse events were reported throughout the whole 9-month study period.

Results

At the time of trial termination, no evidence for a difference in the incidence of vertiginous attacks between groups was detected. For the full analysis set, the incidence rate ratio was 0.983 (95% confidence interval (CI) 0.902–1.071) for metoprolol versus placebo. In both groups, there was a significant decline over time in the overall monthly vertigo attacks by a factor of 0.830 (95% CI 0.776–0.887). Results were consistent for all subjective and objective key measures of efficacy. The treatment was well tolerated with no unexpected safety findings.

Conclusions

After randomizing 130 patients PROVEMIG had to be discontinued because of poor participant accrual not related to the tolerability of the study medication or safety concerns; no treatment benefit of metoprolol over placebo could be established. Additional preparatory work is much needed in the development, psychometric evaluation and interpretation of clinically meaningful end points in trials on episodic syndromes like VM taking into consideration the complexity of this disease entity comprising two domains (vertigo- and headache-related disability).

Trial registration

EudraCT, 2009-013701-34. Prospectively registered on 8 April 2011.

Pharmaceutical Intervention of Aging

The aging population represents a significant worldwide socioeconomic challenge. Aging is an inevitable and multifactorial biological process and primary risk factor for most age-related diseases, such as cardiovascular diseases, cancers, type 2 diabetes mellitus (T2DM), and neurodegenerative diseases. Pharmacological interventions targeting aging appear to be a more effective approach in preventing age-related disorders compared with the treatments targeted to specific disease. In this chapter, we focus on the latest findings on molecular compounds that mimic caloric restriction (CR), supplement nicotinamide adenine dinucleotide (NAD⁺) levels, and eliminate senescent cells, including metformin, resveratrol, spermidine, rapamycin, NAD⁺ boosters, as well as senolytics. All these interventions modulate the determinants and pathways responsible for aging/longevity, such as the kinase target of rapamycin (TOR), AMP-activated protein kinase (AMPK), sirtuins, and insulin-like growth factor (IGF-1) signaling (Fig. 15.1).

IPADAM "Pharmaceutical interventions on the issue of pharmaceutical records and self-medication" quanti survey in 482 French pharmacies

OBJECTIVES

This study aims to: (i) quantify the number of pharmaceutical interventions (PIs) linked to spontaneous requests for the two oral target molecules, ibuprofen and pseudoephedrine (ii) analyse the causes and proposed solutions (iii) quantify the number of registrations in the patient's pharmaceutical record and identify the various causes of non-registration.

METHODS

The study was conducted over a 2 weeks' period in the months of February and April 2014 in 482 pharmacies affiliated to the training supervisor associations of 8 French Faculties of Pharmacy. Data regarding spontaneous requests for the target molecules was collected, with due respect to a patient care flow chart at the pharmacy, by incorporating the systematic proposal for registration of the medication in the patient's pharmaceutical record. Each PI was the subject of a notification made with reference to a standardized grid.

RESULTS

A total of 12,160 dispensations were made over the two weeks of the study. Overall 815 of them gave rise to an PI (6.7%), justified in almost half of the cases by a contraindication. The alternative proposed by the dispensing pharmacist was accepted in more than 9 out of 10 cases. In half of the cases, the dispensing pharmacist had access to the patient's French healthcare card; more than 2/3 of the dispensations thus led to the registration of the medication in the patient's pharmaceutical record.

CONCLUSION

The pairing of the two tools, these being the notification grid and the pharmaceutical record, aims to maximize dispensation security while patients are being guided in their approach to self-medication.

Potential drug-related problems detected by routine pharmaceutical interventions: safety and economic contributions made by hospital pharmacists in Japan

Background

Pharmaceutical intervention enables safe and effective pharmacotherapy by avoiding of adverse drug reactions (ADRs) and efficacy attenuations. Many prescriptions require optimization, and pharmaceutical interventions are inextricably associated with the prevention of potential drug-related problems (DRPs). Although the analysis and understanding of pharmaceutical interventions can lead to improvement in prescription, the analysis of routine pharmaceutical interventions in Japan in insufficient. Thus, we conducted this study to understand potential DRPs by analyzing routine pharmaceutical interventions made by pharmacists in Japan.

