Effect of GP visits in the compliance of preventive services: a cross-sectional study in Europe.

BACKGROUND: Performing cardiovascular and cancer screenings in target populations can reduce mortality. Visiting a General Practitioner (GP) once a year is related to an increased likelihood of preventive care. The aim of this study was to analyse the influence of visiting a GP in the last year on the delivery of preventive services based on sex and household income. METHODS: Cross-sectional study using data collected from the European Health Interview Survey 2013-2015 of individuals aged 40-74 years from 29 European countries. The variables included: sociodemographic factors (age, sex, and household income (HHI) quintiles [HHI 1: lowest income, HHI 5: more affluent]), lifestyle factors, comorbidities, and preventive care services (cardiometabolic, influenza vaccination, and cancer screening). Descriptive statistics, bivariate analyses and multilevel models (level 1: citizen, level 2: country) were performed. RESULTS: 242,212 subjects were included, 53.7% were female. The proportion of subjects who received any cardiometabolic screening (92.4%) was greater than cancer screening (colorectal cancer: 44.1%, gynaecologic cancer: 40.0%) and influenza vaccination. Individuals who visited a GP in the last year were more prone to receive preventive care services (cardiometabolic screening: adjusted OR (aOR): 7.78, 95% CI: 7.43-8.15; colorectal screening aOR: 1.87, 95% CI: 1.80-1.95; mammography aOR: 1.76, 95% CI: 1.69-1.83 and Pap smear test: aOR: 1.89, 95% CI:1.85-1.94). Among those who visited a GP in the last year, the highest ratios of cardiometabolic screening and cancer screening benefited those who were more affluent. Women underwent more blood pressure measurements than men regardless of the HHI. Men were more likely to undergo influenza vaccination than women regardless of the HHI. The highest differences between countries were observed for influenza vaccination, with a median odds ratio (MOR) of 6.36 (under 65 years with comorbidities) and 4.30 (over 65 years with comorbidities), followed by colorectal cancer screening with an MOR of 2.26. CONCLUSIONS: Greater adherence to preventive services was linked to individuals who had visited a GP at least once in the past year. Disparities were evident among those with lower household incomes who visited a GP. The most significant variability among countries was observed in influenza vaccination and colorectal cancer screening.

Impact of hypertension diagnosis on morbidity and mortality: a retrospective cohort study in primary care.

BACKGROUND: Hypertension is responsible for a huge burden of disease. The aim of this study was to evaluate the impact of newly diagnosed hypertension on the occurrence of kidney or cardiovascular events (K/CVEs) and on mortality among community dwellers. METHODS: Retrospective cohort study, conducted from January, 2007, to December, 2018. All patients (age > 18) newly diagnosed with hypertension and no previous K/CVEs in 2007 and 2008, in the primary care centers of Madrid (Spain) (n = 71,770), were enrolled. The control group (n = 72,946) included patients without hypertension, matched by center, sex and age. The occurrence of kidney or CV events, including mortality from these causes and total mortality were evaluated using Cox regression and multistate models. Data were collected from three sources: personal data from administrative records, clinical data from medical records, and mortality data from regional and national databases. RESULTS: The median follow-up was 138.61 months (IQR: 124.68-143.97 months). There were 32,896 K/CVEs (including 3,669 deaths from these causes) and 12,999 deaths from other causes. Adjusted for sex, smoking, diabetes and socioeconomic status, K/CVEs HR was 4.36 (95% CI: 3.80-5.00) for diagnoses before 45 years of age, 2.45(95% CI: 2.28- 2.63) for diagnosis between 45 to 54 years, and HR decreased to 1.86 (95% CI: 1.64-210) for diagnoses over age 85. Total mortality risk was only higher for hypertension diagnosed before 55 years of age (HR: 2.47, 95% CI: 1.90-3.19 for ages 18 to 44; and HR: 1.14, 95% CI: 1.02-1.28 for ages 45 to 54). CONCLUSION: The diagnosis of hypertension in the community environment, in patients without evidence of previous kidney or CV disease, is associated with a large increase in the risk of K/CVEs, but especially in individuals diagnosed before the age of 55. This diagnosis is only associated with an increase in kidney or cardiovascular mortality or overall mortality when it occurs before age 55.

