Improving medication adherence and effective prescribing through a patient-centered prescription model in patients with multimorbidity.

PURPOSE: This study aimed to assess the impact of the patient-centered prescription (PCP) model in medication adherence and effective prescribing in patients with multimorbidity. METHODS: Uncontrolled before-after study in an intermediate care facility in a mixed urban-rural district. Inpatients aged ≥ 65 years with multimorbidity exposed to polypharmacy before hospital admission were consecutively enrolled. Every patient's treatment plan was analyzed through the PCP model, which includes interventions aimed at improving medication adherence. The primary endpoint was the change in the proportion of adherent patients between pre-admission and after discharge for all regularly scheduled long-term medications, using the proportion of days covered (PDC). Secondary endpoints included the change on mean PDC for all long-term medications, number of long-term medications, proportion of patients with hyperpolypharmacy, medication regimen complexity index (MRCI) score, drug burden index (DBI) score, number of potential inappropriate prescribing (PIP), and proportion of patients with ≥ 2 PIPs. RESULTS: Ninety-three non-institutionalized patients were included (mean age 83.0 ± SD 6.1 years). The proportion of adherent patients increased from 22.1 to 51.9% (P < 0.001). Intervention also improved mean PDC [mean difference (95% CI) 10.6 (7.7, 13.5)] and effective prescribing through a reduction on the number of long-term medications [- 1.3 (- 1.7, - 0.9)], proportion of patients exposed to hyperpolypharmacy (- 16.1%, P < 0.001), MRCI score [- 2.2 (- 3.4, - 1.0)], DBI score [- 0.16 (- 1.8, - 1.3)], number of PIPs [- 1.6 (- 1.8, - 1.3)], and proportion of patients with ≥ 2 PIPs (- 53.7%, P < 0.001). CONCLUSION: Studied intervention provides significant effective prescribing and medication adherence enhancements in non-institutionalized older patients with multimorbidity and polypharmacy.

Evaluation of an AI system for the detection of diabetic retinopathy from images captured with a handheld portable fundus camera: the MAILOR AI study.

OBJECTIVES: To evaluate the performance of an artificial intelligence (AI) system (Pegasus, Visulytix Ltd., UK*) at the detection of diabetic retinopathy (DR) from images captured by a handheld portable fundus camera. METHODS: A cohort of 6404 patients (~80% with diabetes mellitus) was screened for retinal diseases using a handheld portable fundus camera (Pictor Plus, Volk Optical Inc., USA) at the Mexican Advanced Imaging Laboratory for Ocular Research. The images were graded for DR by specialists according to the Scottish DR grading scheme. The performance of the AI system was evaluated, retrospectively, in assessing referable DR (RDR) and proliferative DR (PDR) and compared with the performance on a publicly available desktop camera benchmark dataset. RESULTS: For RDR detection, Pegasus performed with an 89.4% (95% CI: 88.0-90.7) area under the receiver operating characteristic (AUROC) curve for the MAILOR cohort, compared with an AUROC of 98.5% (95% CI: 97.8-99.2) on the benchmark dataset. This difference was statistically significant. Moreover, no statistically significant difference was found in performance for PDR detection with Pegasus achieving an AUROC of 94.3% (95% CI: 91.0-96.9) on the MAILOR cohort and 92.2% (95% CI: 89.4-94.8) on the benchmark dataset. CONCLUSIONS: Pegasus showed good transferability for the detection of PDR from a curated desktop fundus camera dataset to real-world clinical practice with a handheld portable fundus camera. However, there was a substantial, and statistically significant, decrease in the diagnostic performance for RDR when using the handheld device.

Therapeutic optimization through goal-oriented prescription in nursing homes.

