Fracture risk after deprescription of bisphosphonates: Application of real-world data in primary care.

PURPOSE: To compare the effect of discontinuing bisphosphonate treatment on fracture risk in postmenopausal women at high versus low risk of fracture. DESIGN: Retrospective, longitudinal and population-based cohort study. SETTING: Barcelona City Primary Care. Catalan Health Institute. PARTICIPANTS: All women attended by primary care teams who in January 2014 had received bisphosphonate treatment for at least five years were included and followed for another five years. INTERVENTION: Patients were classified according to their risk of new fractures, defined as those who had a history of osteoporotic fracture and/or who received treatment with an aromatase inhibitor, and the continuity or deprescription of the bisphosphonate treatment was analyzed over fiver year follow-up. MAIN MEASUREMENTS: The cumulative incidence of fractures and the incidence density were calculated and analyzed using logistic regression and Cox models. RESULTS: We included 3680 women. There were no significant differences in fracture risk in high-risk women who discontinued versus continued bisphosphonate treatment (hazard ratio [HR] 1.17, 95% confidence interval [CI] 0.87-1.58 for total osteoporotic fractures). However, discontinuers at low risk had a lower incidence of fracture than continuers. This difference was significant for vertebral fractures (HR 0.64, 95% CI 0.47-0.88) and total fractures (HR 0.77, 95% CI 0.64-0.92). CONCLUSION: Our results suggest that deprescribing bisphosphonates in women who have already received five years of treatment does not increase fracture risk. In low-risk women, continuing this treatment might could even favor the appearance of new osteoporotic fractures.

Medication-Related Problems in Older People with Multimorbidity in Catalonia: A Real-World Data Study with 5 Years' Follow-Up.

Aging, multimorbidity, and polypharmacy are associated with medication-related problems (MRPs). This study aimed to assess the association that multimorbidity and mortality have with MRPs in older people over time. We followed multimorbid, older (65-99 years) people in Catalonia from 2012 to 2016, using longitudinal data and Cox models to estimate adjusted hazard ratios (HR). We reviewed electronic health records to collect explanatory variables and MRPs (duplicate therapy, drug-drug interactions, potentially inappropriate medications (PIM), and contraindicated drugs in chronic kidney disease (CKD) or liver disease). There were 723,016 people (median age: 74 years; 58.9% women) who completed follow-up. We observed a significant (p < 0.001) increase in the proportion with at least one MRP (2012: 66.9% to 2016: 75.5%); contraindicated drugs in CKD (11.1 to 18.5%) and liver disease (3.9 to 5.3%); and PIMs (62.5 to 71.1%), especially drugs increasing fall risk (67.5%). People with ≥10 diseases had more MRPs (in 2016: PIMs, 89.6%; contraindicated drugs in CKD, 34.4%; and in liver disease, 9.3%). All MRPs were independently associated with mortality, from duplicate therapy (HR 1.06; 95% confidence interval (CI) 1.04-1.08) to interactions (HR 1.60; 95% CI 1.54-1.66). Ensuring safe pharmacological treatment in elderly, multimorbid patient remains a challenge for healthcare systems.

Medication-related problems in older people in Catalonia: A real-world data study.

PURPOSE: The aim of this study was to determine medication-related problems (MRPs) in primary care patients over 65 years of age. METHODS: Cross-sectional study based on the electronic health records of patients (65-99 years of age) visited in 284 primary health care centers during 2012 in Catalonia. VARIABLES: age, sex, sociodemographic variables, number of drugs, kidney and liver function and MRPs (duplicate therapy, drug-drug interactions, potentially inappropriate medications [PIMs] and drugs contraindicated in chronic kidney disease and in liver diseases). Unconditional logistic regression models were used to identify the factors associated with MRPs in patients with multimorbidity. RESULTS: 916 619 older people were included and 853 085 of them met the criteria for multimorbidity. Median age was 75 years and 57.7% of them were women. High percentages of MRPs were observed: PIMs (62.8%), contraindicated drugs in chronic kidney disease (12.1%), duplicate therapy (11.1%), contraindicated drugs in liver diseases (4.2%), and drug-drug interactions (1.0%). These numbers were higher in the subgroup of patients with ≥10 diseases. The most common PIMs were connected to drugs that increase the risk of fall (66.8%), antiulcer agents without criteria for gastroprotection (40.6%), and the combination of drugs with anticholinergic effects (39.7%). In the multivariate analysis, the variables associated with all MRPs among the patients with multimorbidity were the number of drugs and the number of visits. CONCLUSIONS: The coexistence of multimorbidity and polypharmacy is associated with an elevated risk of MRPs in older people. Medication safety for older patients constitutes a pressing concern for health services.

Cardiovascular risk factors in chronic treatment with antipsychotic agents used in primary care.

