Comparison of the methodological quality and transparency of Brazilian practice guidelines.

This study aims to compare the differences between clinical practice guidelines (CPGs) of the Ministry of Health (MoH) and those of other Brazilian health institutions. A systematic review of Brazilian CPGs was carried out. CPGs with recommendations for the pharmacological treatment of non-communicable disease (NCDs) were included. CPG methodological quality and transparency was independently assessed by 2 reviewers using the AGREE II. CPGs were rated as high, moderate, and low quality (ranging from A to C). Twenty-six CPGs were assessed for quality. MoH CPGs were published more recently, and were of better quality than the others: 6/6 (100%) were rated as Moderate-A. Although CPGs presented a wide range of methodological quality and transparency, MoH CPGs presented better consistency in the preparation method. To avoid confusion and to improve the quality of care within finite resources in Brazil, and to avoid potential bias, conflicts of interest, national CPGs used within SUS should be developed by Conitec with partners who have no conflict of interest.

Factors Associated With High-Quality Guidelines for the Pharmacologic Management of Chronic Diseases in Primary Care: A Systematic Review.

Importance: As the rate of publication of new and sometimes conflicting medical research increases, clinicians rely heavily on clinical practice guidelines (CPGs) to inform practice. However, CPGs are of widely variable quality, and there are no existing objective measures to rate the quality of CPGs. Objective: To systematically assess 421 CPGs for the management of common noncommunicable diseases in primary care using the validated Appraisal of Guidelines for Research and Evaluation Instrument, version II (AGREE-II) tool and elucidate the factors associated with quality of CPGs. Evidence Review: MEDLINE, Embase, the Cochrane Library, and 12 websites for CPGs were searched for CPGs for the management of common noncommunicable diseases in primary care published between January 1, 2011, and August 30, 2017. The assessment of the quality of CPGs was performed by 3 appraisers using the 6 domains of the AGREE-II instrument. A multiple logistic regression was performed to identify factors associated with quality of CPGs. Findings: Of the 421 CPGs reviewed, 23.5% (99) were classified as high quality. Among included guidelines, clarity of presentation (70%) and scope and purpose (61%) had the highest median AGREE-II scores. The domains with the lowest median scores were applicability (22%) and rigor of development (33%). Factors associated with high-quality CPGs included having more than 20 authors (odds ratio, 9.08; 95% CI, 3.35-24.62), development at governmental institutions (odds ratio, 10.38; 95% CI, 2.72-39.60), and reporting funding (odds ratio, 10.34; 95% CI, 4.77-22.39). Year of publication, region, guideline version, and scope were not associated with quality among included CPGs. Conclusions and Relevance: Primary care professionals and policymakers should be aware that CPGs in primary care are of widely variable quality, with less than 25% of included CPGs rated as high quality. High-quality CPGs were associated with a higher number of authors, governmental institutions, and the report of funding. Region of origin was not associated with quality of CPGs, which suggests that the improvement of the quality of CPGs should be an international concern.

Methodological quality and transparency of clinical practice guidelines for the pharmacological treatment of non-communicable diseases using the AGREE II instrument: a systematic review protocol.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of death worldwide. Clinical practice guidelines (CPGs) constitute an important tool for the promotion of evidence-based health, which may improve healthcare outcomes for individuals with NCDs. Studies have shown that many CPGs have poor or moderate quality. Therefore, the aim of the proposed study is to systematically identify and appraise CPGs for pharmacological treatment of the most prevalent NCDs in primary care. METHODS: A comprehensive literature search will be conducted in the following databases: MEDLINE, Embase and Cochrane Library. Twelve databases specific to CPGs will also be searched. Three appraisers will assess the quality of the CPGs using the Appraisal of Guidelines Research and Evaluation (AGREE) Instrument, version II. The AGREE II results will be checked for discrepancies. Differences between scores equal than or greater to 2 will be considered discrepant and the appraisers will decide the final score by consensus. If no consensus is reached, a fourth appraiser will decide the score. According to the AGREE II User's Manual, the six domains of the instrument are independent. Thus, each domain score will be calculated by the sum of the individual item scores and scaling the total as a percentage of the maximum possible score for the domain. DISCUSSION: The AGREE II instrument will be applied to evaluate the quality of CPGs and contribute to enhance the discussion and development of guidelines of high quality. The findings will be submitted for publication in high-impact, peer-reviewed scientific journals and will also be disseminated at international conferences. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016043364.