Background People living in nursing homes are highly vulnerable and frail. Polypharmacy and inappropriate prescription (IP) are also common problems. Objectives The objectives of the study are (i) to study the baseline situation and calculate the frailty index (FI) of the residents, (ii) to assess the results of routine clinical practice to do a pharmacotherapy review (patient-centred prescription (PCP) model) (Molist Brunet et al., Eur Geriatr Med. 2015;6:565-9) and (iii) to study the relationship between IP and frailty, functional dependence, advanced dementia and end-of-life situation. Setting Two nursing homes in the same geographical area in Catalonia (Spain). Method This was a prospective, descriptive and observational study of elderly nursing home residents. Each patient's treatment was analysed by applying the PCP model, which centres therapeutic decisions on the patient's global assessment and individual therapeutic goal. Main outcome measure Prevalence of polypharmacy and IP. Results 103 patients were included. They were characterized by high multimorbidity and frailty. Up to 59.2% were totally dependent. At least one IP was identified in 92.2% of residents. Prior to the pharmacological review, the mean number of chronic medications prescribed per resident was 6.63 (SD 2.93) and after this review it was 4.97 (SD 2.88). Polypharmacy decreased from 72.55% to 52.94% and excessive polypharmacy fell from 18.62% to 5.88%.The highest prevalence of IP was detected in people with a higher FI, in those identified as end-of-life, and also in more highly dependent residents (p < 0.05). Conclusions People who live in nursing homes have an advanced frailty. Establishing individualized therapeutic objectives with the application of the PCP model enabled to detect 92.2% of IP. People who are frailer, are functionally more dependent and those who are end-of-life are prescribed with inappropriate medication more frequently.

Optimizing drug therapy in frail patients with type 2 diabetes mellitus.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is closely linked with ageing. In frail diabetic patients, the risks of intensive antidiabetic therapy outweigh the potential benefits. AIMS: To study the prevalence of T2DM in frail elderly patients, to identify inappropriate prescription (IP) of antidiabetic drugs and to study the relationship between patients' frailty index (FI) with polypharmacy and IP. METHODS: This was a prospective, descriptive, observational study of elderly patients. Each patient's antidiabetic treatment was analysed by applying the patient-centred prescription model (PCP), which centres therapeutic decisions on the patient's global assessment and individual therapeutic goal. RESULTS: 210 patients with T2DM were included (25.15% prevalence). They were characterised by high multimorbidity and frailty. 93.3% presented polypharmacy and 51% excessive polypharmacy. IP was identified in 66.2% of patients. A statistically significant relationship was found between the progression in FI degree and IP prevalence (p < 0.05. During the admission, drug therapy regimens were modified in 97.1% of cases with IP (n = 136). DISCUSSION: These results suggest that in clinical practice T2DM treatment is not individualised, but rather is based on the same general recommendations for the population as a whole. CONCLUSIONS: There is a high prevalence of T2DM in the elderly. As the frailty of patients increases, so does the prevalence of IP. The application of PCP model enables drug therapy optimization in frail patients according to their main therapeutic goal, and contributes to provide clinical evidences on the applicability of a set of knowledge areas from the theoretical framework to the daily clinical practice.

Influence of adding etravirine on complexity index and patients' perceived complexity.

WHAT IS KNOWN AND OBJECTIVE: Adherence to highly active antiretroviral treatment (HAART) is an important predictive factor of treatment outcome. Medication regimen complexity can be one of the main causes of non-adherence. Thus, treatment simplification is a key strategy in the development of antiretroviral therapy. The aim of this study was to determine the influence of adding etravirine on complexity index and patients' perceived complexity of their treatment regimen. METHODS: We conducted a prospective two-centre observational study. Patients on etravirine-based therapy, for at least 6 months, who came personally to pharmacy departments for a drug refill from February to July 2012 were included. Data were collected for the current etravirine-based HAART and for the previous HAART without etravirine. The main variables were complexity index and patients' perceived complexity. We also evaluated the adherence during the 6 months before and after the introduction of etravirine into HAART. The complexity index was based on a score which takes into account the number of pills per day, the dosing schedule, the dosage form and any specific instructions linked to use of the drug. To evaluate the patients' perceived complexity of their current and previous HAART, patients were asked to assign a mark on a visual analogue scale ranging from 0 (minimum) to 10 (maximum). We assessed the differences in the variables collected between the current and previous antiretroviral therapy. Finally, we carried out a correlation analysis between the complexity index and the patients' perceived complexity. RESULTS AND DISCUSSION: Eighty patients were included. The complexity index was significantly reduced after the addition of etravirine to HAART (P = 0·035). Perceived complexity was also reduced (P = 0·015). After the introduction of the drug, the proportion of adherent patients increased from 65% to 81·3% (P = 0·002). The correlation between the complexity index and the patients' perceived complexity was positive (r = 0·594). The correlation increased (r = 0·696) when the difference between the complexity index before and after the introduction of etravirine in HAART grew. WHAT IS NEW AND CONCLUSION: The addition of etravirine to HAART results in a significant reduction in complexity index and patients' perceived complexity of their therapy. These changes were associated with better adherence to treatment.

