Discussion

Collaboration between physicians, nurses and pharmacists is normal in our hospital centre. Pharmacists are fully integrated into the multidisciplinary team, so medication review is part of pharmacist daily practice. During the study period, all patient prescriptions (n=3604) were reviewed by pharmacists. Interventions were made for 147 drugs, mainly antibacterial, CNS and cardiovascular system drugs as found in other studies.(Survey, Candice, Annemie, Bedouch 2008) The majority of interventions involved antibacterial drugs (n=543; 43.5%). These data are in accordance with the results from the Institute for Safe Medication Practice Survey where the most common intervention was for this therapeutic group.15 The majority of the PIs concerned acetaminophen (n=226), probably because during the study period pharmacists were promoting a switch from intravenous to oral administration, where possible, as the result of a previously identified drug-related problem. When we analysed the PIs by type, the most frequent reason for the interventions involved dose (n=548; 43.9%) as seen in other studies. (Nick; Boden; Annemie; Hawkey)

The acceptance rates for recommendations made by clinical pharmacists to physicians were generally high, varying from 39% to 100%. Only 2% of the interventions concerned drug interactions, due to the existence of automatic alerts on the electronic prescription system that were implemented during the study period. Five of the drug-interaction interventions identified and evaluated for acceptance were major and four were moderate. Only one of the major interactions was not accepted, and concerned the interaction between haloperidol and trazodone, which has a fair reliability rating.16 The low number of interventions related to adverse drug reactions does not allow further analysis. The low acceptance rate of the interventions related to contraindications is due to the fact that metformin is contraindicated in patients with creatinine clearance less than 60 mL/min as documented in the summary of product characteristics. However, NICE (National Institute for Health and Care Excellence) and HAS (Haute Autorité de Santé) advise against the use of metformin only for values less than 30 mL/min. We were not able to evaluate the acceptance rate for 393 interventions due to patient discharge or transfer between wards before the physician could see the recommendation.

The patient characteristics and the types of drugs prescribed are probably comparable to those in other hospitals; however, prescribing rules and the working methods of physicians and pharmacists may differ between institutions. The detection of drug-related problems and the recommendations provided could strongly depend on the experience of the clinical pharmacist involved. The hospital pharmacists are similar in terms of age and professional experience (all with more than 5 years of experience), so interventions were not stratified on pharmacist. No clinical endpoints were taken into consideration (eg, hospital readmissions, mortality or quality of life). Also, the lack of a control group of patients not undergoing the intervention can be considered a weakness of the study design. Moreover, the aim of this study was not to assess the impact of the clinical pharmacist on clinical outcomes.

The information technology used in our hospital enabled recommendations to be made in the electronic prescribing system and provided immediately to the doctor. Each drug-related problem was specified, with a short explanation, and presented together with a pharmacotherapy recommendation. However, when we analysed acceptance rates by intervention type, we found that it was 57.5% for dosage, 46.2% for drug and 50.0% for administration. These data were somewhat lower than reported in other studies.3 ,17–22 This could probably be explained by the fact that the pharmacist was not present when the recommendations were considered by the treating physician, precluding further discussion at that time.

It should noted that interventions made during ward rounds were not considered in this study since they are not entered in the prescription system. For further evaluation it would probably be interesting to evaluate the acceptance rate by ward speciality or by junior versus senior doctors. The role of the clinical pharmacist might be to detect the over- and underuse of drugs, and to discuss therapeutic goals and drug use with physicians. Pharmacist's recommendations entered in the electronic prescribing system with a short explanation, as well as the pharmacotherapy recommendation, are available immediately to the doctor; however, the relatively low acceptance rates suggest that further study including verbal interventions is needed, since the most urgent recommendations are made verbally, and this would likely increase the acceptance rate.