Implementation of clinical medication review in a geriatric ward to reduce potentially inappropriate prescriptions among older adults.

PURPOSE: The impact of several pharmaceutical interventions to reduce the use of potentially inappropriate medications (PIMs) and potentially omitted medications (POMs) has been recently studied. We aimed to determine whether clinical medication review (CMR) (i.e. a systematic and patient-centred clinical assessment of all medicines currently taken by a patient) performed by a geriatrician and a pharmacist added to standard pharmaceutical care (SPC) (i.e. medication reconciliation and regular prescription review by the pharmacist) resulted in more appropriate prescribing compared to SPC among older inpatients. METHODS: A retrospective observational single-centre study was conducted in a French geriatric ward. Six criteria for appropriate prescribing were chosen: the number of PIMs and POMs as defined by the STOPP/STARTv2 list, the total number of drugs prescribed, the number of administrations per day and the number of psychotropic and anticholinergic drugs. These criteria were compared between CMR and SPC group using linear and logistic regression models weighted on propensity scores. RESULTS: There were 137 patients included, 66 in the CMR group and 71 in the SPC group. The mean age was 87 years, the sex ratio was 0.65, the mean number of drugs prescribed was 9, the mean MMSE was 21 and at admission 242 POMs, and 363 PIMs were prescribed. Clinical medication review did not reduce the number of PIMs at discharge compared to SPC (beta = - 0.13 [- 0.84; 0.57], p = 0.71) nor did it reduce the number of drugs prescribed (p = 0.10), the number of psychotropic drugs (p = 0.17) or the anticholinergic load (p = 0.87). Clinical medication review resulted in more POMs being prescribed than in standard pharmaceutical care (beta = - 0.39 [- 0.72; - 0.06], p = 0.02). Cardiology POMs were more implemented in the medication review group (p = 0.03). CONCLUSION: Clinical medication review did not reduce the number of PIMs but helped clinicians introduce underused drugs, especially cardiovascular drugs, which are known to be associated with morbidity and mortality risk reduction.

Improvement of patient care through hirudotherapy and the management of leeches from their reception to their disposal in France.

OBJECTIVE: Medicinal leech therapy - known as hirudotherapy (HT) - is an empirical medical technique that has become popular again in reconstructive surgery. However, at each step of leech management there are risks for blood contamination of the caregivers and severe infections for patients. This reduces the success of the treatment. The aim of this study was to improve the management of leeches from ordering to disposal to improve patient care. METHODS: First, a review of the literature was performed. Second, we conducted a retrospective study of patients' antibiotic prophylaxis from January 2018 to December 2019. The data we collected were patient characteristics, the specific care unit at the hospital, indication, contra-indication, posology, duration of HT, number of leeches delivered, antibiotic prophylaxis prescribed and microbial organism, if identified. Third, an interdisciplinary meeting was organised to review the entire leech circuit: ordering, maintenance, prescription, dispensing, application and disposal. RESULTS: At the end of the literature review, six articles based on practices implemented in France were selected for inclusion. These articles discussed antibiotic prophylaxis, iron supplementation, and leech storage, application and disposal. On the retrospective study performed, antibiotic prophylaxis for HT was performed for 60% (30/50) of patients, 77% (23/30) of the prescriptions followed the recommendations for antibiotic prophylaxis, and 20 patients did not receive antibiotic prophylaxis. The interdisciplinary meeting made it possible to define a collegially validated protocol, containing a computerised antibiotic prophylaxis prescription, including per os ciprofloxacin antibiotic prophylaxis, intravenous iron supplementation and biological monitoring. A leech application protocol was created, and the method of leech disposal was revised. CONCLUSION: Despite the absence of clear guidelines and heterogeneous practices, this study reveals the importance of a standard procedure including leech management practices before use, antibiotic prophylaxis and application and disposal guides. The interdisciplinary protocol allows improved patient care management and makes leech management safer for caregivers.

[Validation of a method for detecting hospitalizations for falls related to adverse drug reactions in geriatric departments]. / Validation d'une méthode de détection des hospitalisations pour chute liées à un effet indésirable médicamenteux en service de gériatrie aiguë.

Fall is one of the five main causes of drug-related hospital admissions (DRA) in France. A standardized chart review method, to identify DRA adapted to elderly patients, has recently been developed by Thevelin et al. Our first aim was to assess the reliability of this method for detecting DRA for falls in elderly subjects. Our second aim was to assess the feasibility of this method and to evaluate its reliability for assessing causality, the contribution of DRA to hospitalization, and the avoidability of DRAs in elderly patients hospitalized for a medication-related fall. A retrospective observational study was conducted on 16 patient cases admitted to the hospital for falls in May 2022, in the geriatric department of a French university hospital. Six healthcare professionals (pharmacists, pharmacologists, and geriatricians) assessed a method for detecting DRA individually and then in multidisciplinary pairs of raters. Inter-rater agreement (individually and in pairs) was assessed for DRA detection, causality, avoidability, and contribution of the DRA to hospitalization. A κ > 0,4 was considered a satisfactory threshold for agreement. The mean age was 86 years. When the assessment was done individually, detection of DRA-related hospitalizations (κ = 0,46; p < ,001), and DRA contribution to hospitalization (κ = 0,50; p < ,001) were moderately concordant. The causality assessment (κ = 0,09; p = 0,24) did not agree, and the avoidability assessment (κ = 0,63; p < ,001) agreed substantially. When the evaluation was done in pairs, detection of DRA-related hospitalizations (κ = 0,47; p < ,001) was moderately concordant between pairs. Avoidability assessment (κ = 0,79; p < ,001) concurred substantially. The assessment of causality (κ = 0,29; p = 0,01) and DRA contribution to hospitalization (κ = 0,38; p < .001) agreed fairly well. This study validated, individually and in pairs, the reliability of the method to identify DRA in the context of falls. This method will be of great use in research and epidemiological studies.

Impact of pharmacist interventions on clinical outcome and cost avoidance in a university teaching hospital.

Background A significant number of clinical pharmacy services have shown to improve in-hospital medication safety and patient outcome. Prescription review and pharmacist interventions are a fundamental part of hospital clinical pharmacy activities. In a context of restricted financial resources, proving the economic and clinical impact of this activity seems necessary. Objective The aim of this study was to assess the clinical impact on patient outcomes and economic benefit of prescription review by pharmacists. Setting 1624-bed tertiary French university teaching hospital. Method Prospective single center study evaluating prescriptions for which a pharmacist intervention was issued over a 6-month period. The clinical impact of every pharmacist intervention was evaluated by a multidisciplinary experts committee. Economic benefit was evaluated from the public health care system spending standpoint. Main outcome measures Number of avoided hospitalization days and associated public health care system cost-avoidance. Results Prescription review and interventions by pharmacists prevented 73 intensive care unit hospitalization days, 74 continuous monitoring unit hospitalization days and 66 days of conventional hospitalization. €252,294.00 in public health expenditure were thus prevented. For every Euro invested in the prescription review activity, €5.09 of public health spending were potentially saved. Conclusion Our study shows that prescription review and clinical pharmacists' interventions had an impact on clinical outcomes which translated into prevented hospitalization days. Prescription optimization through pharmacist interventions allows significant health care cost savings which makes this service highly efficient.