Medication adherence, related factors and outcomes among patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension: a systematic review.

INTRODUCTION: Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are life-threatening conditions that can progress to death without treatment. Although strong medication adherence (MA) is known to enhance outcomes in chronic illnesses, its association with PAH and CTEPH was sporadically explored. This study aims to examine the MA of patients with PAH or CTEPH, identify factors associated with low adherence and explore the resulting outcomes. METHODS: A systematic review was conducted by searching multiple databases (Medline, Embase, Cochrane Central, ClinicalTrials.gov, Scopus, Web of Science and Google Scholar) from 6 March 1998 to 6 July 2023. We included studies reporting MA as primary or secondary end-points. Study selection, data extraction and methodological quality assessment were performed in duplicate. RESULTS: 20 studies involving 22 675 patients met the inclusion criteria. Heterogeneity was observed, particularly in the methods employed. MA means ranged from 0.62 to 0.96, with the proportion of patients exhibiting high MA varying from 40% (95% CI 35-45%) to 94% (95% CI 88-97%). Factors associated with low adherence included increased treatment frequency, time since diagnosis and co-payment. High MA seems to be associated with reduced hospitalisation rates, inpatient stays, outpatient visits and healthcare costs. CONCLUSIONS: This systematic review underscores the heterogeneity of MA across studies. Nevertheless, the findings suggest that high MA could improve patients' clinical outcomes and alleviate the economic burden. Identifying factors consistently associated with poor MA could strengthen educational efforts for these patients, ultimately contributing to improved outcomes.

Psychometric Properties of a Machine Learning-Based Patient-Reported Outcome Measure on Medication Adherence: Single-Center, Cross-Sectional, Observational Study.

BACKGROUND: Medication adherence plays a critical role in controlling the evolution of chronic disease, as low medication adherence may lead to worse health outcomes, higher mortality, and morbidity. Assessment of their patients' medication adherence by clinicians is essential for avoiding inappropriate therapeutic intensification, associated health care expenditures, and the inappropriate inclusion of patients in time- and resource-consuming educational interventions. In both research and clinical practices the most extensively used measures of medication adherence are patient-reported outcome measures (PROMs), because of their ability to capture subjective dimensions of nonadherence. Machine learning (ML), a subfield of artificial intelligence, uses computer algorithms that automatically improve through experience. In this context, ML tools could efficiently model the complexity of and interactions between multiple patient behaviors that lead to medication adherence. OBJECTIVE: This study aimed to create and validate a PROM on medication adherence interpreted using an ML approach. METHODS: This cross-sectional, single-center, observational study was carried out a French teaching hospital between 2021 and 2022. Eligible patients must have had at least 1 long-term treatment, medication adherence evaluation other than a questionnaire, the ability to read or understand French, an age older than 18 years, and provided their nonopposition. Included adults responded to an initial version of the PROM composed of 11 items, each item being presented using a 4-point Likert scale. The initial set of items was obtained using a Delphi consensus process. Patients were classified as poorly, moderately, or highly adherent based on the results of a medication adherence assessment standard used in the daily practice of each outpatient unit. An ML-derived decision tree was built by combining the medication adherence status and PROM responses. Sensitivity, specificity, positive and negative predictive values (NPVs), and global accuracy of the final 5-item PROM were evaluated. RESULTS: We created an initial 11-item PROM with a 4-point Likert scale using the Delphi process. After item reduction, a decision tree derived from 218 patients including data obtained from the final 5-item PROM allowed patient classification into poorly, moderately, or highly adherent based on item responses. The psychometric properties were 78% (95% CI 40%-96%) sensitivity, 71% (95% CI 53%-85%) specificity, 41% (95% CI 19%-67%) positive predictive values, 93% (95% CI 74%-99%) NPV, and 70% (95% CI 55%-83%) accuracy. CONCLUSIONS: We developed a medication adherence tool based on ML with an excellent NPV. This could allow prioritization processes to avoid referring highly adherent patients to time- and resource-consuming interventions. The decision tree can be easily implemented in computerized prescriber order-entry systems and digital tools in smartphones. External validation of this tool in a study including a larger number of patients with diseases associated with low medication adherence is required to confirm its use in analyzing and assessing the complexity of medication adherence.

