Inappropriate prescribing in elderly people with diabetes admitted to hospital.

AIMS: To assess inappropriate prescribing in older people with diabetes mellitus during the month prior to a hospitalization, using tools on potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs) and comparing inappropriate prescribing in patients with without diabetes. METHODS: In an observational, prospective multicentric study, we assessed inappropriate prescribing in 672 patients aged 75 years and older during hospital admission. The Beers, Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right Treatment (START) criteria and Assessing Care of Vulnerable Elders (ACOVE-3) medicine quality indicators were used. We analysed demographic and clinical factors associated with inappropriate prescribing. RESULTS: Of 672 patients, 249 (mean age 82.4 years, 62.9% female) had a diagnosis of diabetes mellitus. The mean number of prescribing drugs per patient with diabetes was 12.6 (4.5) vs. 9.4 (4.3) in patients without diabetes (P < 0.001). Of those patients with diabetes, 74.2% used 10 or more medications; 54.5% of patients with diabetes had at least one Beers-listed PIM, 68.1% had at least one STOPP-listed PIM, 64.6% had at least one START-listed PPO and 62.8% had at least one ACOVE-3-listed PPO. Except for the Beers criteria, these prevalences were significantly higher in patients with diabetes than in those without. After excluding diabetes-related items from these tools, only STOPP-listed PIMs remained significantly higher among patients with diabetes (P = 0.04). CONCLUSIONS: Polypharmacy is common among older patients with diabetes mellitus. Inappropriate prescribing is higher in older patients with diabetes, even when diabetes-related treatment is excluded from the inappropriate prescribing evaluation.

Impact of a multidisciplinary medication reconciliation program on clinical outcomes: A pre-post intervention study in surgical patients.

BACKGROUND: Previous studies have evaluated the effects of medication reconciliation (MR) and suggest that it is effective in decreasing medication discrepancies. Nevertheless, a recent overview of systematic reviews concluded that there is no clear evidence in favor of MR in patient-related outcomes and healthcare utilization, and further research about it is needed. OBJECTIVE: To evaluate the impact of a multidisciplinary MR program on clinical outcomes in patients with colorectal cancer presenting other chronic diseases, undergoing elective colorectal surgery. METHODS: We performed a pre-post study. Adult patients scheduled for elective colorectal cancer surgery were included if they presented at least one "high-risk" criteria. The MR program was developed by internists, pharmacists and surgeons, and ended with the obtention of the patient's pre-admission medication list and follow-up care until discharge. The primary outcome was the length of stay (LOS). Secondly, we evaluated mortality, preventable surgery cancellations and risk factors for complications. RESULTS: Three hundred and eight patients were enrolled. Only one patient in the pre-intervention group suffered a preventable surgery cancellation (p = 0.317). The mean LOS was 13 ± 12 vs. 11 ± 5 days in the pre-intervention and the intervention cohort, respectively (p = 0.435). A difference in favor of the intervention group in patients with cardiovascular disease (p = 0.038) and those >75 years old (p = 0.043) was observed. No difference was detected in the mortality rate (p = 0.999) neither most of the indicators of risk factors for complications. However, the management of preoperative systolic blood pressure of hypertensive patients (p = 0.004) and insulin reconciliation in patients with treated diabetes (p = 0.003) were statistically better in the intervention group. CONCLUSIONS: No statistically significant change was observed in the mean global LOS. A statistically significant positive effect on LOS was observed in vulnerable populations: patients >75 years old and those with cardiovascular disease, who presented a 5-day reduction in the mean LOS.

Impact of medication reconciliation on health outcomes: An overview of systematic reviews.