Methods

Pharmacists register the details of pharmaceutical interventions (excluding personal patient information) in a web-based database. We classified data of pharmaceutical interventions into 13 DRP types, 43 DRP subtypes, and 10 intervention categories (e.g., avoidance of serious ADRs and renal dosing recommendations). These data were analyzed with a focus on renal dysfunction and polypharmacy.

Results

During the study period, 2376 pharmaceutical interventions were performed. Overall, 68.2% of pharmaceutical interventions were for patients aged over 65 years. The most frequently detected potential DRP was overdosage, followed by omission of prescription, contraindications, and duplication of a drug with similar effect. The main cause of contraindication and overdosage was renal function deterioration, and that of polypharmacy was duplication of a drug with similar effect. Using our original evidence-based approach, we found that 2376 pharmaceutical interventions prevented ADRs for 1678 drugs, with potential cost savings of up to USD 2,657,820.

Conclusions

Our results indicate that the analysis of routine pharmaceutical interventions is beneficial for detecting potential DRPs. Our findings also show that, in an aging society, pharmacists have an important role in providing medication safety, with potential cost savings.

[Benefit of the geriatric mobile unit's intercession on the quality of medical prescriptions for the elderly: Past year assessment]

Our multidisciplinary geriatric mobile unit works in behalf of the frail elderly people, aged at least 75, who are in loss of self-reliance. One of its main aims is so optimize medical prescriptions. The purpose of this study was to show the benefit of geriatrician and pharmacist interventions over the quality of medical prescriptions for the elderly. Medication reconciliation of treatment and reassessment of the appropriateness of the prescriptions was systematically carried out. The problems related to drug therapy have been listed and classified according to the criteria of pharmaceutical interventions defined by the French Society of Clinical Pharmacy (SFPC). Out of 181 patients, 86,2% had potentially an inappropriate or sub-optimal prescription. Finally, 462 optimizations were proposed (2.9±1.9 by patients): 204 withdrawals, 166 additions, 58 dosage adaptations, 21 therapeutic follow-ups and 13 modalities of administration. This reassessment of the prescriptions allowed to develop between our geriatric mobile unit and the liberal professionals a communication focused on the therapeutic optimization and to spread recommendations on the proper use of drugs in the elderly population.

Optimizing parents' performance in anticonvulsant rescue medication administration

OBJECTIVE

Parents of children with epilepsy are at risk of committing high-risk handling errors with a high potential to harm the patient when administering anticonvulsant rescue medication. We developed a training concept addressing identified high-risk handling errors and investigated its effects on parents' skills.

STUDY DESIGN

In a controlled prospective intervention study, parents of children with epilepsy were asked to demonstrate their administration of rescue medication by using dummy dolls. A clinical pharmacist monitored rectal or buccal administration and addressed errors in the intervention group with training and information sheets. Three to 6weeks later, intervention's sustainability was assessed at a home visit.

RESULTS

One hundred sixty-one parents completed full study assessment: 92 in the intervention group and 69 in the control group. The number of processes with at least one handling error was reduced from 96.4% to 56.7% in rectal tube administration and from 66.7% to 13.5% in buccal administration (both p<0.001).

CONCLUSION

A one-time intervention for parents significantly and sustainably reduced high-risk handling errors. Dummy dolls and information sheet were adequate for an effective and feasible training to support the correct administration of anticonvulsant rescue medication.

[IPADAM quali study. Intervention of the Pharmacist in the Issue of Self-medication: Experience of pharmacy team focus groups and patients' perceptions]

OBJECTIVES

This study had two main aims: (i) document the experience of community pharmacists receiving a spontaneous request for ibuprofen and oral pseudoephedrine, and their use of pharmaceutical records, and (ii) explore patients' perceptions of pharmaceutical records and pharmaceutical interventions.

METHODS

The study was conducted over two weeks between February and April 2014 in 482 community pharmacies and 8 French faculties of pharmacy. It was based on data collected by pharmacy team focus groups during patient telephone interviews using standardized question grids. Textual and thematic analyses were made of the patient responses.

RESULTS

Four pharmacy team focus groups carried out 49 telephone interviews. Examination of the practice of the groups showed that pharmaceutical interventions, although incompletely registered, are performed on a daily basis and enhance the value of the pharmacist's function. Analysis of the telephone interviews also showed the importance of the advisory role of the pharmacist in dispensing an optional medical prescription. The thematic analysis of the results identified a positive response of patients to pharmaceutical interventions if made by their regular pharmacist and accompanied by explanatory information. The focus groups and patients agreed that pharmaceutical records were not consulted often enough.

