Our study highlights a 6-year longitudinal description of clinical pharmacy practices in France, by analyzing pharmacists’ interventions documented during daily routine medication order reviews, through new findings on interventions performed by pharmacists in French hospitals. It also supports findings by the previous study [14]. Despite the anteriority of data, partly due to a delay in carrying out research, this study has been led on a large sample, over 6 years and from an entire country, which makes it unique. This work is a follow-up to the first national study done on Act-IP© data from 2006 to 2009, which corresponds to an analysis of pharmacists’ interventions performed in French hospital and registered in Act-IP© during that period [14]. Our results are similar concerning the most frequent DRPs, interventions and drugs involved. In addition, our study highlights this: the increasing number of pharmaceutical interventions over the years and their acceptance by doctors prove to go hand in hand with the deployment of clinical pharmacists and their integration within the ward.
During the study period, the rate of interventions documented per year, as well as the number of pharmacists involved, posted a significant increase compared to the first national study [14]. Nevertheless, contrary to the first study, most participating pharmacists were not regularly integrated into the ward. Thus, the medication order review has since been facilitated by the computerization of prescribing and free accessibility to the Act-IP© observatory. It also highlights that using the Act-IP© observatory has become more common. This is probably because, in addition, the number of pharmacists documenting their interventions might have increased over time, including those pharmacists whose prescriptions were mainly analyzed from the central pharmacy and not directly in the ward.
This work, like many previously conducted on the same subject, confirms that DRPs are frequent in hospitals. The most common DRPs types identified by French pharmacists as well as the most common types of interventions were similar to findings by studies carried out in France [14], Denmark [18], Czech Republic [19] and Finland [20]. In addition, this analysis showed that the highest number of DRPs was detected in medicine wards. In France, clinical pharmacy practice is still being implemented; it has been mostly developed in relation to medicine, where drug therapy management with physicians is most needed. In France, surgery wards, pediatric services and intensive care units are areas where the development of the clinical pharmacy practice is still a work in progress. For example, in pediatrics, the implementation of this practice and clinical research studies are difficult to carry out due to financial constraints and too small patient cohorts [22]; hence, only a few studies on clinical pharmacy practices are made in pediatrics. At international level however, we can cite studies on clinical pharmacy practices in pediatrics, such as two works by Italian [23] and Norwegian [24] researchers.
Drugs groups frequently implicated in pharmacists’ interventions were consistent with the first national study on the Act-IP© observatory [14], but also with observations in many other [19, 25–32]. Systemic anti-infectives were less involved in DRPs (13.6%) than in the previous analysis (16.5%). During that period, many antibiotics awareness campaigns and works on the inappropriate use and prescription of antibiotics were conducted [33, 34]. Moreover, many referrals infectious disease specialist posts were created, in association with an electronic alerts system, to remind the specialist to reassess antibiotics prescriptions. Many studies have shown the impact of the specialist’s intervention on the proportion of inappropriate antibiotics use [35].
One of this study’ main objective was to determine physicians’ acceptance of pharmacists’ interventions as an indicator to express their relevance. The acceptance rate found is approximately similar to figures in other studies [14, 29–30, 36–41].
Several factors were identified to predict pharmacists’ interventions acceptance and are similar to those in the first analysis of Act-IP© data, except for the result on “administration modalities optimization” and “monitoring” [14]. Drugs groups most found in accepted interventions are of the antineoplastic or immunomodulator types). As a matter of fact, dedicated pharmacists in France have participated to elaborating specific protocols with oncologists and their interventions are more careful and relevant due to those practitioners’ specific knowledge. Moreover, a lot of clinical pharmacy practices were developed in this ward, as shown by pharmacists’ interviews on this high-risk drug group [42].
Finally, the pharmacist’s routine presence in the ward was identified as one of the factors promoting intervention acceptance. Another study reported the impact of clinical pharmacists in a ward [41]. This result revealed that direct contact, communication with the healthcare team and a one-on-one discussion foster therapeutic optimization and constitute a driving force that contributes to highlight the dependence of pharmacists’ interventions acceptance on physician-pharmacist relationships [36]. With the pharmacist present in the ward, the medication order review ends up being decentralized, which facilitates access to patients’ data, and improves the relevance of pharmacists’ interventions. This “decentralized” analysis may result from the evolution of clinical pharmacy practices, which place clinical pharmacists in closer contact with health care services.
Several limitations can be addressed here. First, the number of documented pharmacists’ interventions differs greatly among pharmacists. Thereby, a pharmacist with a high number of observations can influence the acceptance of his/her intervention. Moreover, although the number of DRPs documented is high, not all DRPs are identified or documented. Different factors can hinder documentation, like lack of time and lack of confidence on the part of healthcare professionals due to lack of feedback on medication errors and on measures’ implementation after the analysis of documented data. Moreover, the observatory’s documentation is achieved on a voluntary basis. Some interventions are incomplete, in particular regarding the ward specialty, resulting in a bias during the analysis of acceptance factors. The data in Act-IP© focus on DRP and interventions and study neither causes nor consequences. These new functionalities have been implemented in the Act-IP© observatory, with integration of the CLEO© tool in 2016, to assess clinical, economic and organizational outcomes of pharmacists’ interventions. Future studies using Act-IP© observatory data will help analyze these outcomes [42].