Non-Communicable Disease Clinical Practice Guidelines in Brazil: A Systematic Assessment of Methodological Quality and Transparency.

BACKGROUND: Annually, non-communicable diseases (NCDs) kill 38 million people worldwide, with low and middle-income countries accounting for three-quarters of these deaths. High-quality clinical practice guidelines (CPGs) are fundamental to improving NCD management. The present study evaluated the methodological rigor and transparency of Brazilian CPGs that recommend pharmacological treatment for the most prevalent NCDs. METHODS: We conducted a systematic search for CPGs of the following NCDs: asthma, atrial fibrillation, benign prostatic hyperplasia, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease and/or stable angina, dementia, depression, diabetes, gastroesophageal reflux disease, hypercholesterolemia, hypertension, osteoarthritis, and osteoporosis. CPGs comprising pharmacological treatment recommendations were included. No language or year restrictions were applied. CPGs were excluded if they were merely for local use and referred to NCDs not listed above. CPG quality was independently assessed by two reviewers using the Appraisal of Guidelines Research and Evaluation instrument, version II (AGREE II). MAIN FINDINGS: "Scope and purpose" and "clarity and presentation" domains received the highest scores. Sixteen of 26 CPGs were classified as low quality, and none were classified as high overall quality. No CPG was recommended without modification (77% were not recommended at all). After 2009, 2 domain scores ("rigor of development" and "clarity and presentation") increased (61% and 73%, respectively). However, "rigor of development" was still rated < 30%. CONCLUSION: Brazilian healthcare professionals should be concerned with CPG quality for the treatment of selected NCDs. Features that undermined AGREE II scores included the lack of a multidisciplinary team for the development group, no consideration of patients' preferences, insufficient information regarding literature searches, lack of selection criteria, formulating recommendations, authors' conflict of interest disclosures, and funding body influence.

Comparison of the methodological quality and transparency of Brazilian practice guidelines / Comparação da qualidade metodológica e transparência das guias de prática clínica brasileiras

Abstract This study aims to compare the differences between clinical practice guidelines (CPGs) of the Ministry of Health (MoH) and those of other Brazilian health institutions. A systematic review of Brazilian CPGs was carried out. CPGs with recommendations for the pharmacological treatment of non-communicable disease (NCDs) were included. CPG methodological quality and transparency was independently assessed by 2 reviewers using the AGREE II. CPGs were rated as high, moderate, and low quality (ranging from A to C). Twenty-six CPGs were assessed for quality. MoH CPGs were published more recently, and were of better quality than the others: 6/6 (100%) were rated as Moderate-A. Although CPGs presented a wide range of methodological quality and transparency, MoH CPGs presented better consistency in the preparation method. To avoid confusion and to improve the quality of care within finite resources in Brazil, and to avoid potential bias, conflicts of interest, national CPGs used within SUS should be developed by Conitec with partners who have no conflict of interest.

Resumo O objetivo deste estudo é comparar as diferenças entre as guias de prática clínica (GPCs) do Ministério da Saúde (MS) e as de outras instituições de saúde brasileiras. Foi realizada uma revisão sistemática das GPCs brasileiras. Foram incluídas GPCs com recomendações para o tratamento farmacológico de doenças crônicas não transmissíveis elencadas (DCNTs). A qualidade metodológica e a transparência das GPCs foram avaliadas de forma independente por 2 revisores utilizando o AGREE II. As GPCs foram classificadas como alta, moderada e baixa qualidade (variando de A a C). Vinte e seis GPCs foram avaliadas quanto à qualidade. As GPCs do MS foram publicadas mais recentemente, e apresentaram melhor qualidade do que as outras: 6/6 (100%) foram classificadas como Moderada-A. Embora as GPCs tenham apresentado uma ampla gama de qualidade metodológica e transparência, as GPCs do MS apresentaram melhor consistência no desenvolvimento. Para evitar confusão e melhorar a qualidade do cuidado com os recursos limitados no Brasil e, para evitar viés, conflitos de interesse, GPCs nacionais usadas no SUS devem ser desenvolvidas, sobretudo, pela Conitec e parceiros sem conflitos de interesse.

Impact of pharmacist interventions on drug-related problems and laboratory markers in outpatients with human immunodeficiency virus infection.