BACKGROUND: Recent systematic reviews and meta-analyses suggest that medication reconciliation (MR) is effective in decreasing the risk of medication discrepancies. Nevertheless, the association between MR and subsequent improved healthcare outcomes is not well established. OBJECTIVES: This systematic review of reviews set out to identify published systematic reviews on the impact of MR programs on health outcomes and to describe key components of the intervention, the health outcomes assessed and any associations between MR and health outcomes. METHODS: PubMed, EMBASE, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and SCOPUS were searched from inception to May 2019. Systematic reviews of all study designs, populations, intervention providers and settings that measured patient-related outcomes or healthcare utilization were considered. Methodological quality was assessed using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2). Two investigators performed study selection, quality assessment and data collection independently. RESULTS: Five systematic reviews met the inclusion criteria: 2 were rated as low quality and 3 as critically low quality. Reviews included primary studies in different settings (hospitals, the community and residential aged care facilities) that reported the impact of MR on mortality, length of stay, Emergency Department (ED) visits, readmissions, physician visits and healthcare utilization. Only one review reported results on mortality. However, healthcare utilization, which usually included ED visits and readmissions, was communicated in all reviews. Meta-analyses were conducted in all reviews except one. Medication reconciliation was not consistently found to be associated with improvements in health outcomes. CONCLUSIONS: Few systematic reviews support the value of MR in achieving good patient-related outcomes and healthcare utilization improvements. The quality of the systematic reviews was low and the primary studies included commonly involved additional activities related to MR. There was no clear evidence in favor of intervention in mortality, length of stay, ED visits, unplanned readmissions, physician visits and healthcare utilization.

Simplification of the Barthel scale for screening for frailty and severe dependency in polypathological patients. / Simplificación de la escala de Barthel para el cribado de fragilidad y dependencia severa en pacientes pluripatológicos.

OBJECTIVES: To analyse the sensitivity, specificity and positive predictive (PPV) and negative predictive (NPV) values of each measure of the Barthel index (BI) compared with the full questionnaire for polypathological patients (PPPs). METHODS: Multicentre cross-sectional study. We considered 2 cut-off points for the BI (≥90 points for screening frailty and <60 points for diagnosing severe dependence). For each measure and combination of 2 measures, we calculated the sensitivity, specificity, PPV and NPV with respect to the full BI. RESULTS: The mean BI of the 1,632 included PPPs (mean age, 77.9±9.8years; 53% men) was 69±31 (<90 for 58.7% and <60 for 31.4% of the patients). The "feeding" measure achieved the highest NPV, for a BI ≥60 and ≥90 points (87% and 99.6%, respectively). The "walking" and "going up and down stairs" measures achieved the highest PPV, for a BI ≥60 and ≥90 (99.2%/99.5% and 81%/92%, respectively. The combination of the 2 measures increased the PPV to 95% and 99.6%, respectively. CONCLUSIONS: PPPs in hospital settings have a high rate of functional impairment. The measure for feeding achieved the highest NPV and can therefore be employed for diagnosing severe dependence. The combination of the measures for walking and going up and down stairs achieved the highest PPV and can therefore be employed to propose frailty screening for PPPs.

Prognostic stratification and healthcare approach in patients with multiple pathologies. / Estratificación pronóstica y abordaje asistencial de los pacientes pluripatológicos.

Polypathological patients constitute a prevalent, fairly homogeneous population, which is characterised by high clinical complexity, substantial vulnerability and significant resource consumption, in addition to high mortality and the need for comprehensive, coordinated care. It is particularly important to establish a reliable prognosis in these patients. It is also extremely useful for professionals involved in the decision-making process for patients and their families in vital planning and their preferences, for strategic health planning in management fields, and for clinical research, by facilitating their incorporation into clinical trials and other intervention studies. Two prognostic instruments stand out in terms of suitability for polypathological patients: PROFUND and PROFUNCTION. The former faithfully stratifies the risk of dying at 12 months and four years and the latter, the risk of suffering a significant functional deterioration at 12 months. In terms of the healthcare approach in patients with multiple pathologies, creating and executing a consensual, personalised action plan that is adapted to the patient's reality is encouraged. The plan will consider the prognosis, and the evidence and viability of interventions; its ultimate aim will be to ensure the synergy and alignment of the health team's goals and strategies with peoples' values and preferences, in order to achieve a more proactive health model focused on supporting patients in their ability to manage their illnesses. In the personalised action plan, the main areas of intervention are: health promotion and prevention; patient and caregiver activation and self-management; activation of a social support network and social support; optimisation of pharmacotherapy; rehabilitation, functional and cognitive preservation measures; and anticipated decision planning.

Surgical treatment for infective endocarditis in elderly patients.

