This study describes an original experience of integrating clinical pharmacy into an SDC. This review at 2.5 years describes the activities for which caregivers requested assistance from the CP. It also provides better understanding of the ways in which a clinical pharmacy activity can be developed.
Solicitation of the clinical pharmacist
The CP was requested by the health team for 3 main activities: providing pharmaceutical advice (59%), telephone pharmaceutical follow-up of patients (18%), and conducting interviews with patients during hospitalization (11%).
Advice
It should be noted that the medical team got used to the clinical pharmacy approach very quickly: they were the source of most requests. Advice mainly concerned therapeutic strategy. This close cooperation between physicians and CP plays a part in patient safety. Several studies have shown that the presence of a CP in a hospital unit significantly reduces medication errors (10, 17) and promotes acceptance of pharmacist recommendations compared to written advice. (10, 18)
The studies published mainly concern the positive impact of pharmaceutical interventions formulated by pharmacists during prescription validation, i.e. retroactively, after drug prescription. (18–21) However, in our experience, proactive advice was the main activity when the CP was part of the care team. Nevertheless, there is little data available in the literature on the impact of advice provided proactively by pharmacists for medical teams. (22, 23)
Integrating a CP into the SDC staff made him or her a closer partner of the team. This approach promoted trust and mutual understanding. The essentially proactive nature of this approach is adapted to the organization of a hospital ward, and is complementary to the activities carried out at the hospital pharmacy.
This approach also reinforces the relations between the ward staff and the hospital pharmacy. Several studies have shown its role in saving time for various professionals, both in the services and at the hospital pharmacy.
Current HDC interviews
Patients are the second beneficiaries of advice. Within our department, advice to patients was provided particularly during HDC for the application of capsaicin patches. These interviews were set up at the behest of the medical team. During these interviews, we frequently found a lack of knowledge among patients about the difference between background and acute analgesic treatments (34%), about the difference between nociceptive and neuropathic pain (58%) and about other indications for their neuropathic pain treatments and the onset and duration of action (66%). These elements have been reported in the literature as obstacles to drug compliance. Providing appropriate information on the drugs taken by the patient (indications, methods of administration, side effects and how to prevent them, drug interactions, etc.) can improve compliance.(24) According to several studies, clinical pharmacy activities have led to improved drug compliance of 10.9 to 14.5%.(9, 25) Other studies have shown a positive impact of clinical pharmacy services on health in different pathologies. (26, 27)
Pharmaceutical follow-up by telephone
Implementing close pharmaceutical follow-up (668 calls to 109 patients) made personalized accompaniment of the patient possible during a change in analgesic treatment, in particular when a new treatment was introduced. It also made it possible to prevent adverse effects by progressively adapting dosages, improving compliance, and ensuring the correct treatment mode. New medical consultations could be provided only if necessary, thus probably avoiding consultations in hospital emergency departments, and freeing capacity for more urgent painful patients, especially in the fields of cancer pain.