Prostatic artery embolisation versus medical treatment in patients with benign prostatic hyperplasia (PARTEM): a randomised, multicentre, open-label, phase 3, superiority trial.

Background: Prostatic artery embolisation (PAE) is a minimally invasive treatment of symptomatic benign prostatic hyperplasia (BPH). Our aim was to compare patient's symptoms improvement after PAE and medical treatment. Methods: A randomised, open-label, superiority trial was set in 10 French hospitals. Patients with bothersome lower urinary tract symptoms (LUTS) defined by International Prostatic Symptom Score (IPSS) > 11 and quality of life (QoL) > 3, and BPH ≥50 ml resistant to alpha-blocker monotherapy were randomly assigned (1:1) to PAE or Combined Therapy ([CT], oral dutasteride 0.5 mg/tamsulosin hydrochloride 0.4 mg per day). Randomisation was stratified by centre, IPSS and prostate volume with a minimisation procedure. The primary outcome was the 9-month IPSS change. Primary and safety analysis were done according to the intention-to-treat (ITT) principle among patients with an evaluable primary outcome. ClinicalTrials.gov Identifier: NCT02869971. Findings: Ninety patients were randomised from September 2016 to February 2020, and 44 and 43 patients assessed for primary endpoint in PAE and CT groups, respectively. The 9-month change of IPSS was -10.0 (95% confidence interval [CI]: -11.8 to -8.3) and -5.7 (95% CI: -7.5 to -3.8) in the PAE and CT groups, respectively. This reduction was significantly greater in the PAE group than in the CT group (-4.4 [95% CI: -6.9 to -1.9], p = 0.0008). The IIEF-15 score change was 8.2 (95% CI: 2.9-13.5) and -2.8 (95% CI: -8.4 to 2.8) in the PAE and CT groups, respectively. No treatment-related AE or hospitalisation was noticed. After 9 months, 5 and 18 patients had invasive prostate re-treatment in the PAE and CT group, respectively. Interpretation: In patients with BPH ≥50 ml and bothersome LUTS resistant to alpha-blocker monotherapy, PAE provides more urinary and sexual symptoms benefit than CT up to 24 months. Funding: French Ministry of Health and a complementary grant from Merit Medical.

Conditional prescriptions of oral antihypertensive drugs for the management of hypertension urgencies in the inpatient setting: An observational study.

WHAT IS KNOWN AND OBJECTIVES: The management of hypertension urgencies during hospitalization may generally not necessitate urgent care. However, physicians frequently prescribe 'as needed' antihypertensive drugs for which administration is triggered by blood pressure thresholds. The lack of rationale for this hospital practice led us to study oral conditional antihypertensive (OCA) prescriptions. We aimed to estimate the prevalence of OCA prescriptions and to establish their characteristics. METHODS: In our institution, prescriptions are computerized. The study was retrospectively performed using a hospital clinical data warehouse over a 5-year period. RESULTS AND DISCUSSION: The prevalence of OCA prescriptions was 6.9% among subjects treated with an antihypertensive drug. The median duration of these prescriptions was 4 days, until the day of the patient discharge in 78.8% stays. The calcium channel inhibitors were the main (79.9%) pharmacological class prescribed, with mostly prescriptions of nicardipine. OCA prescriptions were associated with another antihypertensive medication in 58.8% of the prescriptions; for 19.3%, it was a medication belonging to the same pharmacological class than the OCA drug prescribed. Regarding the computerized drafting, 39.6% of the conditional prescriptions were considered uninterpretable. At least one administration by nurses concerned 65.1% of the OCA prescriptions. The mean SBP and DBP before the initiation of an OCA drug was 142.9 ± 28.2 and 75.8 ± 24.5 mm Hg, respectively, relative to 143.0 ± 24.9 and 77.6 ± 19.9 mm Hg after the initiation (P = .8 for SBP and P = .06 for DBP). WHAT IS NEW AND CONCLUSION: The originality of this study lies in the use of a clinical data warehouse to evaluate OCA prescriptions in hospital. These prescriptions are current, often uninterpretable and mostly ordered until patient discharge. Such drug orders could be associated with an increased risk of iatrogenic events and/or administration errors. This underlies the need for developing decision support tools and computerized protocols to manage hypertension urgencies.