Sex and income inequalities in preventive services in diabetes.

BACKGROUND: Cancer preventive services (gynaecological cancer screening, colon cancer screening) and cardiometabolic screening are recommended by guidelines to individuals. People with diabetes were less likely to receive them than those without diabetes in some studies. OBJECTIVES: To analyse differences in the coverage of preventive services in people with diabetes compared to non-diabetic individuals and in people with diabetes according to sex and household income. METHODS: We analysed data collected from the European Health Interview Survey 2013-2015, including individuals aged 40-74 (n = 179,318), 15,172 with diabetes from 29 countries. The income of a household (HHI) was described in quintiles. The relationship between the coverage of preventive services (cardiometabolic, vaccination, cancer screening) and sociodemographic characteristics was analysed with multiple logistic regression. RESULTS: Women comprised 53.8% of the total and 40% were 60-74 years. People with diabetes compared to those without diabetes had higher reported coverage of cardiometabolic screening (98.4% vs. 90.0% in cholesterol measurement; 97.0% vs. 93.6% in blood pressure measurement), colorectal cancer screening (27.1% vs. 24.6%) but lower coverage of gynaecological cancer screening (mammography: 29.2% vs. 33.5%, pap smear test: 28.3% vs. 37.9%). Among diabetic patients, women were less likely to receive cholesterol screening (OR = 0.81; 95% CI: 0.72-0.91) and colon cancer screening (OR = 0.79; 95% CI: 0.73-0.86) compared to men. Being affluent was positively associated with receiving cardiometabolic screening and mammography in diabetic patients. CONCLUSION: People with diabetes reported higher coverage of preventive services except gynaecological cancer screening. Disparities were found in diabetes among women and less affluent individuals.

[What have we missed because of COVID-19? Missed diagnoses and delayed follow-ups. SESPAS Report 2022]. / ¿Qué hemos dejado de atender por la COVID-19? Diagnósticos perdidos y seguimientos demorados. Informe SESPAS 2022.

The COVID-19 pandemic and the associated public health emergency have affected patients and health services in non-COVID-19 pathologies. Several studies have shown its dissociation from health services, with a decrease in emergency department visits, in hospital admissions for non-COVID-19 pathologies, as well as in the reported weekly incidence of acute illnesses and new diagnoses in primary care. In parallel, the pandemic has had direct and indirect effects on people with chronic diseases; the difficulties in accessing health services, the interruption of care, the saturation of the system itself and its reorientation towards non-face-to-face formats has reduced the capacity to prevent or control chronic diseases. All this has also had an impact on the different areas of people's lives, creating new social and economic difficulties, or aggravating those that existed before the pandemic. All these circumstances have changed with each epidemic wave. We present a review of the most relevant studies that have been analyzing this problem and incorporate as a case study the results of a retrospective observational study carried out in Primary Care in the Madrid Health Service, which provides health coverage to a population of more than 6 million people, and whose objective was to analyze the loss of new diagnoses in the most prevalent pathologies such as common mental health problems, cardiovascular and cerebrovascular diseases, type 2 diabetes, chronic obstructive pulmonary disease, and breast and colon tumors, in the first and second waves. Annual incidence rates with their confidence interval were calculated for each pathology and the monthly frequency of new codes recorded between 1/01/2020 and 12/31/2020 was compared with the monthly mean of observed counts for the same months between 2016 and 2019. The annual incidence rate for all processes studied decreased in 2020 except for anxiety disorders. Regarding the recovery of lost diagnoses, heart failure is the only diagnosis showing an above-average recovery after the first wave. To return to pre-pandemic levels of diagnosis and follow-up of non-COVID-19 pathology, the healthcare system must reorganize and contemplate specific actions for the groups at highest risk.

Effectiveness of the MULTIPAP Plus intervention in youngest-old patients with multimorbidity and polypharmacy aimed at improving prescribing practices in primary care: study protocol of a cluster randomized trial.