CONCLUSION

This study underlines the need for greater safety in the use of optional medical prescription drugs. Promoting responsible self-medication in compliance with proper use should include systematic reference to a PR and informed dialogue with the patient.

Pharmaceutical interventions on prescribed medicines in community pharmacies: focus on patient-reported problems

Background While dispensing prescribed medicines, pharmacists frequently encounter technical and clinical problems that require a pharmaceutical intervention. Objective To describe the pharmaceutical interventions performed by community pharmacists while dispensing prescribed medicines and to investigate, in-depth, the patient-reported problems with the prescribed medicines that triggered pharmaceutical interventions. Method Twenty-one pharmacists each collected 30 prescriptions requiring a pharmaceutical intervention on five selected days within a five-week period. All pharmaceutical interventions were classified using the PharmDISC system. Results Of all 430 pharmaceutical interventions, 286 (66.5%) pharmaceutical interventions had a clinical cause and 144 (33.5%) pharmaceutical interventions a technical cause. Pharmacists mainly intervened to substitute a drug (n = 132, 30.7%), adjust a dose (n = 57, 13.3%), and clarify/complete information (n = 48, 11.2%). A total of 243 (56.5%) pharmaceutical interventions resulted in a change of the prescription. The implementation rate of pharmaceutical interventions reached 88.6%. Altogether, patient-reported problems triggered 99 (23.0%) pharmaceutical interventions. In 15 (15.2%) of these PIs, contact with the prescriber was necessary, whereas 61 (84.8%) PIs only involved the pharmacist. Conclusion While dispensing prescribed medicines, pharmacists performed individualised pharmaceutical interventions to solve or prevent drug-related problems. That almost a quarter of all pharmaceutical interventions triggered by patient-reported problems highlights the importance of direct patient-pharmacist interaction when dispensing prescribed medicines.

Improvement of time in therapeutic range with warfarin by pharmaceutical intervention

Background Anticoagulation therapy with warfarin is highly effective for prevention and treatment of thromboembolic disorders. Nevertheless, its management is challenging especially in developing countries, where the medical access is difficult and patient education is poor. Objective To determine the effect of pharmaceutical intervention (PI) on the time in therapeutic range (TTR) of a group of anticoagulated patients from our referral center. Method A group of consecutive outpatients previously treated by usual medical care underwent PI. The intervention consisted in the identification and avoidance of food and drug interactions, the confection of medication schedule charts and education to patients regarding side effects and drug monitoring. Mean TTR before and after PI was compared through the Wilcoxon test for repeated measures. Regression analyses were performed to assess the relationship between a TTR level under 65% and potential explanatory variables. Results Mean TTR before PI was 37.4 ± 23.5% and after PI it raised to 67.0 ± 24.9%. Mean change in TTR was +29.5% (95% CI 14.5-44.6; p < 0.001). Before PI only 4 patients had TTR values above 65%, in contrast to 18 patients after PI. Conclusion Our findings support the efficacy of PI to improve TTR values in patients treated with warfarin.

The role of clinical pharmacists in treatment adherence: fast impact in suppression of chronic myeloid leukemia development and symptoms

PURPOSE

Chronic myeloid leukemia (CML) is a clonal myeloproliferative disease, accounting for 15 to 20% of leukemias, with an incidence of one to two cases/100,000 inhabitants. In Brazil, the estimated incidence of leukemia is six cases/100,000 men and 4.28 cases/100,000 women. CML is characterized by the presence of the Philadelphia chromosome. At present, three types of tyrosine kinase inhibitors (TKI) are administered to treat CML patients in the Brazilian public national health system (NHS), called the Unified Health System (in Portuguese, "Sistema Único de Saúde", SUS). Such treatments are only effective if patients adhere to strict dosage regimens; protocol improvements that increase patient adherence to treatment would have economic and health benefits for overburdened health care systems. Here, pharmacist-monitored treatment is assessed.

METHODS

In our study, we applied two questionnaires, one to assess the adherence to pharmacological treatment and another to assess the quality of life. All patients studied (n = 23) were diagnosed with CML at a local hospital in "Espírito Santo" State, the "Hospital Evangélico Vila Velha" (HEVV).