Risk scores identifying elderly inpatients at risk of 30-day unplanned readmission and accident and emergency department visit: a systematic review.

OBJECTIVES: The aim of this systematic review was to describe and analyse the performance statistics of validated risk scores identifying elderly inpatients at risk of early unplanned readmission. DATA SOURCES: We identified potentially eligible studies by searching MEDLINE, EMBASE, COCHRANE and Web of Science. Our search was restricted to original studies, between 1966 and 2018. ELIGIBILITY CRITERIA: Original studies, which internally or externally validated the clinical scores of hospital readmissions in elderly inpatients. DATA EXTRACTION AND SYNTHESIS: A data extraction grid based on Strengthening the Reporting of Observational Studies in Epidemiology and Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis statements was developed and completed by two reviewers to collect general data. The same process was used to extract metrological data of the selected scores. QUALITY ASSESSMENT OF THE INCLUDED STUDIES: Assessment of the quality and risk of bias in individual studies was performed by two reviewers, using the validated Effective Public Health Practice Project quality assessment tool. PARTICIPANTS: Elderly inpatients discharged to home from hospital or returning home after an accident and emergency department visit. RESULTS: A total of 12 studies and five different scores were included in the review. The five scores present area under the receiving operating characteristic curve between 0.445 and 0.69. Identification of Senior At Risk (ISAR) and Triage Risk Screening Tool (TRST) scores were the more frequently validated scores with ISAR being more sensitive and TRST more specific. CONCLUSIONS: The TRST and ISAR scores have been extensively studied and validated. The choice of the most suitable score relies on available patient data, patient characteristics and the foreseen clinical care intervention. In order to pair the intervention with the appropriate clinical score, further studies of external validation of clinical scores, identifying elderly patients at risk of early unplanned readmission, are needed. PROSPERO REGISTRATION NUMBER: CRD42017054516.

Pharmaceutical interventions to improve safety of chemotherapy-treated cancer patients: A cross-sectional study.

PURPOSE: Cancer chemotherapy is a high-risk process. To improve patient safety, a systematic pharmaceutical analysis of chemotherapy prescriptions is performed in our institution. The aim of this study was to assess the impact of pharmaceutical interventions (PIs) on the safety of patient chemotherapy prescriptions. METHODS: This prospective cross-sectional study was conducted in an 800-bed university hospital with oncology departments. All chemotherapy prescriptions were included and PIs were collected prospectively during one month. The clinical impact of PIs was scored by an expert panel of oncologists and pharmacists, using the Hatoum scale. Univariate and multivariate analysis were conducted to identify factors associated with a higher frequency of PIs. RESULTS: Of 1346 prescriptions included, 129 required a PI (9.6% (95% CI: 8.1-11.4)). Most PIs were scored as having at least a significant impact for patient safety (69.8% (95% CI: 60.4-76.9)). The frequency of PIs was significantly associated with tumour site (p = 0.04) and weekday of prescription (p = 0.005). Multivariate analysis identified factors independently associated with PI performance, including pancreas and biliary tract cancers (odds ratio = 2.8 (95% CI: 1.4-5.3)), ovary cancers (odds ratio = 2.4 (95% CI: 1.2-4.8)) and head and neck cancers (odds ratio = 2.4 (95% CI: 1.1-5.1)) and the day 1 of the protocol with a cytotoxic agent (odds ratio = 3.7 (95% CI: 1.1-11.1)). CONCLUSIONS: Oncology pharmacists have a critical role in the safety of chemotherapy prescriptions. The coordination between healthcare professionals and access to patient data seem essential to improve the PIs' relevance and their clinical impact on patient safety.

A centralized automated-dispensing system in a French teaching hospital: return on investment and quality improvement.

