DISCUSSION
Per protocol analysis revealed
a positive effect of the pharmaceutical interventions practiced on
chronic patients. The proportion of patients reaching the therapeutic
goals set by the physician almost doubled at three months (33.3% to
61.7%), consistently to some previous studies[32,37,40]. The lost
to follow up population did not differ from the rest of the patients
included, confirming the suitability of a per protocol analysis.
This difference was also retrieved in the sensitivity analysis,
logically higher and significant in the “best case scenario”. In the
“worst case scenario”, the difference was no more significant but
still suggested a positive effect of the intervention. Thus, if the
number of patients included had reached the number statistically
estimated as necessary, the difference might also get significant in
this more pessimistic analysis. This study therefore demonstrated the
direct clinical effect of a single pharmacist intervention on chronic
patients with hypertension, type 2 diabetes and hypercholesterolemia.
According to a previous study, the benefit of a pharmacist intervention
was greater in polypharmacy patients[54]. The number of patients
achieving therapeutic goals decreased conversely to the total number of
drugs prescribed in the control group. This result is consistent with
the literature, which reports a decrease in compliance with the increase
in the number of daily doses[55,56], and an increase in the risk of
drugs interaction and side effects in polypharmacy patients[57].
Hence, polypharmacy patients appeared to be a preferential population to
benefit from this kind of intervention.
Age and the number of drugs prescribed appeared to have similar effects
on the achievement of therapeutic objectives. However, in our
population, the number of drugs prescribed was correlated with the age
of patients, as previously described[58]. After adjusting for the
number of drugs, age did no longer appear as a factor influencing the
results of pharmaceutical intervention. Therefore, the age-related
effect of pharmaceutical intervention was probably due to the higher
number of prescribed drugs in elderly[58], thus revealing age as a
confounding factor[59]. Age then appeared as a less important
criterion than polypharmacy in selecting a target population for
pharmaceutical interventions.
Surprisingly, the intervention was also more effective on patients with
a high educational level. It is well established that a low
socioeconomic level is related to a bigger morbidity, especially for
cardiovascular diseases[60,61] so we could have expected a more
important effect on low educational level patients. However, this result
should be interpreted with caution, as an inconsistent relationship
between the socioeconomic level and the adherence to medication has also
been reported[19,62]. Thus, we need further studies to confirm the
results related to educational levels and to find a way to reach this
population.
Pharmaceutical intervention was effective for all the studied
pathologies, which is consistent with the literature and corroborates
previous studies concerning hypertension[33,40],
hypercholesterolemia[40] and type 2 diabetes[36,37,63]. However,
the rate of patients achieving therapeutic objectives, regardless of the
group, was lower for type 2 diabetes patients, than for the 2 other
diseases. This could be related to the low adherence of type 2 diabetic
patients found in the literature[64] and it highlights the need for
these interventions in these patients.
Thirty-five minutes were required to discuss all topics with the
patient. In France, the average duration of a consultation with a
general practitioner consultation is 10 to 16 minutes[65].
Unfortunately, prescribers cannot afford to spend an additional 20
minutes with all their patients to discuss drug topics in detail in
addition to their regular consultations. This implies the necessity to
have these interventions performed by a practitioner other than the
physician, with a solid knowledge of medicines, whose activity would be
at least partially devoted to these interventions. This finding
highlighted the difficulty to offer this kind of intervention to all
patients. It is therefore necessary to target these pharmaceutical
interventions to specific populations of patients who need them most.