[Therapeutic education of elderly patients under antivitamin - K treatment: evaluation of the program after 5 years]. / Education thérapeutique de patients âges traités par AVK. Biltan d'un programme après 5 années d'existence.

INTRODUCTION: Elderly people with vitamin K antagonists (VKA) have a higher risk of potentially serious hemorrhagic complications. An education program for patients (EPP) aged > or = 75 years with VKA was set up in 2008 in a French geriatric hospital. It includes individual and group sessions conducted by a nurse and a geriatrician. OBJECTIVES: The aim of this study was to assess this EPP after 5 years. Strengths, weaknesses and difficulties of implementation were highlighted, and some improvements were proposed. METHODS: This study is an external audit conducted by a pharmacist trained in EPP. Files of consecutive patients included in the program between may 2008 and March 2013 were reviewed allowing the data collection of patients characteristics and results of the different sessions. The educational objectives were assessed by the rate of correct responses to the questionnaires during the program. The results are presented taking into account the changes made during the 5 years of the program. RESULTS: One hundred forty-three patients, mean age 83.3 +/- 6.5 years, were included in the EPP. 51 sessions were conducted (2.8 patients/session on average). 58% of selected patients were hospitalized. The mean time between the start of anticoagulant treatment and the incLusion in the program was 48.9 +/- 71 months. For 95 patients (66.4%) the medication management at home required a caregiver who was present for sessions in 82 cases (57.3%). The questionnaires form and the organisation of the sessions were gradually improved between 2008 and the end of 2010. Thus, the impact of the EPP has been estimated from November 2010 to March 2013. The correct responses rates before and after the sessions were respectively: 47.8% vs 91.3% for knowledge of INR target values, 25.4% vs 91.3% for knowledge of hemorrhagic signs, 14.9% vs 87.0% for knowledge of the situations or the medications that may disturb the INR equilibrium. Furthermore, the mean number of correct responses, for the 23 patients participating in the entire program, is statistically different between the educational diagnostic and immediate evaluation (3.7/7 vs 5.4/7 p = 0.023) and no significant difference is observed between immediate and distant evaluation (5.4/7 vs 5.8/7 p = 0.720). CONCLUSION: An improvement of patient knowledge was observed with regard to the main educational objectives. Some improvements are proposed: to disseminate information to general practitioners, to add the follow up of INR values to assess an impact on anticoagulant treatment stability. Furthermore, this program is now adapted to the new oral anticoagulants. It is the role of hospital or community pharmacists to initiate and/or assess this type of EPP.

Cost-effectiveness analysis comparing epidural, patient-controlled intravenous morphine, and continuous wound infiltration for postoperative pain management after open abdominal surgery.

BACKGROUND: Continuous wound infiltration (CWI), i.v. patient-controlled analgesia (i.v.-PCA), and epidural analgesia (EDA) are analgesic techniques commonly used for pain relief after open abdominal surgery. The aim of this study was to evaluate the cost-effectiveness of these techniques. METHODS: A decision analytic model was developed, including values retrieved from clinical trials and from an observational prospective cohort of 85 patients. Efficacy criteria were based on pain at rest (VAS ≤ 30/100 mm at 24 h). Resource use and costs were evaluated from medical record measurements and published data. Probabilistic sensitivity analysis (PSA) was performed. RESULTS: When taking into account all resources consumed, the CWI arm (€ 6460) is economically dominant when compared with i.v.-PCA (€ 7273) and EDA (€ 7500). The proportion of patients successfully controlled for their postoperative pain management are 77.4%, 53.9%, and 72.9% for CWI, i.v.-PCA, and EDA, respectively, demonstrating the CWI procedure to be both economically and clinically dominant. PSA reported that CWI remains cost saving in 70.4% of cases in comparison with EDA and in 59.2% of cases when compared with PCA. CONCLUSIONS: Device-related costs of using CWI for pain management after abdominal laparotomy are partly counterbalanced by a reduction in resource consumption. The cost-effectiveness analysis suggests that CWI is the dominant treatment strategy for managing postoperative pain (i.e. more effective and less costly) in comparison with i.v.-PCA. When compared with EDA, CWI is less costly with almost equivalent efficacy. This economic evaluation may be useful for clinicians to design algorithms for pain management after major abdominal surgery.

Exposure to inhaled THM: comparison of continuous and event-specific exposure assessment for epidemiologic purposes.

Trihalomethanes (THMs) (chloroform, bromoform, dibromochloromethane, and bromodichloromethane) are the most abundant by-products of chlorination. People are exposed to THMs through ingestion, dermal contact and inhalation. The objective of this study was to compare two methods for assessing THM inhalation: a direct method with personal monitors assessing continuous exposure and an indirect one with microenvironmental sampling and collection of time-activity data during the main event exposures: bathing, showering and swimming. This comparison was conducted to help plan a future epidemiologic study of the effects of THMs on the upper airways of children. 30 children aged from 4 to 10 years were included. They wore a 3M 3520 organic vapor monitor for 7 days. We sampled air in their bathrooms (during baths or showers) and in the indoor swimming pools they visited and recorded their time-activity patterns. We used stainless steel tubes full of Tenax to collect air samples. All analyses were performed with Gas Chromatography and Mass Spectrometry (GC-MS). Chloroform was the THM with the highest concentrations in the air of both bathrooms and indoor swimming pools. Its continuous and event exposure measurements were significantly correlated (r(s)=0.69 p<0.001). Continuous exposures were higher than event exposures, suggesting that the event exposure method does not take into account some influential microenvironments. In an epidemiologic study, this might lead to random exposure misclassification, thus underestimation of the risk, and reduced statistical power. The continuous exposure method was difficult to implement because of its poor acceptability and the fragility of the personal monitors. These two points may also reduce the statistical power of an epidemiologic study. It would be useful to test the advantages and disadvantages of a second sample in the home or of modeling the baseline concentration of THM in the home to improve the event exposure method.