OBJECTIVES: To evaluate the return on investment (ROI) and quality improvement after implementation of a centralized automated-dispensing system after 8 years of use. DESIGN: Prospective evaluation of ROI; before and after study to evaluate dispensing errors; user satisfaction questionnaire after 8 years of use. SETTING: The study was conducted at a French teaching hospital in the pharmacy department, which is equipped with decentralized automated medication cabinets in the wards. PARTICIPANTS: Pharmacy staff (technicians and residents). INTERVENTION(S): Implementation of a centralized automated-dispensing robot. MAIN OUTCOME MEASURE(S): The true ROI was prospectively and annually compared to estimated returns calculated after implementation and upgrade of the robot; dispensing errors determined by observation of global deliveries and the satisfaction of users based on a validated questionnaire were evaluated. RESULTS: Following the upgrade, we found little difference for the ROI (+1.86%). The payback period increased by almost 3 years. There was a significant reduction of dispensing errors, from 2.9% to 1.7% (P < 0.001). User satisfaction of the robot by the pharmacy staff was reported (score of 5.52 ± 1.20 out of 7). CONCLUSIONS: These systems are worthwhile investments and largely contribute to improving the quality and safety of the medication process.

[Issues of oral targeted therapies in daily clinical practice: 5th edition of the congress of pharmacology of anticancer drugs]. / Enjeux et écueils des thérapies ciblées orales en pratique clinique quotidienne : 5e journée de pharmacologie des anti-tumoraux.

Oral targeted therapies are a growing class of medication. After clinical trials conducted on a selected population, these molecules are usually approved at a fixed dose. However, oral tyrosine kinase inhibitors are characterized by a large intra and inter-individual pharmacokinetic variability, and a narrow therapeutic index. Hence, their prescription is hazardous and unsafe in non-selected people from daily clinical practice. The increasing number of available targeted therapies point out new challenges. These challenges should especially concern prescription for out of the ordinary patients, rules for dose adjustment according to factors of frailty. The ultimate goal is to ensure a safe and individualized prescription. Moreover, many of these molecules are metabolized by the CYP3A4, leading to a serious risk of drug interaction. These interactions might involve not only conventional medicine but also alternative and complementary medicines. These latter are more and more common but oncologists often lack experience about them. Finally, the oral route raises the issues of adherence, and the question of its assessment should now become a permanent part of patients care.

External validation of the 80+ score and comparison with three clinical scores identifying patients at least 75 years old at risk of unplanned readmission within 30 days after discharge.

AIM OF THE STUDY: A potentially avoidable readmission is an unplanned readmission occurring within 30 days of discharge. As 20% of hospitalised elderly patients are rehospitalised as an unplanned readmission, it is necessary to identify with a clinical score those patients who are at risk of readmission and need discharge interventions as a priority. The main objective of this study was to externally validate and compare the 80+ score with the three other scores predicting the risk of unplanned readmission. METHODS: We conducted a retrospective case-control study using a clinical data warehouse. The study included patients hospitalised between 1 September 2014 and 31 October 2015 in an 800-bed university hospital. We included patients aged 75 and over. Cases were readmitted at the emergency department within 30 days after the index discharge. Controls were not readmitted as an emergency within 30 days. Four clinical scores (80+ score, LACE index, HOSPITAL score, TRST) were externally validated. Discrimination of the scores was assessed by calculating the area under the receiver operating characteristic curves (AUC). Calibration was assessed with a Hosmer-Lemeshow χ2 test. RESULTS: We included 438 patients. For discrimination, the 80+ score, the LACE index, the HOSPITAL score and the TRST had AUCs of 0.506 (95% confidence interval [CI] 0.413-0.546), 0.534 (95% CI 0.459-0.591, 0.517 (95% CI 0.466-0.598) and 0.589 (95% CI 0.524-0.654), respectively. The Hosmer-Lemeshow χ2 tests had p-values of 0.44, 0.43, 0.11 and 0.49, respectively. CONCLUSION: In our study, the 80+ score was externally validated and showed less favourable discrimination than the three other scores in this population.

Prevalence of computerized physician order entry systems-related medication prescription errors: A systematic review.