BACKGROUND: The progressive ageing of the population is leading to an increase in multimorbidity and polypharmacy, which in turn may increase the risk of hospitalization and mortality. The enhancement of care with information and communications technology (ICT) can facilitate the use of prescription evaluation tools and support system for decision-making (DSS) with the potential of optimizing the healthcare delivery process. OBJECTIVE: To assess the effectiveness and cost-effectiveness of the complex intervention MULTIPAP Plus, compared to usual care, in improving prescriptions for young-old patients (65-74 years old) with multimorbidity and polypharmacy in primary care. METHODS/DESIGN: This is a pragmatic cluster-randomized clinical trial with a follow-up of 18 months in health centres of the Spanish National Health System. Unit of randomization: family physician. Unit of analysis: patient. POPULATION: Patients aged 65-74 years with multimorbidity (≥ 3 chronic diseases) and polypharmacy (≥ 5 drugs) during the previous 3 months were included. SAMPLE SIZE: n = 1148 patients (574 per study arm). INTERVENTION: Complex intervention based on the ARIADNE principles with three components: (1) family physician (FP) training, (2) FP-patient interview, and (3) decision-making support system. OUTCOMES: The primary outcome is a composite endpoint of hospital admission or death during the observation period measured as a binary outcome, and the secondary outcomes are number of hospital admission, all-cause mortality, use of health services, quality of life (EQ-5D-5L), functionality (WHODAS), falls, hip fractures, prescriptions and adherence to treatment. Clinical and sociodemographic factors will be explanatory variables. STATISTICAL ANALYSIS: The main result is the difference in percentages in the final composite endpoint variable at 18 months, with its corresponding 95% CI. Adjustments by the main confounding and prognostic factors will be performed through a multilevel analysis. All analyses will be carried out in accordance to the intention-to-treat principle. DISCUSSION: It is important to prevent the cascade of negative health and health care impacts attributable to the multimorbidity-polypharmacy binomial. ICT-enhanced routine clinical practice could improve the prescription process in patient care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04147130 . Registered on 22 October 2019.

How to Improve Healthcare for Patients with Multimorbidity and Polypharmacy in Primary Care: A Pragmatic Cluster-Randomized Clinical Trial of the MULTIPAP Intervention.

(1) Purpose: To investigate a complex MULTIPAP intervention that implements the Ariadne principles in a primary care population of young-elderly patients with multimorbidity and polypharmacy and to evaluate its effectiveness for improving the appropriateness of prescriptions. (2) Methods: A pragmatic cluster-randomized clinical trial was conducted involving 38 family practices in Spain. Patients aged 65-74 years with multimorbidity and polypharmacy were recruited. Family physicians (FPs) were randomly allocated to continue usual care or to provide the MULTIPAP intervention based on the Ariadne principles with two components: FP training (eMULTIPAP) and FP patient interviews. The primary outcome was the appropriateness of prescribing, measured as the between-group difference in the mean Medication Appropriateness Index (MAI) score change from the baseline to the 6-month follow-up. The secondary outcomes were quality of life (EQ-5D-5 L), patient perceptions of shared decision making (collaboRATE), use of health services, treatment adherence, and incidence of drug adverse events (all at 1 year), using multi-level regression models, with FP as a random effect. (3) Results: We recruited 117 FPs and 593 of their patients. In the intention-to-treat analysis, the between-group difference for the mean MAI score change after a 6-month follow-up was -2.42 (95% CI from -4.27 to -0.59) and, between baseline and a 12-month follow-up was -3.40 (95% CI from -5.45 to -1.34). There were no significant differences in any other secondary outcomes. (4) Conclusions: The MULTIPAP intervention improved medication appropriateness sustainably over the follow-up time. The small magnitude of the effect, however, advises caution in the interpretation of the results given the paucity of evidence for the clinical benefit of the observed change in the MAI. Trial registration: Clinicaltrials.gov NCT02866799.

Trends in urinary tract infection hospitalization in older adults in Spain from 2000-2015.

