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.

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.

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.

[Correlation between the various measurements of obesity and the degree of resistance to insulin]. / Correlación entre las diferentes medidas de obesidad y el grado de resistencia a la insulina.

OBJECTIVE: To determine the correlation between certain obesity measurements and insulin resistance (measured by HOMA). DESIGN: Descriptive cross-sectional study. SETTING: Urban health centre with elderly population. PARTICIPANTS: A random sample of 70 people was chosen from among an adult population with risk factors for DM2 or already diagnosed. MAIN MEASUREMENTS: Parameters of obesity were collected (weight, BMI, body perimeters, waist/hip index, and cutaneous folds), as were clinical parameters (blood pressure and cardiovascular risk), and analyses (glycaemia and insulinaemia--both basal and after 2 hours of oral overload of glucose--, HOMA, lipid profile, and microalbuminuria study). Resistance to insulin (IR) was defined as a HOMA > or =3.8. RESULTS: Individuals with IR had significantly higher values of weight (85.5 vs 75.5 kg), BMI (35.1 vs 29.4 kg/m2), waist perimeter (108 vs 100.3 cm) than those without IR. In neither group were any significant differences as to the waist/hip index found. The BMI and/or waist perimeter values that were more likely to suffer IR were established. In men, the values were waist >107 cm (sensitivity, 43%; specificity, 62%) and BMI>29 (sensitivity, 57%; specificity, 50%). In women, they were a waist >102 cm (sensitivity, 64%; specificity, 89%) and BMI>34 (sensitivity, 91%; specificity, 89%). CONCLUSIONS: In clinical practice the BMI and the diameter of the waist are very good predictors of IR, whilst the waist/hip index and cutaneous folds do not provide any information of value.

[Variability in the calculation of coronary risk in type-2 diabetes mellitus]. / Variabilidad en la estimación del riesgo coronario en la diabetes mellitus tipo 2.

OBJECTIVE: To determine the concordance and predictive capacity of various methods for calculating coronary risk in diabetic patients. DESIGN: Prospective study of cohorts, with a 10-year follow-up. SETTING: Urban health centre in a socially depressed area, with high prevalence of DM2. PARTICIPANTS: Population diagnosed with type-2 diabetes mellitus in 1991-93 (112 individuals, with an average age of 66.7+/-11.6 years, 59% of whom were male). MAIN MEASUREMENTS: At the moment of diagnosis, the parameters normally used to calculate coronary risk were determined. The tables of the Framingham scale '91 and '98, of the United Kingdom Prospective Study (UKPDS) (based on an exclusively diabetic population) and of the REgistre GIroni del COr (REGICOR-Girona Heart Register) (based on a Mediterranean population) were each used to calculate individually coronary risk at 10 years. The coronary events suffered in the 10 years following DM2 diagnosis were recorded. The Kappa indices for concordance of the tables and their predictive capacity were calculated. RESULTS: 18.2% of men and 15.2% of women suffered some coronary event. The coronary risk calculations were, for men and women, 30%-20% (Framingham '91), 36%-21% (Framingham '98), 38%-23% (UKPDS), and 15%-10% (REGICOR). CONCLUSIONS: The various methods for calculating coronary risk in diabetics suffer large variability. We should highlight their low diagnostic value in individual cases, with sensitivities of 25%-75% and low specificity (mainly in men) regarding real risk of coronary disease.

[Diagnosing type 2 diabetes mellitus: in primary care, fasting plasma glucose and glycosylated haemoglobin do the job]. / Diagnosticando la diabetes mellitus tipo 2: en atención primaria, con la glucemia basal y la hemoglobina glucosilada es suficiente.

OBJECTIVE: To determine the validity of glycosylated hemoglobin (HbA1c) values as a method to diagnose type 2 diabetes mellitus (DM2) in a population at risk seen in primary care. DESIGN: Cross-sectional analytical study. SETTING: Data were obtained for the Raval Sud study population (epidemiologic study of alterations in glucose metabolism in a population at risk). PARTICIPANTS: 454 subjects from this population (mean age, 65 +/- 3 years; 52% male) at high risk for DM2, seen at a primary care center, were included in the study. MAIN MEASURES: We recorded demographic data and laboratory values for fasting plasma glucose (FPG), oral glucose tolerance test (OGTT), and HbA1c. The diagnostic criteria used for DM2 were those published by the WHO in 1999. Values for HbA1c were expressed as the number of standard deviations (SD) above the mean. RESULTS: Levels of HbA1c correlated with FPG (r=0.72) and glucose levels 2 h after oral glucose overload (r=0.43). Thirty percent of the patients with FPG between 110 and 125 mg/dL had HbA1c values higher than the reference limits. A combined technique based on FPG>125 mg/dL or FPG 110-125 mg/dL with HbA1c > or = 3 SD (5.94%) showed a sensitivity of 92% and a specificity of 95%. CONCLUSIONS: When FPG is inconclusive (110-125 mg/dL), an HbA1c value more than 3 standard deviations above the mean (>5.94%) is useful in suggesting a likely diagnosis of diabetes and identifying patients who require treatment.