AIM: To compare the prevalence of cardiovascular risk factors (CVRF) and vascular events, between patients treated and untreated with antipsychotic drugs. SUBJECTS AND METHODS: A cross-sectional study was done in Barcelona. We compared patients attended in Primary Health Care Centres, treated with or without antipsychotics between 2008 and 2010. Anthropometric measurements, clinical variables, and CVRF were assessed. Adult and elderly patients, typical and atypical antipsychotics, were studied separately. RESULTS: 14,087 patients had been prescribed antipsychotics (63.4% atypical), the most common being risperidone. We selected 13,724 patients with the same age and gender but not treated (total of 27,811 patients). Patients receiving antipsychotic had higher prevalence of obesity (16.9% vs. 11.9%), smoking (22.2% vs. 11.1%), diabetes mellitus (16% vs. 11.9%), and dyslipidemia (32.8% vs. 25.8%) (p < 0.001). The prevalence of stroke was significantly higher in the treated patients, both in adults (odds ratio = 2.33) and the elderly (odds ratio = 1.64). The prevalence of coronary heart disease was similar in both groups (odds ratio = 0.97). Among patients treated with antipsychotic, differences were not observed depending typical or atypical ones. CONCLUSIONS: Patients treated with antipsychotic drugs had a greater prevalence of several CVRF (diabetes mellitus, obesity, and smoking). The presence of stroke was higher in those treated with antipsychotics. No relevant differences were observed between patients receiving typical or atypical antipsychotics.

TITLE: Factores de riesgo cardiovascular en el tratamiento cronico con antipsicoticos en atencion primaria.Objetivo. Comparar la prevalencia de factores de riesgo cardiovascular (FRCV) y eventos vasculares en pacientes tratados con antipsicoticos, comparandolos con los no tratados. Sujetos y metodos. Estudio descriptivo transversal de pacientes atendidos en atencion primaria de la ciudad de Barcelona y tratados con antipsicoticos entre el 2008 y el 2010, comparandolos con una poblacion no tratada. Se registraron las variables antropometricas y clinicas y los FRCV. Se estudio por separado a pacientes adultos y ancianos, y a los tratados con antipsicoticos tipicos y atipicos. Resultados. Un total de 14.087 pacientes habian sido tratados con antipsicoticos (63,4% atipicos). El mas prescrito fue la risperidona. Se aparejaron 13.724 pacientes de la misma edad y genero, pero no tratados (n total = 27.811). Los tratados con antipsicoticos presentaron una prevalencia superior de obesidad (16,9% frente a 10,6%), tabaquismo (22,2% frente a 11,1%), diabetes mellitus (16% frente a 11,9%) y dislipemia (32,8% frente a 25,8%) (p < 0,001). La prevalencia de accidente vascular cerebral fue significativamente superior entre los tratados, tanto en los adultos (odds ratio = 2,33) como en los ancianos (odds ratio = 1,64). La prevalencia de cardiopatia isquemica fue similar en ambos grupos (odds ratio = 0,97). No se observaron diferencias significativas entre los tratados con un antipsicotico tipico o atipico. Conclusiones. Los pacientes tratados con antipsicoticos presentaron una mayor prevalencia de FRCV (diabetes, obesidad y tabaquismo). La presencia de ictus fue superior entre los tratados con antipsicoticos. No se detectaron diferencias importantes entre los pacientes tratados con antipsicoticos tipicos y atipicos.

[Perception in chronic illnesses: linguistic validation of the revised Illness Perception Questionnaire and the Brief Illness Perception Questionnaire for a Spanish population]. / Percepción en enfermedades crónicas: validación lingüística del Illness Perception Questionnaire Revised y del Brief Illness Perception Questionnaire para la población española.

OBJECTIVE: To obtain adapted versions for the Spanish population of a specific version of the Revised Illness Perception Questionnaire Revised (IPQ-R(e)) and the Brief Illness Perception Questionnaire (BIPQ), conceptually and linguistically equivalent to the original questionnaires. DESIGN: Cultural adaptation of questionnaires: linguistic validation. SETTING: Five primary care centres and a tertiary hospital. PARTICIPANTS: A multidisciplinary team was selected. A pilot study was performed on 30 people with chronic diseases (hypertension, diabetes mellitus, stable ischaemic heart disease, asthma, chronic obstructive pulmonary disease or osteoarthritis) METHOD: The project proceeded in 3 phases: I) Double forward-translation, II) Pilot study and III) Double back-translation. Three consensus meetings were held, one in each phase. Another meeting was held with one of the authors of the original questionnaire, where we knew about a short version, the BIPQ. It was also included in the study. Double forward and back-translations were performed and consensus was reached in both stages. RESULTS: Phase I) The majority of IPQ-R(e) items did not raise problems of translation. Phase II) In the pilot study we detected that patients found some difficulties in connection with the comprehension and self administration of some items. Therefore it was decided to employ trained interviewers, to introduce changes in the IPQ-R(e) format and vocabulary and to adapt a specific version with fewer items that solved most of these difficulties Phase III) Back-translations were very similar to the original version. The BIPQ forward and back-translation process caused no difficulties. CONCLUSIONS: After lingüistic validation, IPQ-R(e) and BIPQ versions conceptually and lingüistically equivalent to original instruments were obtained.

