MULTI-CRITERIA DECISION ANALYSIS AS A DECISION-SUPPORT TOOL FOR DRUG EVALUATION: A PILOT STUDY IN A PHARMACY AND THERAPEUTICS COMMITTEE SETTING.

OBJECTIVES: The aim of this study was to develop and to assess a specific Multi-Criteria Decision Analysis (MCDA) framework to evaluate new drugs in an hospital pharmacy and therapeutics committee (P&TC) setting. METHODS: A pilot criteria framework was developed based on the EVIDEM (Evidence and Value: Impact on DEcisionMaking) framework, together with other relevant criteria, and assessed by a group of P&TC's members. The weighting of included criteria was done using a 5-point weighting technique. Two drugs were chosen by evaluation: an orphan-drug for Gaucher disease, and a nonorphan drug for the treatment of inflammatory bowel disease. Evidence matrices were developed, and value contribution of each drug was evaluated by P&TC's members. An agreed final framework was obtained through a discussion between the P&TC's members. RESULTS: After criteria assessment, the pilot framework included eight quantitative criteria: "disease severity," "unmet needs," "comparative efficacy/effectiveness," "comparative safety/tolerability," "comparative patient-reported outcomes," "comparative cost consequences-cost of treatment," "comparative cost consequences-other medical costs," and "quality of evidence"; and one contextual criterion: "opportunity costs and affordability." The most valued criteria were: "comparative safety/tolerability," "disease severity," and "comparative efficacy/effectiveness." When assessing the drugs most valued characteristics of the MCDA were the possibility that all team may contribute to drug assessment by means of scoring the matrices and the discussion to reach a consensus in drug positioning and value decision making. CONCLUSIONS: The reflective MCDA would integrate quantitative and qualitative criteria relevant for a P&TC setting, allowing reflective discussions based on the criteria weighting score.

[A review of the medication in polymedicated elderly with vascular risk: a randomised controlled trial]. / Revisión de la medicación en ancianos polimedicados en riesgo vascular: ensayo aleatorizado y controlado.

OBJECTIVE: To analyse the effectiveness of a medication review based on intervention directed at improving the appropriateness of drug treatments according to the established guidelines, as well as blood pressure, serum lipid and blood glucose control in elderly patients on multiple medication, and cardiovascular disease or high risk of cardiovascular disease. DESIGN: A randomised controlled trial with blind evaluation. SETTING: Fourteen Primary Health Care centres in Andalusia PARTICIPANTS: A total of 323 patients older than 65 on polypharmacy and cardiovascular disease or high risk of cardiovascular disease. INTERVENTION: A pharmacist interviewed the patient, reviewed the appropriateness of the drug treatment, taking in account health record data, proposed modifications and communicated them to the general practitioner or nurse. The control group received usual health care. MAIN MEASUREMENTS: Percentage of patients with appropriate use of low doses of acetylsalicylic acid, blood pressure, LDL-cholesterol, HbA(1c), and quality of life scores. RESULTS: A total of 41% of patients (average age 74, 61% women) had cardiovascular disease. Ten months after the intervention (18.3% withdrawals), more patients in the intervention group used low dose acetylsalicylic acid than in the control group (52.3% vs 38.6%; P=.024). There were no differences between groups in intermediate clinic outcomes. Quality of life scores improve in intervention group by 6.1 points (100 points scale), but was not statistically significant (P=.051). CONCLUSION: Clinical medication review improves the appropriateness of antiplatelet treatment in the elderly on polypharmacy and with high risk of cardiovascular disease. No improvement in biochemistry measurements was found.

[Prevalence of multiple medication and cardiovascular risk in patients over 65 years]. / Prevalencia de polimedicación y riesgo vascular en la población mayor de 65 años.