BACKGROUND: Substantial complexity has been introduced into treatment regimens for patients with human immunodeficiency virus (HIV) infection. Many drug-related problems (DRPs) are detected in these patients, such as low adherence, therapeutic inefficacy, and safety issues. We evaluated the impact of pharmacist interventions on CD4+ T-lymphocyte count, HIV viral load, and DRPs in patients with HIV infection. METHODS: In this 18-month prospective controlled study, 90 outpatients were selected by convenience sampling from the Hospital Dia-University of Campinas Teaching Hospital (Brazil). Forty-five patients comprised the pharmacist intervention group and 45 the control group; all patients had HIV infection with or without acquired immunodeficiency syndrome. Pharmaceutical appointments were conducted based on the Pharmacotherapy Workup method, although DRPs and pharmacist intervention classifications were modified for applicability to institutional service limitations and research requirements. Pharmacist interventions were performed immediately after detection of DRPs. The main outcome measures were DRPs, CD4+ T-lymphocyte count, and HIV viral load. RESULTS: After pharmacist intervention, DRPs decreased from 5.2 (95% confidence interval [CI] =4.1-6.2) to 4.2 (95% CI =3.3-5.1) per patient (P=0.043). A total of 122 pharmacist interventions were proposed, with an average of 2.7 interventions per patient. All the pharmacist interventions were accepted by physicians, and among patients, the interventions were well accepted during the appointments, but compliance with the interventions was not measured. A statistically significant increase in CD4+ T-lymphocyte count in the intervention group was found (260.7 cells/mm(3) [95% CI =175.8-345.6] to 312.0 cells/mm(3) [95% CI =23.5-40.6], P=0.015), which was not observed in the control group. There was no statistical difference between the groups regarding HIV viral load. CONCLUSION: This study suggests that pharmacist interventions in patients with HIV infection can cause an increase in CD4+ T-lymphocyte counts and a decrease in DRPs, demonstrating the importance of an optimal pharmaceutical care plan.

A criação de sítio para disseminar informações sobre medicamentos no SUS: um relato de experiência / Creating site to disseminate information about medicines in the SUS: an experience report / Creación de sitio para difundir información acerca de los medicamentosen el SUS: un relato de experiencia

Neste estudo é relatado o processo de desenvolvimento de sítio sobre medicamentos no SUS. Para a escolha dos temas a serem inseridos no sítio, primeiramente foram elencadas as dificuldades de entendimento quanto a Assistência Farmacêutica apresentada pelos profissionais de saúde e usuários do SUS. Em seguida, estes problemas foram discutidos com farmacêuticos especialistas para delimitação dos tópicos e conteúdo para criação das páginas no sítio. Os tópicos incluídos estão divididos em 2 grandes temas: informações sobre a Assistência Farmacêutica no SUS e orientações para a promoção do uso racional de medicamentos. O processo de desenvolvimento do sítio pode servir como exemplo para outros programas de residência, contribuindo para realização de trabalhos de conclusão de residência que disseminem informações relevantes para o usuário do SUS (profissional de saúde ou paciente) na internet e favoreçam a integração entre serviço, ensino, pesquisa e comunidade.

The aim of this study was to report the process of a website creation that disseminates information on SUSdrugs. First, topics for the website were selected based on problems in understanding the Pharmaceutical Service presented by healthcare providers and patients. Then these problems were discussed with pharmaceutical specialists to determine the topics and content to be included on the website. The topics were divided into two mains themes: information on the Pharmaceutical Service in SUS, and guidelines to promote the rational use of medicines. The website development report may serve as an example for other residency programs, and may contribute to the development of other residency theses that disseminate relevant information to patients and healthcare providers, promoting the integration of service, teaching,research and community.

El objetivo de este estudio fue describir el proceso de creación de un sitio web que difunde información sobre las drogas SUS. En primer lugar, fueron seleccionados los temas para el sitio basado en problemas en la comprensión del Servicios Farmacéuticos presentado por los profesionales sanitarios y los pacientes. Entonces estos problemas se discutieron con especialistas farmacéuticos para delimitación de los temas y el contenido para crear las páginas en el sitio. Los temas fueron divididos en dos principales temas: información sobre el Servicios Farmacéuticos en el SUS, y directrices para promover el uso racional de los medicamentos. El proceso de desarrollo del sitio puede servir de ejemplo para otros programas de residencia, y puede contribuir al desarrollo de otras tesis de residencia que difunden información relevante para los pacientes y los profesionales de la salud, la promoción de la integración de los servicios, la enseñanza, la investigación y la comunidad.