RESULTS

Treatment adherence was significantly higher in pharmacist-monitored patients than in nonmonitored patients (p = 0.0135). The quality of life of CML patients was also analyzed, indicating that monitored patients had a lower number of symptoms/complaints during treatment periods than nonmonitored patients. Finally, improved treatment adherence also translated into better clinical conditions, particularly during the early stage of treatment (e.g., the first 4 months).

CONCLUSIONS

The intervention of a clinical pharmacist is significant to obtain positive clinical results. Therefore, it is recommended that this protocol be included in the standard NHS treatment protocol CML patient outcomes to reduce the indirect and recurring costs to the health care system caused by nonadherence.

Impact of pharmaceutical intervention on quality of life and coping strategies in patients with haematological malignancies

OBJECTIVES

We conducted a prospective study approved by the local ethics committee to determine the impact of a pharmaceutical intervention (PI) on pain, fatigue, quality of life (QoL) and coping strategies in patients with HMs starting chemotherapy sessions.

MATERIAL AND METHODS

Patients received either usual care (UC)+PI (PI group) or UC alone (UC group). They had to complete 2 questionnaires, QLQ-C30 and MAC 21, at 3 different time points: before starting the 1st chemotherapy session (T1), during the intercure (T2) and the day before starting the 2nd chemotherapy session (T3). To determine predictive factors of pain, fatigue, QoL and coping scores at T3, a multivariate ANOVA was used. QoL and coping scores were analysed longitudinally using a linear mixed model.

RESULTS

Sixty-eight patients were included in the PI (n=34) or UC groups (n=34). Ninety-two percent of the patients returned all the questionnaires. At inclusion, QoL was significantly better in the PI group (P=0.047). At T3, the group had no influence on pain, fatigue, nor coping scores but a trend towards a better QoL was observed in the PI group (P=0.090). Longitudinally, the PI group did not present significantly better scores on pain, fatigue but both a trend toward better Qol scores and lower anxious preoccupations scores.

CONCLUSION

A PI at the beginning of chemotherapy sessions did not have any significant impact on pain and fatigue but a trend towards better Qol scores and lower anxious preoccupations scores.

The Role of the Pharmacist in the Treatment of Patients with Infantile Hemangioma Using Propranolol

INTRODUCTION

Infantile hemangiomas (IH) are the most common benign vascular tumors of childhood, with an incidence of 5-10% during the first year of age. Propranolol is considered the first-line treatment for this condition. Potentially there is a high probability of negative results to therapy, because in many countries there are no treatment protocols or propranolol formulations appropriate for the pediatric population. The objective of the present study was to evaluate the impact of pharmacist interventions such as detecting, analyzing, and solving problems presented during treatment with propranolol in patients with IH.

METHODS

An open observational prospective study was performed over 25 months in a group of pediatric patients diagnosed with infantile hemangioma treated with propranolol. Pharmacist participation consisted of development of an extemporaneous formulation and counseling the child's parents. At each visit to the pharmacy service, family members were interviewed, detecting and classifying problems related to treatment.

RESULTS

Sixty-three children with IH were treated during the period under review. Patient ages ranged from 3 to 11 months old; 64% were female and 36% were male. Forty-nine problems in 30 patients were detected, principally inadequate dose (18.4%), non-adherence to treatment (16.3%), side effects (14.3%), and wrong administration (14.3%). Of the problems detected, 81.6% were resolved. Interventions by the pharmacist in 27 patients were intensive counseling on adherence to therapy (20%), detection of adverse effects (11.4%), and adjustment of the dose (22.9%). In 95.2% of patients a good response to treatment was obtained compared with 77.2% reported in European studies without pharmacist intervention.

CONCLUSION

It seems that pharmacist participation increases adherence to treatment and reduces the likelihood of adverse effects, allowing for safe and effective therapy in patients with IH.

[Risk/benefit assessment in the treatment of Alzheimer's disease. Drug interactions]

INTRODUCTION

Anticholinergic drugs reduce the efficacy of acetylcholinesterase inhibitors (AChEI) and are inappropriate in elderly patients. The aim of this study is to determine the prevalence rate of prescription AChEI drugs and anticholinergics in a Healthcare Area, to identify the affected patients, and to inform the attending physicians, in order to evaluate the suitability of treatments.