OBJECTIVE: To describe the prevalence of multiple medication in patients over 65 years. DESIGN: Cross-sectional study. SETTING: Sevilla and Jerez-Costa North-West Primary Health Care Districts. PARTICIPANTS: Patients older than 65 years randomly chosen from district databases. Patients in nursing homes, with major mental disease, or end-of- life situations were excluded. MAIN MEASUREMENTS: Multiple medication was defined as a prescription of five or more drugs during the last six months. We assessed the medication used by clinical health records audit. Other characteristics were studied by interviewing a subsample of patients. RESULTS: A total of 2,919 clinical health records from 14 centres were reviewed. The prevalence of multiple medication was 49.6% (95% CI: 47.7-51.4) with a range from 33% (95% CI: 26.8-39.3) to 82% (95% CI: 74,3-89,7) between centres. The large majority of patients (90.2% [95% CI: 88.7-91.8]) of patients showed criteria to be included in Cardiovascular Risk Health Care Process. Interviewed patients confirmed taking an average of 8.7 drugs (95% CI: 8.4-9.0). Among them, 83.2% (95% CI: 78.9-87.4) were high cardiovascular risk patients. CONCLUSIONS: Prevalence of multiple medication in patients over 65 years is about 50% with wide variations between centres. The number of drugs per patient ratio was close to eight. A large majority of them were high risk cardiovascular patients.

Pharmacoepidemiological patterns of antidepressant prescribing in primary care in rural Spain (1995-1999).

BACKGROUND: The prescribing of psychoactive drugs is increasing progressively in western countries. The new psychiatric care modalities, in contact with the primary care centres and closer to the population, might be determining this increase in a major way. METHODS: Official data of prescription were collected from the Public Primary Care Department of Pharmacy, to monitor the use of antidepressants during a five year period in a rural health area (140,359 inhabitants). Daily defined dosage (DDD) was used as the measuring unit. RESULTS AND CONCLUSIONS: The total use of antidepressants increased progressively during the period studied from 10.47 DDD/1000 inhabitants/day in 1995 to 18.50 in 1999 (an increase of 77.08%). The majority of this increase is explained by the greater use of SSRIs for which prescribing multiplied by 2.5. It is significant that the figure for the use of tricyclics has not fallen parallel to the increase of SSRIs. General practitioners might be losing their fear of diagnosing and treating mood disorders. Probably a pool of patients is included who were not receiving the correct treatment a few years ago, but to what level are we going to lower the symptomatic threshold for prescribing antidepressants?

Prevalencia de polimedicación y riesgo vascular en la población mayor de 65 años / Prevalence of multiple medication and cardiovascular risk in patients over 65 years

Objetivo: Estudiar la prevalencia de polimedicación en mayores de 65 años. Diseño: Estudio descriptivo transversal. Emplazamiento: Distritos sanitarios de atención primaria Sevilla y Jerez-Costa Noroeste. Participantes: Población mayor de 65 años, seleccionada por un procedimiento aleatorio estratificando por centros. Se excluyeron pacientes institucionalizados, con trastornos de salud mental mayores y enfermedad terminal. Mediciones principales: Se definió polimedicación como el consumo de 5 o más fármacos de forma continuada durante los últimos 6 meses, basado en el registro en historia clínica. Se exploraron otras características de los pacientes mediante entrevista a una submuestra seleccionada aleatoriamente. Resultados: Se evaluaron las historias clínicas de 2.919 pacientes procedentes de 14 centros de salud. La prevalencia encontrada fue de 49,6% (IC 95%: 47,7-51,4), con un rango entre centros de un 33% (IC 95%: 26,8-39,3) a un 82% (IC 95%: 74,3-89,7). El 90,2% (IC 95%: 88,7-91,8) tenía criterios de entrada al Proceso Asistencial Integrado Riesgo Vascular. La entrevista confirmó un consumo promedio de 8,7 medicamentos (IC 95%: 8,4-9,0). Un 83,2% (IC 95%: 78,9-87,4) eran pacientes en riesgo vascular alto. Conclusiones: La prevalencia de polimedicación en mayores de 65 años es cercana al 50%, con amplia variabilidad entre centros. El consumo promedio de medicamentos por paciente es de 8 y la gran mayoría son pacientes en riesgo vascular alto(AU)

