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:
- Chinese clinical pharmacists treat consultation as a vital role in
demonstrating their professionalism and participation.
- So far, consultation work is mainly for the purpose of anti-infection
treatment and the recommendations are limited in this.
- Few studies have proposed new mode to improve the current consultation
status.
What this study adds:
- The multidisciplinary individualized medication consultation mode may
increase the types, quantity and quality of consultations, and expand
clinical pharmacists’ influence.
- Consultation recommendations on anticoagulant, PPIs and nutritional
support can reflect individualized rational medication.
- Clinical pharmacists should focus on all the medication of patients’
other than consultation itself.
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.