A retrospective cohort study on a pharmaceutical consultation mode of multidisciplinary individualized medication recommendations
Xiucong Fan, Danxia Chen, Siwei Bao, Rong Bai, Fang Fang, Xiaohui Dong, Yuyi Zhang, Xiaogang Zhang, Yabin Ma, Xiaobo Zhai
Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
Correspondence: Xiaobo Zhai and Yabin Ma, Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China. Email: xiaobo_zhai@163.com and 15021877977@163.com
Funding information: Key Specialties Foundation of Clinical Pharmacy of Shanghai Municipal Health Commission in China, Grant/Award Number: SWLCYXZX-2018-001; Research on the Epidemiology of Severe Drug-induced Diseases of the Chinese Society of Toxicology, Grant/Award Number: CST2019CT304
Conflict of interest: The authors have no conflicts of interest to declare.
Ethics statement: The Ethics Board of the Shanghai East Hospital, Tongji University School of Medicine, China, reviewed and approved the study protocol.
Xiucong Fan and Danxia Chen are joint first authors.
PI statement: The authors confirm that the Principal Investigators for this paper are Xiaobo Zhai, and Xiaobo Zhai had direct clinical responsibility for patients.
Patient consent statement: Not required.
Data Availability Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.
Key words: clinical pharmacy, clinical pharmacists’ consultations, multidisciplinary individualized medication recommendations, rational drug use
Word count: 4443, table count: 3, figure count: 3
What is already known about this subject:
What this study adds:
Abstract: Aims: To develop a pharmaceutical consultation mode of multidisciplinary individualized medication recommendations, to improve the quantity and quality of clinical pharmacists’ consultations
Methods: A retrospective study of 542 clinical pharmacists-led consultations was conducted. In the pre-intervention group, medication advice was given based on the purpose of the consultation. In the post-intervention group, a consultation mode of multidisciplinary individualized medication recommendation was implemented, in which clinical pharmacists with specialties of anticoagulation, gastroenterology and nutrition were asked to give individualized medication recommendations and a set of evaluation criteria for rational drug use was formulated. Outcomes, including the patterns and number of consultations, individualized medication recommendations, acceptance rate and effectiveness rate, were compared between the two periods.
Results: A total of 651 cases were reviewed, and 542 cases of which meeting the predesigned inclusion and exclusion criteria were included, with 94 and 448 patients in the pre-intervention and post-intervention groups, respectively. The total number of consultations increased year by year, so did the number of general consultations, multidisciplinary difficult consultations, departments applying for general consultations, departments applying for multidisciplinary difficult consultations, anti-infection consultations and non-anti-infection consultations in details. The effectiveness rate of consultations in the post-intervention group was 81.7% vs 70.2% in the pre-intervention group (P < 0.05). No difference was shown between two groups in acceptance rate (96.9% vs 95.7%, p=0.578).
Conclusions: Our study preliminarily suggests that the development of the new consultation mode can improve the quantity and quality of pharmaceutical consultations, which is worthy of further promotion and large-scale research.
1.Introduction
In China, the pilot work of Chinese clinical pharmacist system began in 2008. Then the regulations on ”Administration of Pharmaceutical Affairs in Medical Institutions”[1] promulgated and implemented in 2011 further promoted the transformation of pharmacists’ role and refined their responsibilities in clinical work. In the same year, the pharmacist-led management method was introduced into Antimicrobial Stewardship Program，which strengthened the status of clinical pharmacists in the treatment of infectious diseases. According to the guidance of documents and preliminary practices, Chinese clinical pharmaceutical work mainly includes pharmaceutical ward round, medical order review, prescription review, consultation, therapeutic drug monitoring, adverse drug reaction monitoring and reporting[2]. Among them, consultation plays a vital role in demonstrating their professionalism and participation，the importance of which is pointed out in ”Notice on Strengthening Pharmacy Administration and Changing the Pattern of Pharmaceutical Care” issued in July 2017 [3]. As a result, Chinese clinical pharmacists take improving the quantity and quality of consultations as an important task during the construction of clinical pharmacy specialty.
In order to improve the clinical recognition and irreplaceability, vast majorities of clinical pharmacists in different specialties choose anti-infection treatment as their main entry point to participate in clinical drug medication, and the effect is remarkable. This is clearly reflected in the purpose and acceptance rate of clinical pharmacists’ consultations [4-7]: more than 80% of the consultation purposes are the rational use of antibiotics. The acceptance rate of consultations is more than 90% and the effectiveness rate is close to 90%.
The clinical pharmacy specialty of Tongji University Affiliated East Hospital is the key specialty of clinical pharmacy in Shanghai, China. During the construction of it, improving the quantity and quality of clinical pharmacists’ consultations is the key work. We integrated multidisciplinary individualized medication recommendations into the anti-infection consultations, so as to achieve the goal. In this study, we retrospectively analyzed the consultations and improvement measures in last three years (2018-2020), in order to provide a reference for developing better approaches for consultations and improving the expertise of clinical pharmacists.
2. Methods
2.1Patients and Setting
A single-center retrospective pre- and post-intervention study was conducted in Tongji University Affiliated East Hospital, which is a tertiary teaching hospital with 2000 beds. Clinical pharmacists’ consultations applied by clinical departments in 2018 and 2019-2020 were enrolled in the pre-intervention and post-intervention group, respectively. Consultations received by clinical pharmacists were eligible. The exclusion criteria were as follows: incomplete consultation records, consultation cases about permissions to drug use and consultation patients died within 72 hours after consultation or stopped treatment for other reasons.
2.2Intervention
In the pre-intervention period, upon receiving the consultation application from clinical department, any qualified clinical pharmacist evaluated the current situation of the patient and proposed consultation recommendations according to the purpose of the consultation.