Assessment of new drugs in a tertiary hospital using a standardized tool.

OBJECTIVE: To describe the profile of new drugs evaluated by the Pharmacy and Therapeutics committee in a tertiary hospital using a standardized tool, the Guideline for the Introduction of New Drugs in the Formulary (GINF form), as main objective. MATERIALS AND METHODS: Retrospective observational study of drugs was assessed during 2008-2011. Variables related to the drug, the request, and the result of the evaluation were collected based on information contained in the GINF form and in the assessment reports. RESULTS: 63 of 75 assessed drugs (84%) were included in the hospital formulary. Only one drug (1%) was included without any restrictions. The rest of them were included as therapeutic equivalents (23%) or under specific recommendations (61%). Half of the drugs (6) not included had insufficient evidence of effectiveness compared with current treatments. Haematology and Medical Oncology were found to be the most active medical services in the application process. There was a high prevalence of drugs that had more than one advanced clinical trial (phase III and/or phase IV). Furthermore, 28% of assessed drugs were associated with a financial burden of more than ?10,000 per year for our hospital. Highquality information was provided by applicants to the P&T committee for drugs that were finally included. However, the relationship between the information provided to the P&T committee and its decision was not statistical significance. CONCLUSION: The requests received were primarily related to drugs intended for parenteral use and most of them were antineoplastic drugs. The medical departments most heavily represented were Haematology and Oncology.

Objetivo: Describir las características de los nuevos fármacos evaluados por la Comisión de Farmacia y Terapéutica (CFyT) en un hospital terciario mediante el empleo de una herramienta normalizada, la Guía para la valoración de Inclusión de Nuevos Fármacos, como objetivo principal. Material y métodos: Estudio observacional retrospectivo de aquellos fármacos evaluados en el periodo 2008-11. Fueron recogidas variables relativas al fármaco, a la solicitud y al resultado final de la evaluación mediante la información contenida en las guías GINF y en los informes finales de evaluación. Resultados: De los 75 medicamentos evaluados, 63 (84%) fueron incluidos en la Guía Farmacoterapéutica del Hospital. Únicamente 1 (1,3%) lo fue sin ningún tipo de restricción. El resto fueron incluidos como equivalentes terapéuticos (21,3%) o bajo recomendaciones específicas (61,3%). La mitad de los fármacos no incluidos (6) presentaban insuficiente evidencia respecto a su eficacia frente a los tratamientos habituales. Hematología y Oncología Médica se encontraron entre los servicios médicos más activos en la solicitud. Se observó un alto porcentaje de fármacos que disponían de más de un ensayo clínico en fase avanzada (III y/o IV). Por otra parte, el 28% de los fármacos evaluados se relacionaron con un impacto financiero superior 10.000 ??anuales. Las guías GINF proporcionadas por los solicitantes a la CFyT se caracterizaron por la alta calidad de la información contenida en ellas. Sin embargo, la relación entre la información proporcionada a la CFyT y la decisión final de la misma no fue estadísticamente significativa. Conclusiones: Las solicitudes recibidas pertenecieron principalmente a fármacos de administración parenteral, siendo la mayor parte de ellos antineoplásicos. Los servicios médicos más intensamente representados fueron Hematología y Oncología.