OBJECTIVE: The positive impact of computerized physician order entry (CPOE) systems on prescription safety must be considered in light of the persistence of certain types of medication-prescription errors. We performed a systematic review, based on the PRISMA statement, to analyze the prevalence of prescription errors related to the use of CPOE systems. MATERIALS AND METHODS: We searched MEDLINE, EMBASE, CENTRAL, DBLP, the International Clinical Trials Registry, the ISI Web of Science, and reference lists of relevant articles from March 1982 to August 2017. We included original peer-reviewed studies which quantitatively reported medication-prescription errors related to CPOE. We analyzed the prevalence of medication-prescription errors according to an adapted version of the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) taxonomy and assessed the mechanisms responsible for each type of prescription error due to CPOE. RESULTS: Fourteen studies were included. The prevalence of CPOE systems-related medication errors relative to all prescription medication errors ranged from 6.1 to 77.7% (median = 26.1% [IQR:17.6-42,1]) and was less than 6.3% relative to the number of prescriptions reviewed. All studies reported "wrong dose" and "wrong drug" errors. The "wrong dose" error was the most frequently reported (from 7 to 67.4%, median = 31.5% [IQR:20.5-44.5]). We report the associated mechanism for each type of medication described (those due to CPOE or those occurring despite CPOE). DISCUSSION: We observed very heterogeneous results, probably due to the definition of error, the type of health information system used for the study, and the data collection method used. Each data collection method provides valuable and useful information concerning the prevalence and specific types of errors related to CPOE systems. CONCLUSIONS: The reporting of prescription errors should be continued because the weaknesses of CPOE systems are potential sources of error. Analysis of the mechanisms behind CPOE errors can reveal areas for improvement.

Providing physicians with feedback on medication adherence for people with chronic diseases taking long-term medication.

BACKGROUND: Poor medication adherence decreases treatment efficacy and worsens clinical outcomes, but average rates of adherence to long-term pharmacological treatments for chronic illnesses are only about 50%. Interventions for improving medication adherence largely focus on patients rather than on physicians; however, the strategies shown to be effective are complex and difficult to implement in clinical practice. There is a need for new care models addressing the problem of medication adherence, integrating this problem into the patient care process. Physicians tend to overestimate how well patients take their medication as prescribed. This can lead to missed opportunities to change medications, solve adverse effects, or propose the use of reminders in order to improve patients' adherence. Thus, providing physicians with feedback on medication adherence has the potential to prompt changes that improve their patients' adherence to prescribed medications. OBJECTIVES: To assess the effects of providing physicians with feedback about their patients' medication adherence for improving adherence. We also assessed the effects of the intervention on patient outcomes, health resource use, and processes of care. SEARCH METHODS: We conducted a systematic search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase, all from database inception to December 2016 and without any language restriction. We also searched ISI Web of Science, two trials registers, and grey literature. SELECTION CRITERIA: We included randomised trials, controlled before-after studies, and interrupted time series studies that compared the effects of providing feedback to physicians about their patients' adherence to prescribed long-term medications for chronic diseases versus usual care. We included published or unpublished studies in any language. Participants included any physician and any patient prescribed with long-term medication for chronic disease. We included interventions providing the prescribing physician with information about patient adherence to medication. Only studies in which feedback to the physician was the sole intervention or the essential component of a multifaceted intervention were eligible. In the comparison groups, the physicians should not have had access to information about their patients' adherence to medication. We considered the following outcomes: medication adherence, patient outcomes, health resource use, processes of care, and adverse events. DATA COLLECTION AND ANALYSIS: Two independent review authors extracted and analysed all data using standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care group. Due to heterogeneity in study methodology, comparison groups, intervention settings, and measurements of outcomes, we did not carry out meta-analysis. We describe the impact of interventions on outcomes in tabular form and make a qualitative assessment of the effects of studies. MAIN RESULTS: We included nine studies (23,255 patient participants): eight randomised trials and one interrupted time series analysis. The studies took place in primary care and other outpatient settings in the USA and Canada. Seven interventions involved the systematic provision of feedback to physicians concerning all their patients' adherence to medication, and two interventions involved issuing an alert for non-adherent patients only. Seven studies used pharmacy refill data to assess medication adherence, and two used an electronic device or self-reporting. The definition of adherence differed across studies, making comparisons difficult. Eight studies were at high risk of bias, and one study was at unclear risk of bias. The most frequent source of bias was lack of protection against contamination.Providing physicians with feedback may lead to little or no difference in medication adherence (seven studies, 22,924 patients), patient outcomes (two studies, 1292 patients), or health resource use (two studies, 4181 patients). Providing physicians with feedback on medication adherence may improve processes of care (e.g. more medication changes, dialogue with patient, management of uncontrolled hypertension) compared to usual care (four studies, 2780 patients). None of the studies reported an adverse event due to the intervention. The certainty of evidence was low for all outcomes, mainly due to high risk of bias, high heterogeneity across studies, and indirectness of evidence. AUTHORS' CONCLUSIONS: Across nine studies, we observed little or no evidence that provision of feedback to physicians regarding their patients adherence to prescribed medication improved medication adherence, patient outcomes, or health resource use. Feedback about medication adherence may improve processes of care, but due to the small number of studies assessing this outcome and high risk of bias, we cannot draw firm conclusions on the effect of feedback on this outcome. Future research should use a clear, standardised definition of medication adherence and cluster-randomisation to avoid the risk of contamination.

