Évaluation de la sévérité des problèmes liés à la pharmacothérapie chez les patients souffrant d’insuffisance rénale chronique : la perspective de la pharmacie communautaire

The prevalence of drug-related problems (DRPs) in chronic kidney disease (CKD) patients is high. However, little is known about their severity and management by community-pharmacists.   The purpose of this doctoral thesis was to evaluate the severity of DRPs in CKD patients and provide a better understanding of the factors influencing DRPs management by community pharmacists. This research program is composed of three projects, which aimed to: 1) develop and validate a list of criteria to evaluate the severity of DRPs in CKD patients from a community pharmacy perspective (PROJECT 1); 2) to describe DRPs prevalence by severity level in CKD patients; 3) to assess the impact of a training-and-communication network program in nephrology (ProFiL) on these DRPs (PROJECT 2); and 4) to identify the beliefs of community pharmacists related to DRPs identification and management. (PROJECT 3).   As a first step, the criteria were adapted from an existing tool for the evaluation of DRPs severity in hospital settings and were validated by an expert panel. The new criteria include six levels of severity (I to VI); with two levels per category (mild, moderate and severe). More severe DRPs require more intense pharmaceutical interventions. The criteria were reliable [kappa coefficient: 0.79 (inter-rater) and 0.85 (test-retest)] and results were correlated with those based on clinical judgement.   Then, as part of a clinical trial, the criteria were used to evaluate the prevalence of DRPs and the impact of the ProFiL program on the quality of medication use, by severity level. The prevalence of DRPs was equal to 0.39, 0.55 and 1.04 DRP/patient for the level I (mild), II (mild) and III (moderate), respectively. No statistically significant difference was observed between the study groups, although the prevalence of level III DRPs was reduced in the ProFiL group.  Finally, in a qualitative study guided by the theory of planned behaviour and conducted among fifteen community pharmacists, participants reported that they do not systematically identify CKD patients. However, they thought that their interventions are beneficial to patients, health-systems, and themselves. They felt their interventions are accepted by patients and health-care providers and thought that DRPs identification and management is an essential component of their professional role. Pharmacists generally felt able to manage DRPs in CKD patients. But they felt that significant organisational barriers that impede their ability to intervene.   This thesis brings a new perspective on several issues related to pharmaceutical care for CKD patients. My work resulted in the development of a new tool for the assessment of DRPs severity and allowed for the identification of various avenues to optimise the quality of pharmaceutical care. In this context, pharmacy practice research remains crucial to improve pharmaceutical practices for CKD patients in primary care.

Keyphrases: Drug-related problems, Severity, Community pharmacy, Chronic kidney disease, Randomized controlled trial, Qualitative methods