In the post-intervention period, the following interventions were taken on the basis above: After comprehensively evaluating the patient’s situation, clinical pharmacists with specialties of anticoagulation, gastroenterology and nutrition were asked to give individualized medication recommendations. In addition to the anti-infection treatment, consultation recommendations were recorded in terms of the consultation purpose, anticoagulation treatment, the usage of proton-pump inhibitors (PPIs) and nutrition support. After consultation, follow-up monitoring measures were taken. A set of evaluation criteria for rational use of anticoagulant, PPIs, anti-infection and nutrition support were formulated according to the latest guidelines, experts’ recommendations and previous pharmaceutical practices. Furthermore, clinical pharmacists regularly discussed difficult consultation cases for re-examination and internal business learning. At last, the acceptance of consultation recommendations and patients’ outcomes were assessed.
2.3 Evaluation criteria and the consultation mode of multidisciplinary individualized medication
2.3.1 Anti-infection treatment consultation recommendations
The current anti-infection treatment or prevention effect was evaluated based on the current infection of the patient. The main consultation mode was that under the guidance of anti-infection pharmacists, the consultation pharmacists on duty give treatment recommendations, including drug name, dosage, frequency and route of administration, and the course of treatment. The precautions and adverse events to be monitored were also put forward.
2.3.2 Anticoagulant consultation recommendations
Padua [8] score and Caprini[9,10] score were used to evaluate the embolism risk of internal medicine inpatients and surgical patients, respectively, whose hemorrhage risk was evaluated according to Crusade score [11-12].The hemorrhage risk assessment criteria for Atrial Fibrillation (AF) patients and patients taking oral anticoagulant was HAS-BLED score [13].The stroke risk of AF patients was evaluated by CHA2DS2-VASc score[13]. According to the scoring criteria above, patients were given individualized scores and consultation recommendations. If the risk of embolism was significantly higher than that of hemorrhage, anticoagulant medication shall be given. If equivalent, physical prevention advice or consultation with Department of Rehabilitation shall be given. For patients with hemorrhage or consultations aimed at the application of anticoagulant drugs, suggestions shall be given by pharmacists of anticoagulant specialty.
2.3.3 PPIs use recommendations
The evaluation criteria for the rational use of PPIs are mainly divided into two parts: one was the necessity of preventive medication, while the other was the rationality of therapeutic medication. The evaluation criteria referred to Stress ulcer prophylaxis in the postoperative period[14], Stress-related mucosal disease in the critically ill patient：risk factors and strategies to prevent stress-related bleeding in the intensive care unit[15], Stress ulcer prophylaxis in hospitalized patients not in intensive care units[16], Expert recommendations for stress ulcer prophylaxis (2018)[17] and Expert consensus on optimal application of proton pump inhibitors [18]. Stressors should be recorded. If the preventive measure was needed, recommended PPIs and dosage shall be given. If the current utilization was inappropriate, suggestions for improvement shall be put forward. In terms of consultations for the purpose of PPIs application, pharmacists of gastroenterology specialty shall give suggestions.
2.3.4 Nutrition support recommendations
Nutritional risk assessment was performed for patients who were highly suspected to need nutritional support. The assessment standard was Nutritional Risk Screening 2002 (NRS 2002). According to patients’ risk assessment scores, current dietary status, relevant guidelines and recommendations [19-21], corresponding enteral/parenteral nutritional suggestions were given. The key principle was that enteral nutrition supplement was given priority for patients who were unable to eat on their own [22]. Supplementary parenteral nutrition could be given only when enteral nutrition was absolutely contraindicated or cannot meet the target requirement. The supply standard is described as follows: the energy supply is 25-30kcal/ (kg/d), the protein is 1.2-2g/ (kg/d), and the ratio of sugar to lipid and non-protein calorie: nitrogen is 5:5 and (100-200): 1, respectively. For the consultations aimed at the application of nutrition support, pharmacists of nutrition specialty will give recommendations. If necessary, the nutrition department should be invited to assist in the consultation.
2.4 Evaluation of consultation effectiveness and acceptance
Effectiveness rate of consultations: 72 hours after consultation, two off-duty pharmacists evaluated the effectiveness, which was defined as one or more of relevant symptoms and signs have significantly improved or laboratory tests have decreased by more than 30%. The main reference standard was based on the outcome evaluation of the consultation purpose. If the medication suggestion was given for the purpose of prevention, patients’ positive signs should be examined.
Effectiveness rate of consultations (ERC) = Effective consultations/ (Effective consultations + Ineffective consultations) ×100%.
Acceptance rate of consultations: (1) Not accepted: the physician rejected the consultation suggestions; (2) Partially accepted: the physician partially accepted the consultation suggestions; (3) Completely accepted: the physician completely accepted the consultation suggestions. Accepted consultations=completely accepted consultations+ partially accepted consultations.
Acceptance rate of consultation (ARC) = Accepted consultations / Total consultations ×100%.
2.5 Data collection and statistical analysis
The data were gathered and recorded from Electronic Medical Record System, which were crosschecked by two independent pharmacists using Microsoft Office Excel 2017.Software IBM SPSS 25.0 was applied to perform statistical analyses. Categorical variables were presented as numbers with percentages. Chi-square tests were used for group comparisons. P<0.05 was considered statistically significant.
3. Results
From 2018 to 2020, 651 consultation cases were included in the study, of which 542 cases met the inclusion criteria. Among the 542 consultation cases, 94 cases of 2018 were in the pre-intervention group, and 448 cases (2019 / 2020,197 / 251) were in the post-intervention group. Figure 1 describes the procedure of case selection.