A systematic review of regulatory and educational interventions to reduce the burden associated with the prescriptions of sedative-hypnotics in adults treated for sleep disorders.

BACKGROUND: The burden of Sedative-Hypnotics (SHs) has been known since the 1980s. Yet, their consumption remains high. A systematic review of the literature should help to assess efficient interventions to improve the appropriate use of SHs in sleep disorders. OBJECTIVES: To identify and assess regulatory and educational interventions designed to improve the appropriate use of SHs for insomnia treatment. METHODS: We conducted a systematic review of the literature according to PRISMA guidelines. A systematic search covering the period 1980-2015 was carried out in Medline, Web of Science, Embase and PsycInfo. We included studies reporting the implementation of regulatory or educational strategies directed towards patients and/or healthcare professionals to improve the appropriate use of SHs to treat insomnia in the community, hospitals and nursing homes. RESULTS: Thirty-one studies were included: 23 assessed educational interventions (recommendations by mail/email, computer alerts, meetings, mass media campaigns, prescription profile), 8 assessed regulatory interventions (prescription rule restriction, end of reimbursement). The most recent was implemented in 2009. Restrictive prescription rules were effective to reduce the consumption of targeted SHs but led to a switch to other non-recommended SHs. Among educational interventions, only 3 studies out of 7 reported positive results of mono-faceted interventions; whereas, 13 out of the 16 multi-faceted interventions were reported as efficient: particularly, the active involvement of healthcare professionals and patients and the spread of information through mass media were successful. The risk of bias was high for 24 studies (mainly due to the design), moderate for 3 studies and weak for 4 studies. CONCLUSION: Educational multifaceted studies are presented as the most efficient. But further better designed studies are needed to make evidence-based results more generalizable.

Cardiovascular risk associated with high sodium-containing drugs: A systematic review.

BACKGROUND: Excess dietary sodium is associated with increased blood pressure (BP). Some drugs are associated with high sodium intake (in particular effervescent tablets), but the cardiovascular risk associated with such high sodium-containing drugs (HSCD) is largely underevaluated. OBJECTIVES: To summarize the evidence for a potential cardiovascular risk associated with exposure to HSCD, and to highlight possible risk factors associated with this iatrogenic issue; in general and/or specific populations. METHODS: We conducted a systematic review, by searching electronic databases including MEDLINE, EMBASE, Web of Science, CENTRAL and grey literature between 1960 and 2015. We included studies that reported modification of cardiovascular parameters or incidence/prevalence of cardiovascular outcomes, between a group of subjects exposed to HSCD relative to a non-exposed group. The threshold used to identify HSCD was 391 mg/day. We did not consider studies evaluating exposure to sodium as an active ingredient or those focusing on dialysis solutions or enteral/parenteral nutrition. Study quality was assessed using the EPHPP tool. RESULTS: A total of eight studies met our inclusion criteria. Four reported results for short-term exposure to HSCD (≤ 7 days) on BP fluctuations. One study reported an elevation of BP (associated sodium intake: 1,656 mg/day). Four studies evaluated a long-term exposure (≥ 2 years or discontinuation of a chronic treatment). Two studies reported iatrogenic risk. For these studies, drug associated sodium intake was high (> 1,500 mg/day) in patients with comorbidities (in particular, diabetes mellitus and hypertension). CONCLUSION: Despite numerous study limitations, this systematic review suggests three potential synergistic risk factors for cardiovascular complications after exposure to HSCD: a high sodium intake (≥ 1,500 mg/day), a long duration of exposure, and the presence of comorbidities. Further studies are required to characterize this iatrogenic risk. TRIAL REGISTRATION: PROSPERO CRD42016047086.