OBJECTIVE: To analyze trends in urinary tract infection hospitalization (cystitis, pyelonephritis, prostatitis and non-specified UTI) among patients over 65 years in Spain from 2000-2015. METHODS: We conducted a retrospective observational study using the Spanish Hospitalization Minimum Data Set (CMBD), with codifications by the International Classification of Diseases (ICD-9). We collected data on sex, age, type of discharge, main diagnosis, comorbid diagnosis, length of stay, and global cost. All the hospitalizations were grouped by age into three categories: 65-74 years old, 75-84 years old, and 85 years old and above. In the descriptive statistical analysis, crude rates were defined as hospitalizations per 1,000 inhabitants aged ≥65. To identify trends over time, we performed a Joinpoint regression. RESULTS: From 2000-2015, we found 387,010 hospitalizations coded as UTIs (54,427 pyelonephritis, 15,869 prostatitis, 2643 cystitis and 314,071 non-specified UTI). The crude rate of hospitalization for UTIs between 2000 and 2015 ranged from 2.09 in 2000 to 4.33 in 2015 Rates of hospitalization were higher in men than in women, except with pyelonephritis. By age group, higher rates were observed in patients aged 85 years or older, barring prostatitis-related hospitalizations. Joinpoint analyses showed an average annual percentage increase (AAPC) in incidence rates of 4.9% (95% CI 3.2;6.1) in UTI hospitalizations. We observed two joinpoints, in 2010 and 2013, that found trends of 5.5% between 2000 and 2010 (95% CI 4.7;6.4), 1.5% between 2010 and 2013 (95% CI -6.0;9.6) and 6.8% between 2013 and 2015 (95% CI -0.3;14.4). CONCLUSIONS: The urinary infection-related hospitalization rate in Spain doubled during the period 2000-2015. The highest hospitalization rates occurred in men, in the ≥85 years old age group, and in non-specified UTIs. There were increases in all types of urinary tract infection, with non-specified UTIs having the greatest growth. Understanding these changing trends can be useful for health planning.

[Chronic diseases and multimorbidiy in patients with toxic oil syndrome: a comparative study with general population.] / Enfermedades crónicas y multimorbilidad en pacientes con síndrome de aceite tóxico: estudio comparativo con población general.

OBJECTIVE: Toxic oil syndrome is a multisystemic disease that arose in 1981 due to the ingestion of contaminated rapeseed oil. Previous studies have found a higher prevalence of cardiovascular risk factors in these patients. The aim of this study was to analyze the differences in the prevalence of chronic diseases among a population affected by Toxic oil syndrome compared with a reference population in the Community of Madrid. METHODS: Cross-sectional observational study of patients with a registry diagnosed with Toxic oil syndrome in the primary care medical record and a reference sample without Toxic oil syndrome matched by age group and sex. Sociodemographic variables, cardiovascular risk factors, cardiovascular and cerebrovascular disease, anxiety, depression, asthma, chronic obstructive pulmonary disease, and low back pain, and multimorbidity (≥2 chronic diseases) were assesed. Descriptive and multivariate analysis was performed to study the association between morbidity and Toxic oil syndrome. RESULTS: 3,527 patients (1,394 Toxic oil syndrome) were included with a mean age of 66 (SD14) years, 71% women. Patients with a diagnosis of SAT were more likely to present multimorbidity (OR 1.36; 95%CI: 1.10-1.45), diabetes (OR 1.55; 95%CI: 1.29-1.86), complicated hypertension (OR 1.77; IC95%: 1.31-2.39), heart attack (OR 2.23; 95%CI: 1.47-3.38), depression (OR 1.39; 95%CI: 1.17-1.66) and asthma (OR 1.56; 95%CI: 1.23-1.97). The prevalence of anxiety was lower in TOS (OR 0.35; 95% CI: 0.18-0.69) as well as low back pain (OR 0.77; 95%CI: 0.65-0.91). CONCLUSIONS: Patients with toxic oil syndrome have a higher frequency of chronic diseases and mutimorbidity compared to the general population of the same sex and age.

