DISCUSSION
The present study on pharmaceutical analysis in a geriatric care unit at a teaching hospital reports that clinical pharmacists detected a higher number of DRPs within prescriptions during the first wave of the COVID-19 pandemic than beforehand. Associated therapeutic advice focused on the use of drugs specific to the management of COVID-19 infected patients rather than geriatric routine treatments. The needs for clinical pharmacists were strengthened during the pandemic. With the persistence of hospitalizations for COVID-19, this work may be used to improve practices and provide better adapted PIs to support patient care.
To date, several articles on the roles of pharmacists during the COVID-19 pandemic have been published [18,19]. These articles emphasize the importance of pharmacists in managing stocks of health products but also their support role for the medical staff in the proper use of these treatments. This optimization of therapeutics is part of the routine job for clinical pharmacists, but has increased due to the health context [20]. Previous reports on PIs during this pandemic focused specifically on the management of COVID+ patients, whether via pharmaceutical teleconsultations in a tertiary care centre [21] or in hospitalised patients in a community teaching hospital [22,23]. We provide here, to the best of our knowledge, the first review of pharmaceutical analysis activity in a population of frail, elderly inpatients - regardless of their COVID status, and the first comparative review of the pharmaceutical analysis practices prior to and during the first wave of this pandemic.
The main result of our study is that, during the COVID-19 pandemic, pharmacists released significantly more PIs per stay, per patient and also per line of treatment than prior to the pandemic.
During the first wave of COVID-19, 6.0% of PIs were performed out of the total number of treatment lines analysed, 53.4% of hospital inpatients’ prescriptions were subject to a PI and the total number of PIs per patient was 0.94. This rate is higher than those presented by two other studies in French geriatric acute care units [24,25] and whose results were similar to ours prior to the pandemic. On the other hand, the works of Collins et al. [22] and Perez et al. [23] have shown higher rates of PIs than ours, up to 8 PIs per patient. These higher figures might be explained by the greater number of staff in the clinical pharmacy team; nevertheless these studies suggest that the medical management of COVID+ patients is particularly at risk of medication errors.
This can be explained in different ways. Firstly, the mean length of stay for patients was shorter during the COVID-19 pandemic than beforehand. We therefore analysed more first-prescriptions that were more at risk of DRPs. Indeed, previous works have shown that approximately 50% of prescriptions on admission in a hospital unit include a DRP [26,27]. Secondly, the number of treatment lines per patient is higher among those hospitalized during the first wave and thus increases their risk of exposure to an iatrogenic event and potential DRP identified by the pharmacists. Thirdly, during the pandemic there were significantly more PIs on anti-infectious drugs than before. Their high prescription rate in the pandemic context is likely explained by the recommendation of their probabilistic prescription for suspicious or infected COVID-19 patients. These drugs are frequently cited as a cause of DRPs, due to their prescription in acute illness and their specificities of use in elderly patients (dosage adjustment, biological monitoring) which reinforced the pharmacists’ vigilance during the analysis [28,29].
Our results showed a significant difference in the types of the PIs achieved over the two periods.
During the first-wave of the pandemic there was a focus on drugs that are part of the medical management protocol of COVID+ patients: the drugs with the higher number of PIs were anti-infectious ones (20.3%), acetaminophen (17.5%) and anticoagulant ones (9.6%).
The DRPs found in anti-infectious drug prescriptions were mostly an improper administration (e.g. an injectable form prescribed when the oral route is possible, a prescription with no duration of treatment) or a supratherapeutic dosage.
There were no significant differences in the number of DRPs in the prescription of acetaminophen and anticoagulants drugs. Acetaminophen is the most frequently prescribed molecule during hospitalisation in France [30] and particular attention is paid to its correct prescription in geriatric care (respecting the maximum dosage for older adults and according to the patients’ weight, adapted route of administration or verification of the absence of double prescription lines). Anticoagulants are a class of drugs that are particularly at risk of serious adverse effects in older adults [31]; the pharmaceutical team therefore focused attention on their prescription as they require reinforced vigilance in their use (duration of treatment, route of administration, adapted dosage, biological monitoring).