Knowledge and adherence to antihypertensive therapy in primary care: results of a randomized trial.

OBJECTIVES: To evaluate the efficacy of a healthcare education program for patients with hypertension. METHODS: A multicenter, prospective, cluster-randomized trial was conducted. Randomization was by primary care center; 18 of 36 urban primary care centers in Barcelona and its metropolitan area were randomized to the intervention group (IG) and 18 to the control group (CG). The study sample consisted of patients with hypertension (n=996; 515 in the IG and 481 in the CG) receiving outpatient treatment with antihypertensive drugs. The intervention consisted of personalized information by a trained nurse and written leaflets. Questionnaires on knowledge and awareness of hypertension and its medication, treatment adherence, healthy lifestyle habits, systolic and diastolic blood pressure, and body mass index were assessed at each visit, with a 12-month follow-up. An intention-to-treat analysis was applied. RESULTS: Knowledge of hypertension increased by 27.8% in the IG and by 18.5% in the CG, while that of medication increased by 10.1% in the IG and 5.5% in the CG. Treatment adherence measured by the Morisky-Green test increased by 9.6% (95% CI: 5.5-13.6) in the IG and 8.8% (95% CI: 4.9-12.6) in the CG. There were no differences in adherence on the other tests used. No differences were observed between the IG and CG in clinical variables such as blood pressure or BMI at the end of the trial. CONCLUSIONS: The educational intervention had no significant impact on patients' adherence to the medication.

[Prescribing non-steroidal antiinflammatory drugs and gastrointestinal protection in primary care]. / Adecuación de la prescripción de antiinflamatorios no esteroideos y gastroprotección en atención primaria.

OBJECTIVE: To assess whether prescribing non-steroidal anti-inflammatory drugs (NSAIDs) is adequate for gastrointestinal protection associated with NSAID use. DESIGN: Cross-sectional descriptive study. SETTING: Primary Care Centre in La Mina, Barcelona, Spain. PARTICIPANTS: A random sample of 500 patients, stratified by doctor was selected from a total of 4504 patients with an NSAID prescription. MAIN MEASUREMENTS: The dependent variables were the adequacy of NSAID prescription and gastrointestinal protection. The independent variables were: age, sex, concomitant treatments, type and number of NSAIDs. The variables were collected from the clinical history. RESULTS: The 476 patients included with an NSAID prescription had a mean age of 47.9 (18.1) years, and 63.4% were women. The NSAIDs most prescribed were, ibuprofen (60.3%), diclofenac (23.1%), and naproxen (4.0%). The most common reason for prescribing the NSAID was locomotor system pathology; 45.4%. The prescription was adequate in 44.7% (95% CI, 40.2-49.3), and inadequate in 23.5% (95% CI, 19.8-27.6). It was inadequate in 49.5% of patients over 65 years, while in under 65 year-olds 16.5% were inadequate. Gastrointestinal protection was inadequate in 28.2% (95% CI, 22.7-35.7); 12.8% excessive and 16% insufficient. In the multivariate analysis, the inadequacy probability of NSAIDs is 5.45 times greater in patients of 65 or more years than in younger patients. CONCLUSIONS: NSAID prescribing and gastrointestinal protection can be considered to be inadequate in 25% of patients. Advanced age is a major risk factor in inadequate prescribing.

Effectiveness of the combination of feedback and educational recommendations for improving drug prescription in general practice.

BACKGROUND: Although there is a great concern regarding rational use of drugs, the available evidence for the most appropriate strategies to improve prescribing is scarce. GOAL: The goal of this study was to evaluate the effectiveness of the combination of feedback of individualized prescribing data and educational recommendations for improving the quality of prescribing in general practice. METHOD: A quasiexperimental intervention study was conducted in which prescribing rates of 282 family physicians before and after the intervention were compared. Physicians assigned to the individualized feedback group (n = 195) received individual instruction with specific recommendations for improvement according to their baseline prescribing quality levels, whereas physicians in the minimal intervention group (n = 87) only received standard nonindividualized prescribing data for the practice group as a whole. RESULTS: A trend toward increasing high pharmacologic intrinsic value in both groups was observed. Overprescription of antibiotics showed a decrease in the individualized feedback group (P = 0.006) and it did not change in the minimal intervention group. A different trend in the values in each group was observed with nonsteroidal antiinflammatory drugs, although it was not statistically significant. Overprescription of antiulcerative agents decreased among physicians in the individualized feedback group (P = 0.003); however, there were not statistically significant differences as compared with the minimal intervention group. Changes in indicators of drug selection were more favorable for the group with individualized feedback, although no statistically significant differences were observed. Pharmaceutical expenditure increased significantly in the minimal intervention group as compared with the individualized feedback group, with an approximate difference of dollars 7.87 per inhabitant and trimester (P = 0.003). CONCLUSION: The intervention showed that improving the quality of prescribing was feasible, particularly in overprescribing, and was associated with considerable savings in pharmaceutical costs.