A simulation study of the interception of prescribing errors by clinical pharmacists in an acute hospital setting.

RATIONALE, AIMS AND OBJECTIVES: To evaluate the performance of several pharmacists in the same department who analysed the same prescriptions in a simulation study. METHODS: One hundred prescriptions were retrospectively extracted from the prospective database of our hospital. Five clinical pharmacists working in the same department were asked to analyse individually the order lines of each prescription as if it were part of their routine daily practice. Afterward, an independent committee of five other clinical pharmacists reviewed the same 100 prescriptions. We calculated the sensitivity and the specificity of error detection in a line order by using the results of the committee as the gold standard. RESULTS: A total of 908 order lines were analysed (mean 9 ± 3 order lines per prescription). Fifty-one medication errors were identified by the committee (5.6%), including 23 related to laboratory test results: renal failure, or therapeutic concentrations being too low or too high. The sensitivity of the five pharmacists ranged between 19.6% and 56.9% and the specificity between 92.8% and 98.7%. The rates of agreement between each pharmacist and the committee, assessed using kappa coefficient, were between 0.20 and 0.39. The main factors affecting sensitivity and/or specificity in univariate analysis were the number of drugs per prescription, type of drug prescribed (ATC classification) and the glomerular filtration rate. CONCLUSION: Discrepancies between the performances of pharmacists exist, as there are between other health care professionals. Pharmacist training, standardization of the pharmaceutical analysis of drug prescription, and implementation of a clinical decision support system allowing biological values to be linked to drug prescriptions could improve individual performance.

[Improving practice and organisation of care: methodology for systematic reviews]. / Améliorer les pratiques et l'organisation des soins?: méthodologie des revues systématiques.

The number of intervention studies designed to improve quality of care is increasing exponentially, making it difficult to access all available information on a given subject. Systematic reviews are tools that provide health professionals with comprehensive and objective information. This article describes the main phases of a systematic review: formulating the research question, search and selection of studies, data extraction and analysis, assessment of the methodological quality of studies, and synthesis of the results. Interventions designed to improve professional practices and organisation of care have specific characteristics that determine the methodology of systematic reviews. For example, the often substantial heterogeneity between populations, organisations, and intervention settings among studies must be taken into account, which makes meta-analysis more difficult. Knowledge on specific features of systematic reviews designed to improve quality of care is essential to ensure a good review of the literature, or to evaluate the level of evidence of published systematic reviews.

[Improving health care practices and organization: methodology for intervention studies]. / Améliorer les pratiques et l'organisation des soins?: méthodologie des études d'interventions.

Interventions designed to improve professional practices and healthcare organization are regularly implemented in all health systems. Their effectiveness on quality of care should be properly evaluated prior to their widespread implementation. Intervention studies can be conducted for this purpose according to a rigorous methodology in order to provide results with a good level of evidence. This article describes the main phases of an intervention study, including definition of the intervention, choice of study design, outcomes assessment, and writing of the report. It also addresses methodological issues of intervention studies designed to improve quality of care, such as cluster-randomization or the use of quasi-experimental designs. One of the specific features of these studies is that professionals are the targets, while patients are the beneficiaries of the intervention. A good knowledge of the specific features of studies designed to improve quality of care is essential to conduct research, or to evaluate the quality of the evidence from published studies.

Information about medication in HIV-infected patients and its relation to adherence.