OBJETIVO: El síndrome del aceite tóxico es una enfermedad multisistémica que surgió en 1981 debido a la ingesta de aceite de colza contaminado. Estudios previos han encontrado en estos pacientes una mayor prevalencia de factores de riesgo cardiovascular. El objetivo de este estudio fue analizar las posibles diferencias en prevalencia de morbilidad crónica entre una población afectada por síndrome de aceite tóxico comparada con una población de referencia en la Comunidad de Madrid. METODOS: Estudio observacional transversal de pacientes diagnosticados de síndrome del aceite tóxico en la historia clínica de atención primaria y una muestra de referencia sin síndrome del aceite tóxico apareados por grupo de edad y sexo. Se recogieron variables sociodemográficas, factores de riesgo cardiovascular, enfermedad cardiovascular y cerebrovascular, ansiedad, depresión, asma, enfermedad pulmonar obstructiva crónica, lumbalgia y multimorbilidad (≥2 enfermedades crónicas). Se realizó análisis descriptivo y multivariante para estudiar la asociación entre morbilidad y síndrome del aceite tóxico. RESULTADOS: Se incluyeron 3.527 pacientes (1.394 SAT) con una edad media de 66 (14) años, el 71% mujeres. Los pacientes con diagnóstico de síndrome del aceite tóxico tuvieron mayor probabilidad de presentar multimorbilidad (OR 1,36; IC95%: 1,10-1,45), diabetes (OR 1,55; IC95%: 1,29-1,86), hipertensión arterial complicada (OR 1,77; IC95%: 1,31-2,39), infarto (OR 2,23; IC95%: 1,47-3,38), depresión (OR 1,39; IC95%: 1,17-1,66) y asma (OR 1,56; IC95%: 1,23-1,97). La prevalencia de ansiedad fue menor (OR 0,35; IC95%: 0,18-0,69) así como de lumbalgia (OR 0,77; IC95%: 0,65-0,91). CONCLUSIONES: Los pacientes con síndrome de aceite tóxico presentan una mayor frecuencia de enfermedades crónicas y mutimorbilidad comparado con población general del mismo sexo y edad.

Breaking Barriers: Prospective Study of a Cohort of Advanced Chronic Obstructive Pulmonary Disease Patients To Describe Their Survival and End-of-Life Palliative Care Requirements.

BACKGROUND AND AIM: Consensus has been reached on the need to integrate palliative care in the follow-up examinations of chronic obstructive pulmonary disease (COPD) patients. We analyzed the survival from the initiation of follow-up by a palliative home care team (PHCT) and described the needs and end-of-life process. SETTING AND DESIGN: This study was a prospective observational cohort study of advanced COPD patients referred to a PHCT. Sociodemographic variables, survival from the start date of follow-up using the Kaplan-Meier model, health resource consumption, perceived quality of life, main symptomatology, opioid use, and advanced care planning (ACP) were analyzed. RESULTS: Sixty patients were included. The median survival was 8.3 months. Forty-two patients died at the end of the study (85% at home or in palliative care units). The most frequent cause of death was respiratory failure in 39 patients (93%), with 29 of these patients requiring sedation (69%). Dyspnea at rest, with an average of 5 (standard deviation [SD] 2) points, was the main symptom. Fifty-five patients (91%) required opioids for symptom control. The median score in the St. George's Respiratory Questionnaire was 72 (SD 13). The mean number of visits by the home team was 7 (SD 6.5). The mean number of admissions during the monitoring period was 1.5 (SD 0.15). CONCLUSIONS: The characteristics of the cohort appear suitable for a PHCT. The follow-up care provided by our multidisciplinary unit decreased the number of hospitalizations, favored the development of ACP, and enabled death at home or in palliative care units.

Risk-Taking Attitudes of Patients who Seek Health Care: An Exploratory Approach through Lottery Games. / La valoración de la actitud ante el riesgo en personas que demandan cuidados en salud: una aproximación mediante juegos de loterías utilizando generalized estimating equations.