Before the COVID-19 pandemic, the drugs with the highest number of PIs were laxatives (13.0%), acetaminophen and proton pump inhibitors (11.1%). These therapeutic classes are frequently found in prescriptions for older adults, and correspond to standard geriatric care. We noted significantly more DRPs for a prescription without an indication and advice on drug discontinuation. This is consistent with the specificities of routine geriatric care where particular attention is paid to the reassessment of inappropriate prescriptions (i.e., overuse, misuse, underuse). The purpose is to encourage deprescribing whenever possible in order to limit avoidable iatrogenic risks, the prevalence of which is particularly high in this population [32,33].
This difference in practices adopted during the pandemic, and significantly highlighted, can be explained by the notion of emergency in the management of COVID+ patients on their admission to the unit. Indeed, PIs on inappropriate administration or dosage adjustments are more in line with those expected for acute care management as this was the case during the first wave of the pandemic; whereas PIs on laxatives or drugs without an indication are more appropriate for routine management, when the patient stays long enough on the ward to benefit from geriatric therapeutic optimisation.
Our PIs during the pandemic were similar to the advice for therapeutic optimisation during COVID-19 proposed by the work of Burgess et al. [20] and found in the reviews by Surapat et al. [21], Collins et al. [22] and Perez et al. [23]. Basically, we proposed dosage adjustments to use the optimal dose for each patient, we insisted on the optimisation of the administration of drug modalities and advised on deprescription to ease the treatment regimens for those patients, but we note, however, a lower proportion of PIs on treatment monitoring in our results.
Concerning the clinical impact of our PIs, no significant difference was found between the two periods of analysis. Only 3 studies proposing an evaluation of the impact of PIs using the CLEO scale were found in the literature [34-36]. The CLEO scale being a French scale and of recent implementation, is currently little used.
Other scales have been used in previous works (Hatoum, Pippins) and these tools have demonstrated that PIs in geriatrics most often have a clinical impact considered as ”significant” [25,37,38]. This is similar to our results. As the pharmaceutical team works in partnership with the medical team, PIs have little major or even vital clinical impact for patients.
The acceptance rate of our PIs is similar for both analysis periods, with an average value of 60.2%. This result is lower than those found in the literature, ranging from 63.3% to 92.0%. The main hypothesis to explain this lower acceptance rate is the lack of systematic oral communication of the PI. Indeed, it has been proven that PIs have a better chance of being accepted if they are discussed with the medical team [39]. We did not distinguish the mode of transmission of our PIs to the prescribers in our data collection. Studies that have shown an acceptance rate of computer-transmitted-only PIs in their results have similar results to ours [25]. Following the awareness of the need for oral transmission, proposals to improve our communication were discussed with the medical team but were not always successful in the health context of the pandemic which reduced the contact between pharmacists and the healthcare team. While PIs focusing on compliance with good prescribing practices, in accordance with protocols or based on biological elements, may be considered relevant, some advice for therapeutic optimisation may have been less appropriate for prescribers during the pandemic.
This study had some limitations. Contrary to other works, we decided to compare the PIs carried out over two distinct periods of time rather than between COVID+ and COVID- patients. This may have caused a bias in our analysis practices. As the clinical pharmacy team has only been working in the unit since November 2019, its efficiency in analysing prescriptions was not optimal at the beginning of the data collection. As the gain in experience through contact with the medical team and the performance of clinical pharmacy activities is acquired over time, it is logical to highlight an improvement in the pharmacists’ practices in this activity during the 2nd period of data collection.
Also, due to the difficulties in determining the proportion of COVID+ patients in our population, the results of our work are more a reflection on general geriatric management during this pandemic than specific geriatric management for COVID+ patients.