Objetive: To describe the prevalence of multiple medication in patients over 65 years. Design: Cross-sectional study. Setting: Sevilla and Jerez-Costa North-West Primary Health Care Districts. Participants: Patients older than 65 years randomly chosen from district databases. Patients in nursing homes, with major mental disease, or end-of- life situations were excluded. Main measurements: Multiple medication was defined as a prescription of five or more drugs during the last six months. We assessed the medication used by clinical health records audit. Other characteristics were studied by interviewing a subsample of patients. Results: A total of 2,919 clinical health records from 14 centres were reviewed. The prevalence of multiple medication was 49.6% (95% CI: 47.7-51.4) with a range from 33% (95% CI: 26.8-39.3) to 82% (95% CI: 74,3-89,7) between centres. The large majority of patients (90.2% [95% CI: 88.7-91.8]) of patients showed criteria to be included in Cardiovascular Risk Health Care Process. Interviewed patients confirmed taking an average of 8.7 drugs (95% CI: 8.4-9.0). Among them, 83.2% (95% CI: 78.9-87.4) were high cardiovascular risk patients. Conclusions: Prevalence of multiple medication in patients over 65 years is about 50% with wide variations between centres. The number of drugs per patient ratio was close to eight. A large majority of them were high risk cardiovascular patients(AU)

Revisión de la medicación en ancianos polimedicados en riesgo vascular: ensayo aleatorizado y controlado / A review of the medication in polymedicated elderly with vascular risk: a randomised controlled trial

Objetivo: Evaluar la efectividad de una intervención basada en la revisión de la medicación dirigida a mejorar la adecuación de los tratamientos a recomendaciones establecidas, el control tensional, lipídico y glucémico de pacientes mayores polimedicados en alto riesgo vascular, en comparación con la asistencia sanitaria habitual. Diseño: Estudio controlado, aleatorizado, con evaluación ciega. Emplazamiento: Catorce centros de salud de Andalucía. Participantes: Se incluyeron 323 personas mayores de 65 años con enfermedad o riesgo vascular alto y polimedicadas. Intervención: Un farmacéutico entrevista al paciente, revisa la adecuación de cada tratamiento teniendo en cuenta los datos de la historia clínica, elabora propuesta de modificaciones y las comunica al médico de familia o enfermera. El grupo control recibe asistencia habitual. Mediciones principales: Proporción de pacientes con uso adecuado de ácido acetilsalicílico en dosis bajas, presión arterial, colesterol LDL, hemoglobina glucosilada y calidad de vida. Resultados: De la población estudiada (edad media de 74 años, 61% mujeres), el 41% presenta enfermedad vascular. Diez meses después de la intervención (tasa de pérdidas del 18,3%) se observó que más pacientes del grupo intervenido frente al control tomaban ácido acetilsalicílico en bajas dosis (52,3 vs. 38,6%; p = 0,024). No se observaron diferencias significativas en otras variables. La calidad de vida percibida tiende a ser mejor, no significativamente, en los intervenidos en 6,1 puntos (escala de 100; p=0,051). Conclusión: La revisión sistemática de la medicación mejora la adecuación de uso del tratamiento antiagregante en ancianos polimedicados en alto riesgo vascular, sin afectar negativamente su calidad de vida. No se constatan mejoras en otras variables(AU)

