Application of comprehensive pharmaceutical care program in identifying and addressing drug-related problems in hospitalized patients with osteoporosis

Osteoporosis, characterized by reduction of bone mass and disruption of the microarchitectural structure of bone tissue, has developed into a serious public health concern worldwide [1]. Like other chronic medical conditions, hospitalized osteoporosis patients tended to be burdened with multiple comorbidities, particularly in postmenopausal women and elderly men [2]. Therefore, treatment of osteoporosis typically consisted of complicated medication regimens during hospitalization, which resulted in a high rate of drug-related problems (DRPs) [3‐5]. Optimization of drug therapy to solve and prevent DRPs could ameliorate the healthy and economic burden for patients with osteoporosis [6, 7].

Currently, routine pharmaceutical services provided by pharmacists, such as prescription-checking, were hard to detect and address DRPs comprehensively [8, 9]. Therefore, it is necessary to establish comprehensive pharmaceutical care program (CPCP) to solve DRPs in patients with osteoporosis during the entire duration in the hospital. Additionally, the clinical characteristics of DRPs in patients with osteoporosis have varied greatly from study to study due to the lack of a normative classification system, making it difficult for comparison. In order to describe and assess the clinical characteristics of DRPs consistently, a standardized classification system of DRPs is crucial in hospital settings.

Of various classification systems that have been used to categorize DRPs in the world [10], the Pharmaceutical Care Network Europe (PCNE) classification system has been widely used in clinical practice and has internal consistency as it is updated and revised periodically [11]. Previous studies indicated that clinical pharmacists could record DRPs according to standard pattern with the help of PCNE classification system [12‐15]. Up to now, there was only one study evaluating the prevalence and nature of DRPs in osteoporosis patients based on PCNE classification V6.2 10 years ago [16]. A better knowledge of DRPs among hospitalized osteoporosis patients based on the updated PCNE classification V9.0 would provide up-to-date and valuable information for medication management in the treatment of osteoporosis.

Therefore, it is of great significance to obtain sufficient data on the evaluation of CPCP and description of DRPs in patients with osteoporosis. This study represented an attempt to describe the characteristics of DRPs in hospitalized osteoporosis patients and the implementation of CPCP in identifying and addressing DRPs.

To the best of our knowledge, this is the first prospective study to evaluate the prevalence of DRPs in patients with osteoporosis based on PCNE classification V9.0. DRPs were remarkably common in hospitalized patients with osteoporosis, with an average of 1.57 DRPs per patient.

The average number of DRPs in this study was higher than that in the previous study (0.39 DRPs per patient) conducted among Malaysian postmenopausal osteoporotic women prescribed bisphosphonates [16]. Discrepancies in the average number of DRPs might be explained by the following two reasons. First, the establishment and implementation of CPCP in the present study was very convenient for the identification of DRPs. With the help of pre-prescription review (PPR) system, DRPs could be identified automatically by software audit. However, counseling session was the only way to achieve DRPs in the previous Malaysia study. Second, different versions of PCNE classification system were used. This study used the PCNE classification V9.0 while the Malaysia study used the PCNE classification V6.2. These two versions were not compatible as many sections were added or revised in PCNE classification V9.0. For example, “possible adverse drug event occurring P2.1” was added into the PCNE classification V9.0, which indicated that many suspected adverse drug events would be identified as DRPs. Therefore, recent studies using similar version of PCNE reported similar incidence of DRPs as the present study [15, 18]. A research conducted in hospitalized patients with chronic obstructive pulmonary disease showed an average of 1.6 DRPs per patient [15]. Similarly, an average of 1.67 DRPs per patient was reported by Hon et al. in a study carried out in general paediatric ward [18]. All DRPs in the above two studies were categorized according to PCNE classification V8.02. Nevertheless，the average number of DRPs (1.9 DRPs per patient) presented in a prospective study conducted among geriatric patients was more than what was found in this study [19]. This could be explained by that geriatric patients were particularly vulnerable to DRPs caused by multiple factors such as polypharmacy and inappropriate prescribing [19].

In this study, more than half of the DRPs (66.8%) were related to treatment safety. The result was in line with previous studies, in which treatment safety was also the major type of DRPs [15, 16, 18, 20]. This indicated that clinical pharmacists should pay more attention to optimization of medication use to improve treatment safety. The primary cause of DRPs was “dose selection C3” (35.9%, 211/588). Namely, inappropriate dosage regimen and drug dose were major reasons for most DRPs in patients with osteoporosis. Considering this situation, CPCP conducted by clinical pharmacists was needed to play a unique role in addressing DRPs and ensuring the treatment safety for patients with osteoporosis. Clinical pharmacists performed clinical pharmacy activities through participating in clinical rounds and providing reasonable medication recommendations to support the MDT with a focus on identification, prevention, and resolution of DRPs to improve patient outcomes. Many studies had shown that clinical pharmacists played a crucial role in medication therapy management services in patients with osteoporosis by a multidisciplinary approach [21, 22]. For patients, medication education provided by clinical pharmacists was more conducive to solve the DRPs in the process of pharmacotherapy [23]. In our study, medication education was carried out frequently for osteoporosis patients during patient-pharmacist interview. Finally, a very high rate of intervention acceptance (95.9%) was reported in the present study, consistent with other related studies (91.0-99.4%) [15, 16, 19, 23]. As a result, 91.0% (312/343) of the DRPs were fully or partially solved (DRP status solved O1 and O2). This finding highlighted the importance of clinical pharmacists as part of the MDT, who could facilitate the identification of DRPs among patients and resolve the problems by providing reasonable medication recommendations for physicians or giving medication education to patients.

Consistent with findings from other studies [4, 24], this study also found that the number of drugs was the only predictor for DRPs occurrence. This could be explained by that as the number of drugs increased, there would be more possible drug-drug interactions and higher risk of medication errors, leading to more DRPs. Therefore, for patients with polypharmacy, clinical pharmacists should provide pharmaceutical care to identify and solve DRPs timely.

Several limitations should be mentioned. First, this was a single-center study with a relatively small sample size, which might prevent the generalization of our findings to other hospitals. Second, patients’ outcomes related to the resolution of DRPs were not available. Third, some risk factors of DRPs, such as number of diseases, number of review sessions and hospital stay days, were not researched in the present study.

The prevalence of DRPs is relatively common in Chinese patients with osteoporosis. Implementation of CPCP could identify and solve DRPs effectively and play a positive role in optimizing medication therapy. Clinical pharmacists should pay special attention to osteoporosis patients with polypharmacy to identify and solve DRPs in a timely manner.