In 2006, Wu et al. published a randomized controlled study of poly-medicated patients who were not compliant at inclusion. In the intervention arm, telephone follow-up with a CP was set up. After 2 years (6 to 8 calls in the intervention group, none in the control group), and after adjustment for confounding factors, the relative risk of death decreased by 41% (RR = 0.59, IC95 = 0.35–0.97). Adherence, assessed by a structured self-report questionnaire describing patient compliance with the prescribed treatment regimen, was improved by 23% (p = 0.038). (28)
In 2015, a study also reported patient satisfaction with these telephone follow-ups, carried out when a drug was introduced (OR = 2.2; [1.3–3.6]), with patients feeling less concern about their treatment (OR = 0.5; [0.3–0.9]). (29)
Link between community medicine and hospital
The interface between hospital and community medicine is a major concern, as it is still one of the weak points in the care pathway in France.(30–35) Most problems of collaboration and continuity of care are concentrated around hospital admission and discharge. The French Institute for Healthcare Improvement estimates that up to 50% of medication errors in hospitals are due to poor communication of medical information at different transition points, particularly admission.(36) Several studies have shown that when there is a lack of medication reconciliation on admission, the rate of medication errors that could have had serious clinical consequences for the patient is about 5% (37, 38). Similarly, on discharge, 36.4% of hospitalization reports contain errors according to Wilson.(39) Mention and justification of therapeutic changes made during hospitalization appear to be insufficient in between 2 and 40% of hospitalization reports.(40)
It is therefore essential that the link between community and hospital care be strengthened. CP participates in improving this link through its activities of medication reconciliation on admission and discharge, plus telephone follow-ups. The benefits of medication reconciliation have been fully demonstrated and published. According to the studies and services concerned, reconciliation makes it possible to detect medication errors in 38 to 68% of patients on admission(41–43) and around 40% of patients on discharge.(41, 42) According to Vira et al., drug reconciliation showed that 60% of patients had at least one unintentional discrepancy, taking admission and discharge together.(42)
Deployment method
Clinical pharmacy started to develop in the 1960s in North America, arriving in France more recently, where hospital pharmacies were given this mission. Our model is different: pharmacists are recruited by, and in, a medical department; they are therefore hierarchically attached to a non-pharmacist head of department.
Within the SDC, we initiated the development of CP by first offering traditional activities, and then followed up on the team's requests. For example, one of the first activities set up was medication reconciliation on admission, which is one of the most widespread activities and the one most described in the literature.(14, 44) However, after 2.5 years of experience, we noted that this activity represents only 4.6% of the requests (2.3% on admission and 2.3% on discharge).
Finally, the clinical pharmacy activities for which the CP were most solicited are not described in the literature and were developed as the CP integrated into the service. They were increasingly specific, such as implementing pharmaceutical telephone follow-up. This activity was initially aimed at post-consultation cancer pain patients and then, with the current opioid crisis in the United States and the increased vigilance in France on this subject, hospital practitioners asked the CPs for closer monitoring of patients for whom a reduction in opioid use was necessary.
These telephone follow-ups can be similar to health coaching and thus go far beyond simple advises. In fact, in addition to ensuring that the methods used to treat and manage pain are correct and respected by the patient, these close follow-ups make it possible to maintain a dynamic and educational relationship between the healthcare teams and the patient, encouraging patients in their approach and giving them a sense of responsibility.(35, 45)
Our experience shows the variability in needs, depending on the specificities of each department, and the value of adapting the activities deployed to the expectations of the healthcare teams. As the CP becomes part of the unit, activities diversify, allowing the CP to specialize in a specific areas.
Observations made by pain physicians working with CP are rich and qualitative, especially in the cancer pain or pediatric fields. In particular, physicians report a change in their working mode, notably in consultations, both by learning specialized pharmaceutical fields in contact with pharmacists, but also inversely by delegating medical tasks to the pharmacist. As a result, these changes have a positive impact on the management of consultations: telephone follow-ups avoid systematic reconvening of patients who are doing well, and conversely, allow earlier management of unbalanced treatments or pain emergencies.
Healthcare professionals' satisfaction with the activities of the CP is very high. It reflects the good integration of the CP into the service and the team's interest in the activities implemented.
Limitations
This work presents an assessment of CP activities in a medical department. While the clinical and relational impacts are recognized by all, we did not measure the clinical impact with objective criteria. Proactive advice represents the majority of the CP’s work, yet the medico-economic impact of something that was not done cannot be evaluated. Nor did we assess the medico-economic impact of the interventions carried out. However, in the literature, several studies have reported that implementing clinical pharmacy activities is associated with a reduced risk of iatrogenicity, mortality and length of stay.(46–49) Most studies report that these activities are cost-effective or have a good cost/benefit ratio.(50–55)
Furthermore, we did not rate the potential seriousness of the interventions carried out. This is less amenable to a severity rating, as may be the case for retroactive pharmaceutical interventions for which many articles have been published.(56, 57)