Objective: To analyse the effectiveness of a medication review based on intervention directed at improving the appropriateness of drug treatments according to the established guidelines, as well as blood pressure, serum lipid and blood glucose control in elderly patients on multiple medication, and cardiovascular disease or high risk of cardiovascular disease. Design: A randomised controlled trial with blind evaluation. Setting: Fourteen Primary Health Care centres in Andalusia. Participants: A total of 323 patients older than 65 on polypharmacy and cardiovascular disease or high risk of cardiovascular disease. Intervention: A pharmacist interviewed the patient, reviewed the appropriateness of the drug treatment, taking in account health record data, proposed modifications and communicated them to the general practitioner or nurse. The control group received usual health care. Main measurements: Percentage of patients with appropriate use of low doses of acetylsalicylic acid, blood pressure, LDL-cholesterol, HbA1c, and quality of life scores. Results: A total of 41% of patients (average age 74, 61% women) had cardiovascular disease. Ten months after the intervention (18.3% withdrawals), more patients in the intervention group used low dose acetylsalicylic acid than in the control group (52.3% vs 38.6%; P=.024). There were no differences between groups in intermediate clinic outcomes. Quality of life scores improve in intervention group by 6.1 points (100 points scale), but was not statistically significant (P=.051). Conclusion: Clinical medication review improves the appropriateness of antiplatelet treatment in the elderly on polypharmacy and with high risk of cardiovascular disease. No improvement in biochemistry measurements was found(AU)

Estudio sobre la utilización y adecuación de absorbentes para la incontinencia urinaria en un distrito de atención primaria / The use and suitability of absorbent products for urinary incontinence in a primary health care district

Objetivo: Calcular el consumo de absorbentes en pacientes con incontinencia urinaria pertenecientes al Distrito Sanitario de Atención Primaria Sevilla (DSAPS) y comparar la evolución a lo largo de los años 2005-2009, así como, calcular el gasto sanitario que supone dicho consumo y su variación en el periodo estudiado. Método. Estudio observacional descriptivo transversal sobre la utilización de absorbentes de incontinencia urinaria (AIU) en el DSAPS entre 2005 y 2009. La población de estudio fueron los pacientes registrados a los que se les dispensó AIU durante dicho periodo. Indicadores principales: número de envases de absorbentes/número de tarjetas ajustadas por edad del paciente y por tipo de aportación (TAFE) y gasto sanitario en AIU/TAFE. Resultados. Entre los años 2005 y 2009 se observa un crecimiento de prescripción en absorbentes ajustado por TAFE del 0,71%. Por áreas, el incremento fue del 1,06% en el área Virgen del Rocío y del 1,28% en el área hospitalaria Virgen de Macarena. El gasto sanitario empleado en el consumo de AIU durante el total de los cinco años fue de 4.100.765€. Ésto supuso un crecimiento del gasto sanitario del 17,8%. Conclusiones. Ha habido un incremento en el consumo de absorbentes a lo largo del tiempo, lo que se traduce también en un aumento del gasto sanitario. Ante esto, cabe quizás plantearse una intervención dirigida a los prescriptores que potencie el tratamiento escalonado y multifactorial de la IU (AU)

Objective: To calculate the use of absorbent products in patients with urinary incontinence in the Seville District Primary Health Care, and to compare the use over time, and to calculate the health costs and their variation during the period 2005-2009. Method. A cross-sectional and descriptive observational study was conducted on the use of urinary incontinence absorbents in the Seville District Primary Health Care, from 2005 and 2009. Patients registered as using urinary incontinence absorbents (UIA) during that period were included as the study population. Main variables: number of absorbent packages/number of healthcare cards by patient age and by type of contribution, and cost of UIA/number of cards by patient age and by type of social security contribution. Results. There was an increase of 0.71% in the prescription of absorbents by healthcare card, patient age and by type of contribution. When comparing the different Health Areas, there was an increase of 1.06% within the Virgen del Rocío Hospital Area and an increase of 1.28% within Virgen de Macarena Hospital Area. The health expense incurred in the use of UIA during these five years was 4,100,765 €, which is an increase of 17.8%. Conclusions. There is a high increase in the use of UIA with time, causing an increase in the health costs. There was also a high frequency in the use of special beds. Therefore, it would be reasonable to train the prescribers to promote progressive and multidisciplinary treatment of UI (AU)