[The best time for a medication: how to sweeten the pill ?] / Le bon moment pour un médicament: comment faire passer la pilule ?

Is it worth improving the effectiveness of a treatment by modulating the prescription schedule? Data show that the preferred administration timing depends on biological rhythms. Taking this into consideration can improve efficiency or reduce side effects. Food also plays a role. However, for most medications, setting a schedule that is too strict in relation to meals may not be clinically relevant and can lead to « therapeutic weariness ¼. To ensure effectiveness, tolerance and economy of a treatment, it is more important to ask patients about their habits and to define with them the best schedule.

Comment améliorer l'efficacité d'un traitement en modulant l'horaire de prise ? Différentes données montrent que le moment d'administration préférentiel dépend en partie des rythmes biologiques. En tenir compte peut améliorer l'efficacité ou diminuer les effets indésirables. La nourriture joue également un rôle. Cependant, pour la plupart des médicaments, fixer un horaire trop strict par rapport aux repas n'apporte rien cliniquement et entraîne une « fatigue thérapeutique ¼. Pour garantir l'efficacité, la tolérance et l'économicité d'un traitement, il est plus important d'interroger les patients sur leurs habitudes et de définir avec eux le bon moment de prise.

Medication reconciliation in a Swiss hospital: methods, benefits and pitfalls.

OBJECTIVES: To assess the feasibility and main obstacles to the implementation of a medication reconciliation (MR) process in a Swiss hospital and to develop a standardised method which can be used in similar healthcare systems. METHODS: For this prospective, observational single-centre and single-ward study, a best possible medication history (BPMH) was established by a clinical pharmacist for 147 patients with heart failure based on two sources and a patient interview for each case. Identified discrepancies with medication histories established during emergency service were conveyed to the ward physician. At the end of each hospital stay, the planned discharge treatments were compared with the BPMHs to identify discrepancies and to propose modifications. After a final validation, the comparative treatment plans were distributed. RESULTS: MR was conducted for 120 (82%) patients and the mean time needed was 74 min/patient. At least one discrepancy was identified among 94% of the patients on admission, with 4.1 discrepancies found per patient (mainly omissions). At discharge, 83% of the patients had at least one discrepancy, with 2.3 discrepancies found per patient (mainly unintentional substitutions). The majority (86%) of pharmaceutical interventions to adjust the discharge prescriptions were accepted by the physician. CONCLUSIONS: A standardised method of MR which offers precise definitions of discrepancies and key tools for the process was developed. This method was applicable to most of our cohort and it effectively identified medication discrepancies. Two potential obstacles for its implementation are the time needed for MR and the questionable impact of pharmaceutical interventions on discrepancies.

Effectiveness of a transition plan at discharge of patients hospitalized with heart failure: a before-and-after study.

AIMS: We evaluated the effectiveness of a multidisciplinary transition plan to reduce early readmission among heart failure patients. METHODS AND RESULTS: We conducted a before-and-after study in a tertiary internal medicine department, comparing 3 years of retrospective data (pre-intervention) and 13 months of prospective data (intervention period). Intervention was the introduction in 2013 of a transition plan performed by a multidisciplinary team. We included all consecutive patients hospitalized with symptomatic heart failure and discharged to home. The outcomes were the fraction of days spent in hospital because of readmission, based on the sum of all days spent in hospital, and the rate of readmission. The same measurements were used for those with potentially avoidable readmissions. Four hundred thirty-one patients were included and compared with 1441 patients in the pre-intervention period. Of the 431 patients, 138 received the transition plan while 293 were non-completers. Neither the fraction of days spent for readmissions nor the rate of readmission decreased during the intervention period. However, non-completers had a higher rate of the fraction of days spent for 30 day readmission (19.2% vs. 16.1%, P = 0.002) and for potentially avoidable readmission (9.8% vs. 13.2%, P = 0.001). The rate of potentially avoidable readmission decreased from 11.3% (before) to 9.9% (non-completers) and 8.7% (completers), reaching the adjusted expected range given by SQLape® (7.7-9.1%). CONCLUSIONS: A transition plan, requiring many resources, could decrease potentially avoidable readmission but shows no benefit on overall readmission. Future research should focus on potentially avoidable readmissions and other indicators such as patient satisfaction, adverse drug events, or adherence.