QUESTIONS UNDER STUDY: In HIV-infected patients, comprehension of medication instructions is an essential condition for adherence to Highly Active Antiretroviral Therapy (HAART). In this study, we used a self-reported questionnaire to know which sources of medication information HIV-infected patients used and their impact on adherence. In secondary objectives, we determined profiles of non-adherent patients and specified the role of the pharmacist. METHODS: A cross-sectional, observational study was conducted in one community pharmacy and one French university hospital pharmacy, in HAART-naïve or not patients, from April to June 2009. RESULTS: During the 3-month study period, 233 HIV-infected patients were included. The majority of patients sought information about their HAART treatments from the hospital physician (79.8%), the community physician (74.2%), and patient information leaflets (73.8%). The community and hospital pharmacists were consulted by respectively 16.3% and 3.4% of patients. According to multivariate regression analysis, adherence seemed to be associated with the sources of information "community physician", "hospital physician", "internet", and the potential support of patient associations. A total of 65.7% of patients were considered to be adherent. CONCLUSIONS: In our study, among sources used by HIV-infected outpatients, their physicians are the most helpful sources of information about HAART. Regarding practice implications, the key role of the pharmacist is underutilised, indicating the need for improved communication between the pharmacist and outpatients.

Validation of a French version of the 8-item Morisky medication adherence scale in hypertensive adults.

The aim of this study was to validate a French translation of the structured self-report 8-item Morisky Medication Adherence Scale (MMAS-8) and determine its psychometric properties in patients taking antihypertensive medication. An observational cross-sectional study was conducted in the hypertensive unit of a French university hospital. The MMAS-8 was translated according to international guidelines. Internal consistency was assessed using Cronbach α coefficient, construct validity using principal component and confirmatory factor analyses, and the test-retest reliability at 1-month interval using the intraclass correlation coefficient (ICC). Three levels of adherence were considered (low: scores of 0 to <6; medium: 6 to <8; high: 8) and risk factors were explored in ordinal logistic regression models. A total of 199 patients were included: mean age, 55.7±14.6 years, 57.3% men (114 of 199), and 39.5% (66 of 167) had uncontrolled blood pressure. The French MMAS was moderately reliable (α=0.54), one-dimensional, and reproducible (ICC=0.68). The mean score was 6.96 (standard deviation 1.25) and 17.6% (35 of 199), 37.7% (75 of 199), and 43.7% (87 of 199) of patients had low, medium, and high adherence, respectively. The only factor significantly associated with adherence was age. The French MMAS has acceptable psychometric effects to measure medication adherence in hypertensive patients and may be useful in detecting nonadherent hypertensive patients.

Knowledge of oral drug treatment in immunocompromised patients on hospital discharge.

PRINCIPLES: Several studies have shown that patients' inappropriate knowledge about their medication is associated with non-adherence. The aim of this study was to assess immunocompromised inpatient knowledge of their oral drug treatment on discharge. METHODS: We conducted a single-centre, prospective, cross-sectional study from July to November 2008 in the Immunology unit of a university-based hospital. Knowledge of all oral prescribed medication was assessed before discharge of immunocompromised inpatients using a self-administered questionnaire, assessing drug name, dosage, indication and administration guidelines. Prescribed drugs were classified as treatments for chronic disease, or as adjuvant treatments which were differentiated regarding their link with the chronic disease. RESULTS: Over four months, 17 transplant recipients and 38 HIV-infected patients were included. Overall, 57% of the 497 prescribed drugs were adequately known. The proportions of drugs adequately known were 79%, 91%, 81% and 62% respectively for the drug name, dosage, indication and administration guideline components. Drugs for the treatment of chronic disease were more adequately known than adjuvant treatments. Older age and a low educational level were significantly associated with poor knowledge of drugs. CONCLUSIONS: Immunocompromised patients demonstrated moderate to good knowledge of oral drugs on discharge. Adjuvant treatments were less well known than drugs for the treatment of chronic disease. Some recommendations for interventions aimed at utilising the skills of clinical pharmacists are needed. Efforts which encourage patients to be active participants in their own treatment could improve therapeutic adherence and reduce potential complications.