METHODS
All inpatients whose medical prescription was analysed by clinical
pharmacists (1 senior pharmacist or 1 resident) in the geriatric acute
care unit between January 27 and April 30, 2020 were included in this
single-centre, observational, retrospective and comparative cohort
study. The characteristics of those patients collected for the study
were the following: demographical measures (age and gender), autonomy
score (AGGIR scale - Autonomy Gerontology Iso-Resources Groups), length
of stay and in-unit mortality. Those data were retrieved by consulting
the hospital medical records.
All PIs carried out by the clinical pharmacy team during the patients’
prescriptions analysis were gathered. They were distinguished according
to whether they were conducted prior to COVID-19 (between January 27 and
March 18) or during the first wave of COVID-19 (between March 19 and
April 30).
The endpoints to answer our main objective were the rate of PIs per
patient and per line of treatment analysed. To answer our secondary
objectives we collected the following data: drug class managed by the
PI, DRP identified and nature of advice given. The PIs data were
collected for the study via Business Object© (v12.1.0,
SAP Walldorf, Germany).
The study was conducted in accordance with the ethical standards set
forth in the Helsinki Declaration (1983). The Angers ethical committee
approved the study protocol under number 2020/140. The study protocol
was declared to the National Commission for Information Technology and
civil Liberties (CNIL) under number ar20-0058v1.
Computerized medication orders and pharmaceutical analysis were allowed
with three interfaced software packages (v8.2.6, Maincare, Cestas,
France): Crossway® and Horizon Expert Order® for the medical
prescription and M-Pharmacie® for the pharmaceutical analysis.
The prescriptions were analysed on working days (Monday to Friday) by
the senior clinical pharmacist or their resident according to the
standards set out by the French Society of Clinical Pharmacy (SFPC)
[13] based on the patient’s medical records, test results,
medication records and with the Hospital’s therapeutic booklet taken
into account.
The tools used for analysing were: i) the French drug compendium (Vidal
Hoptimal® database), ii) the kidney adapted prescription guide website
(GPR®) which provides dosing adjustments according to renal clearance,
iii) the screening tool to detect potentially inappropriate prescribing
in persons aged 65 or older (Laroche list [14] and STOPP/START list
[15]) and iiii) the Geriatric Dosage Handbook 14th Edition (Semla
T., Beizer J., Higbee M.). The latest internal clinical guidelines for
COVID-19 were used during the pandemic.
PIs can be carried out by treatment lines. A treatment line corresponds
to the prescription of a new drug (original prescription or addition
during hospitalisation), a discontinuation or suspension of a drug or a
dosage adjustment.
The standardisation of the PIs was proposed by the SFPC [16]. Their
tool for the documentation of PIs includes the identification of the
drug related problem and the therapeutic advice given. The detailed
categories are presented in Appendix 1.
A PI is notified in both the analysis software and the prescription
software. PIs are discussed orally with the medical team and considered
as accepted if they lead to a change in the prescription. The acceptance
rate of our PIs was assessed in this study.
The clinical impact of a PI was evaluated with the Clinical, Economic
and Organizational (CLEO) tool v3 [17] after a consultation between
the senior pharmacist and a geriatrician from the unit. This
consultation was made retroactively while analysing the data and the
assessment of the problem wasn’t patient-specific. The clinical impact
scale ranges from −1C (harmful) to 4C (vital). The different scores are
presented in Appendix 2.
All statistics were performed using SAS© (v9.4, SAS
Institute Inc., Cary, NC, USA). The Chi-squared test or Fisher test were
used for assessing differences in proportions and the Student test or
the Mann–Whitney–Wilcoxon test were used to compare the distribution
of ranks between the groups. P-values<0.05 were considered
significant.