[Evaluation of the collaboration between Primary and Hospital Care in order to improve inappropriate prescription]. / Evaluación de la colaboración entre atención primaria y hospitalaria para mejorar la polimedicación inapropiada.

INTRODUCTION AND OBJECTIVES: To evaluate the implementation of a collaborative experience between Primary (PC) and Hospital Care (HC) aimed at reducing potentially inappropriate prescribing (PIP) in patients with polypharmacy. MATERIALS AND METHODS: Collaborative experience including a controlled before-after intervention study, carried out in the Donostialdea Integrated Health Organization (IHO), with Bilbao Basurto IHO as control group, Osakidetza, Basque Health Service. Participant were 227 PC physicians and physicians from 7 hospital services, and patients with 5 or more drugs meeting at least one PIP criteria. The intervention consisted of communication and knowledge between professionals, PC-HC consensus, training, identification of patients at risk, medication review, evaluation and feed-back. The collaboration process (agreements, consensus documents, training activities) and the change in the prevalence of PIP in polymedicated patients (using computerised health records) were evaluated. RESULTS: A total of 21 PIP criteria and 6 recommendation documents were agreed. An analysis was performed on 15,570 PIP from OSI Donostialdea and 24,866 from the control group. The prevalence of PIP in polymedicated patients was reduced by -4.53% (95% CI: -4.71 to -4.36, P< .0001) in comparison with the control group. The before-after differences were statistically significant across the 7 services. CONCLUSIONS: PC-HC collaboration is feasible and, along with other intervention components, reduces inappropriate polypharmacy in the context of a recently integrated healthcare organisation. The collaboration process is complex and requires continuous monitoring, policy involvement, leadership that encourages health professional participation, and intensive use of information systems.

Donor kidney volume and outcomes following live donor kidney transplantation.

Pre-donation kidney volume and function may be crucial factors in determining graft outcomes in kidney transplant recipients. We measured living donor kidney volumes by 3D helical computed tomography scanning and glomerular filtration rate (GFR) by (125)I-iothalamate clearances in 119 donors, and correlated these values with graft function and incidence of acute rejection at 2 years post-transplantation. Kidney volume strongly correlated with GFR (Pearson r= 0.71, p < 0.001). Body size and male gender were independent correlates of larger kidney volumes, and body size and age were predictors of kidney function. The effects of transplanted kidney volume on graft outcome were studied in 104 donor-recipient pairs. A transplanted kidney volume greater than 120 cc/1.73 m(2) was independently associated with better estimated GFR at 2 years post-transplant when compared to recipients of lower transplanted kidney volumes (64 +/- 19 vs. 48 +/- 14 mL/min/1.73 m(2), p < 0.001). Moreover, recipients of lower volumes had a higher incidence of acute cellular rejection (16% vs. 3.7%, p = 0.046). In conclusion, kidney volume strongly correlates with function in living kidney donors and is an independent determinant of post-transplant graft outcome. The findings suggest that (1) transplantation of larger kidneys confers an outcome advantage and (2) larger kidneys should be preferred when selecting from otherwise similar living donors.