Estudo da prevalência de competições terapêuticas entre idosos com multimorbidades do estudo SABE (Saúde, Bem-estar e Envelhecimento) / Therapeutic competition in community-living elderly with multimorbidity (Health, Well-being and Aging - SABE study)

O envelhecimento da população implica em aumento da prevalência de doenças crônicas não transmissíveis (DCNT) e uso de polifarmácia (uso de 5 ou mais medicamentos concomitantemente). Porém, o uso de medicamentos pode ter um efeito negativo em pacientes com multimorbidade. Entende-se como competição terapêutica (CT) a interação medicamento-doença em que o tratamento recomendado para certa condição pode alterar negativamente (competir com) outra condição coexistente. Neste âmbito, o objetivo principal deste trabalho foi estimar a prevalência de CT e avaliar características associadas à CT em idosos da comunidade. O presente estudo usou como base o estudo populacional de idosos do município de São Paulo: Estudo Saúde, Bem-estar e Envelhecimento, onda 2015. As CTs foram definidas a partir de guias de prática clínica (GPCs) com alta qualidade, selecionados a partir de revisão sistemática e avaliação da qualidade. Somente cerca de um quarto dos GPC apresentaram alta qualidade e foram usados para extração das CTs. A média de idade dos 1.224 idosos do SABE foi 70,8, 56,2% eram mulheres, 84% viviam acompanhados, 27,5% estudaram 9 anos e mais, quase 50% declararam renda insuficiente para cobrir com as despesas diárias, metade autoavaliaram a saúde como regular ou ruim, cerca de 40% relataram polifarmácia. Estatinas, inibidores da enzima de recaptação de angiotensina e inibidores da bomba de próton foram as classes de medicamentos mais relatadas. Multimorbidade foi reportada por 61,7% dos idosos. A prevalência de CT foi de 13,2%. Entre idosos com multimorbidade, a prevalência de CT foi de 21,4%. No modelo final de regressão logística, CT foi associada com polifarmácia (OR: 4,70; IC 95% 3,00 7,36), hospitalização no último ano (OR: 1,75; IC 95% 1,07 2,87), queda no último ano (OR: 1,57; IC 95% 1,04 2,36) e pior autoavaliação de saúde (OR: 1,92; IC 95% 1,23 2,99). Profissionais de saúde devem ter cautela ao selecionar GPC e ao prescrever medicamentos a idosos com multimorbidade

Aging implies in an increasing prevalence of noncommunicable diseases (NCDs) and polypharmacy use (use of 5 or more medications concomitantly). However, medications may have a negative effect on patients with multimorbidity. Therapeutic competition (TC) is known as a drug-disease interaction in which the treatment recommended for a certain condition can negatively alter (compete with) another coexisting condition. In this context, the main objective of this study was to estimate the prevalence of TC and evaluate characteristics associated with TC in community dwelling older adults. The present study used the population-based study of older adults living in the city of São Paulo (SABE study, 2015 survey). TCs were identified by using clinical practice guidelines (CPGs) with high quality. A systematic review and critical appraisal of CPGs were conducted to identify high-quality CPGs. Only about a quarter of CPGs were of high quality and were used for CT extraction. A total of 80 CTs were identified from the high-quality CPGs. The mean age of the 1,224 SABE participants was 70.8, 56.2% were women, 84% did not live alone, 27.5% studied 9 years and over, almost 50% declared insufficient income to cover daily expenses, half self-assessed health, such as regular or poor, about 40% reported polypharmacy. Statins, angiotensin-reuptake enzyme inhibitors and proton pump inhibitors were the most commonly reported drug classes. Multimorbidity was reported by 61.7% seniors. The prevalence of TC was 13.2%. Among seniors with multimorbidity, the prevalence of TC was 21.4%. In the final logistic regression model, TC was associated with polypharmacy (OR: 4.70, 95% CI 3.00 - 7.36), hospitalization in the last year (OR: 1.75, 95% CI 1.07-2 , 95% CI 1.04 - 2.36) and worse health self - assessment (OR: 1.92, 95% CI 1.23 - 2.99), a decrease in the last year (OR: 1.57; Health professionals should be careful when selecting CPGs and prescribing medications to older adults with multimorbidity