OBJECTIVES: We evaluate the clinical, echographic and prognostic characteristics of infective endocarditis (IE) in a large population of elderly patients, and the results of surgical approach. METHODS: Multicentric, prospective, observational cohort study with 961 consecutive left-sided IE: 356 patients aged ≥65 years were compared with 605 younger. Indications for cardiac surgery, potential surgical risk, time and outcome, were compared. RESULTS: Hospital-acquired endocarditis, comorbidity, renal failure and septic shock were more frequent in elderly, but embolisms were less. Intracardiac destruction and ventricular failure were similar in both groups, but significantly fewer elderly patients underwent cardiac surgery (36% vs 51%; p < 0.01), and this group showed a worse outcome (43.2% of mortality vs 27% in younger; p < 0.01), resulting age as an independent predictor of mortality (OR: 1.02 CI95%: 1.01-1.03). Compared with medical treatment, surgery showed lower percentages of mortality compared with medical treatment (23.3% vs 31.3%; p = 0.03) in younger group, but a high mortality was observed with both procedures (47.6% vs 40.3%; p = 0.1) in the elderly. CONCLUSIONS: Although similar percentages of heart failure and intracardiac complications, increasing age is associated with higher mortality in IE. Lower rates of surgical treatment and a worse outcome after operation are common features in elderly patients.

[Evaluation of the satisfaction with a care coordination program between Primary Care and general internists]. / Evaluación de la satisfacción de un programa de colaboración entre Atención Primaria y Medicina Interna.

OBJECTIVES: To evaluate the level of knowledge, participation and satisfaction with a continuity of care program between Primary Care and a group of general internists, and to analyse the most frequent reasons for consulting. MATERIAL AND METHODS: Cross-sectional study including all primary care physicians from 10 Family Practice Care Centres using a questionnaire containing these objectives. RESULTS: Eighty-three family physicians (92.2%) answered the survey. All physicians knew of the collaboration program and had also participated. The most common clinical problems seen were: patients with multiple health problems(26.5%), cardiovascular risk factors (16.8%) and diagnosis of the asthenia syndrome (141%), with these three problems obtaining the best evaluation in the satisfaction survey. Almost all (98.8%) of the family physicians were satisfied with the program. CONCLUSIONS: Our continuity care program was very well evaluated in the satisfaction survey by family physicians. The participation index was very high and the clinical problems most frequently consulted and best evaluated were those that traditionally have been seen by the internists.

[Clinical, functional, mental and sociofamiliar features in pluripathological patients. One-year prospective study in Primary Health Care]. / Características clínicas, funcionales, mentales y sociales de pacientes pluripatológicos. Estudio prospectivo durante un año en Atención Primaria.

OBJECTIVES: To analyze clinical, functional, mental, sociofamiliar, and evolutional characteristics of pluripathological patients (PP) in Primary Health Care setting. PATIENTS AND METHOD: Prospective, multiinstitutional cohort study in four Primary Health Care Institutions by active identification of PP from a computerized registry using the Spanish Andalusian Health Care Council criteria. A clinical interview was proposed to all identified patients. The clinical data, Barthel index (BI), Pfeiffer scale, clinical vulnerability (CV), sociofamiliar features by the Gijon scale, and 1-year admissions and mortality were analyzed. An univariant and multivariant analysis was performed in order to know the risk factors associated to previously described variables. RESULTS: Overall, 806 PP were detected (1.38% of the population). Cardiovascular categories were the most prevalent. A total of 662 patients (69%) were eligible for the interview. Median BI was 90 (0-100), and 24% of patients had severe functional impairment (BI < 60). Twenty-nine percent of them had been admitted to hospital at least once in the last 3 months. Patients with more functional impairment and CV were older, having more defining categories, especially E category. A total of 174 patients (37.75%) had cognitive impairment. This group was older, with more functional impairment, and worse sociofamiliar support. One-year mortality was 6.1%, and was correlated with CV and older age. CONCLUSIONS: The definition of PP used selects in the Primary Care setting a population with a high level of multidimensional frailty having a high prevalence of functional, cognitive deterioration, sociofamiliar problems, CV and consumption of health care resources. Due to this multidimensional deterioration, it is recommendable to make an integral evaluation in the health care practice of these patients.