MATERIAL AND METHODS

A descriptive cross-sectional observational study of prevalence. Patients on treatment with AChEI and any anticholinergic drug in the first quarter of 2015 were selected. The review of Duran et al. was used as reference to identify anticholinergics, assigning a score to each drug according to its anticholinergic potency. Physicians were provided with a report about the interaction, the list of affected patients, and recommendations.

RESULTS

A total of 486 patients were included in the study, representing 59.0% of total patients with Alzheimer's disease in the Area. There were 66.0% women, and 86.8% of the patients were older than 75 years, and with a mean of 9.2 drugs per patient. The mean number of anticholinergic drugs was 1.6, and 38.3% of patients were prescribed various anticholinergic drugs, with 23.9% on high potency anticholinergic drugs. A statistically significant association was found between taking an anticholinergic and AChEI concomitantly (P=.000; OR: 3.9).

CONCLUSIONS

The prevalence of interactions between AChEI and anticholinergic drugs is relevant, considering that it affects vulnerable members of the population. Providing physicians with information about the interaction could help them make clinical decisions, and could improve patient safety, as well as health outcomes.

Evaluation of the role and usefulness of a pharmacist outpatient service for patients undergoing monotherapy with oral anti-cancer agents

Introduction When rapid feedback to physicians must be provided, e.g. monitoring therapy with the oral anticoagulant warfarin or providing therapeutic support for patients undergoing cancer chemotherapy, the involvement of pharmacists is required for outpatients. We launched a pharmacist outpatient service for patients with cancer taking oral anti-cancer agents. We evaluated the role and usefulness of the pharmacist outpatient service for these patients undergoing oral monotherapy with anti-cancer agents. Methods Data regarding prescription recommendations were collected from the drug management guidance records of 154 patients who consulted the pharmacist outpatient service between July 2013 and September 2015. In addition, the rates of prescription recommendation adherence were calculated. Between April and August 2015, a self-reported questionnaire was administered to 47 patients undergoing therapy with oral anti-cancer agents who were visiting the pharmacist outpatient service at the Ogaki Municipal Hospital (Ogaki, Japan). Results Prescription recommendations were given to 235 cases. The total rate of adherence to the prescription recommendations was 94.9% (223/235 cases). The majority of prescription recommendations regarding supportive care were those for moisturizing agents (20.9%), analgesics (20.9%), steroid ointments (12.7%), and antihypertensive agents (10.8%). When continued guidance was provided, significant changes were observed for survey items 3 (knowing the side effects of the medication), 8 (worrying about side effects), and 12 (interest in prescribed medicine) ( p = 0.0049, p < 0.0001, and p = 0.0164, respectively). Conclusion Our study showed that continued pharmaceutical intervention resulted in a deeper understanding of the medications' side effects, and it reduced anxiety levels in patients undergoing monotherapy with oral anti-cancer agents.

[Drug management of prisoners: Role of the pharmaceutical staff to ensure patient safety]

OBJECTIVES

In the prisons of Lyon, drug management of inmates implies cooperation between general practitioners, psychiatrists and pharmacists. All the medical prescriptions are reviewed by the pharmacists of the medical unit. The aim of this work was to synthesize the pharmaceutical interventions performed and show the implication of the pharmaceutical staff in detecting and handling prescribing errors.

METHODS

Pharmaceutical interventions performed between the 1st of June 2012 and the 31st December 2014 and entered in the Act-IP(®) database (SFPC) were retrospectively analyzed.

RESULTS

Among the 18,205 prescriptions reviewed, 4064 (22.3%) had a prescription error. The main problems encountered were by decreasing order of frequency: missing monitoring (15% of the interventions), lack of compliance (13%), over dosage (10%), lack of conformity with recommendations or consensus (8%). Interventions were accepted in 78% cases. Most prescribing errors implied medications of the central nervous system. Among the interventions, 8% were initiated by pharmacy technicians, mainly lack of compliance.

CONCLUSIONS

The pharmaceutical interventions reported reflected actions of securisation initiated by the pharmacists in cooperation with physicians: monitoring of patients taking antipsychotic medications or benzodiazepines maximal dosages. Besides, in this population with a high prevalence of psychiatric comorbidities and important suicide rate, detection of patients with default of compliance is one of the keys for drug optimization among these patients as it is an explanation for therapeutic failure.