BACKGROUND: The characterization of the risk-taking attitude of individuals may be useful for planning health care interventions. It has been attempted to study expressions of risk-taking attitude and evaluate characteristics of a standard lottery game in a population that seeks health care to elicit these attitudes. METHODS: Multicentric cross-sectional study. Demographic and socioeconomic characteristics, quality of life (EuroQol-5D), and health risk behaviors were collected from 662 users of 23 health centers selected by random sampling. Risk-taking attitude was evaluated by means of a self-evaluation scale and two lottery games, (L1 and L2; L2 included the possibility of economic losses). Generalized estimating equations (GEE) explicative models were used to evaluate the variability of risk-taking attitude. RESULTS: Nineteen percent out of interviewed people (CI95%: 15.6-22.6%) expressed a high risk appetite, but only 10.0% (CI95% 7.0 to 13.0) were classified as risk-seeking by L2. It was found association between increased risk appetite and having a better perception of health status (0.110, CI95%: 0,007-0,212) or a higher income (0.010, CI95%: 0.017- 0.123) or smoking status (0.059, CI95%: 0.004- 0.114). Being Spanish was associated with lower risk appetite (-0.105, CI95%: -0.005 --0.205), as being over 65 (-0.031, CI95%:- 0.061- -0.001) or a woman (-0.038, CI95%:-0.064- -0.012). The intraclass correlation coefficient for self-evaluation scale was 0.511 (95% CI: 0.372 to 0.629), 0.571 (95% CI: 0.441 to 0.678) for L1 and 0.349 (95% CI: 0.186-0.493) to L2. CONCLUSIONS: People who seek health care express certain inclination to risk, but this feature is attenuated when methodologies involving losses are used. Risk appetite seems greater in young people, males, people with better health, or more income, and in immigrants. Lottery games such as the proposed ones are a simple and useful tool to estimate individuals' inclination to risk.

OBJETIVO: La caracterización de la actitud ante el riesgo puede ser útil en la planificación de las intervenciones sanitarias. El objetivo fue estudiar la actitud ante el riesgo de una población que demanda cuidados de salud y evaluar la capacidad de un juego de loterías para evidenciar dicha actitud. METODOS: Estudio multicéntrico transversal. Se recogieron características demográficas, socioeconómicas, de calidad de vida y conductas de riesgo en salud de 662 personas usuarias de 23 centros de salud seleccionadas mediante muestreo aleatorio. La actitud ante el riesgo se evaluó mediante una escala subjetiva y mediante dos juegos de azar (L1 y L2; L2 incluía la posibilidad de pérdidas económicas). Se realizaron modelos explicativos para valorar la variabilidad de la propensión al riesgo utilizando Generalized Estimating Equations (GEE). RESULTADOS: El 19,1% (IC95%:15,6-22,6%) de los sujetos expresaron una propensión al riesgo alta, el 10,0% (IC95%:7,0-13,0) fueron clasificados como propensos al riesgo con L2. Se encontró asociación entre una mayor propensión al riesgo y tener mejor percepción del estado de salud (0,110; IC95%:0,007- 0,212) o mayor renta (0,010; IC95%: 0,017- 0,123) o ser fumador (0,059; IC95%: 0,004-0,114). Ser español se relacionaba con menor propensión al riesgo (-0,105; IC95%: -0,205- -0,005), al igual que ser mayor de 65 años (-0,031; IC95%:-0,061- -0,001) o ser mujer (-0,038, IC95%:-0,064- -0,012). El coeficiente de correlación intraclase para la escala subjetiva fue 0,511 (IC95%:0,372-0,629), 0,571 (IC95%:0,441-0,678) para L1 y 0,349 (IC95%:0,186-0,493) para L2. CONCLUSIONES: Las personas que demandan cuidados de salud presentan con frecuencia propensión al riesgo, la cual se atenúa cuando se caracteriza mediante metodologías que implican pérdidas. La propensión al riesgo parece mayor en personas jóvenes, varones, con mejor estado de salud, con mayor renta y en inmigrantes.

Study CAMBIMED: Effects of changes in medication appearance on safety of antihypertensive and hypolipidemic treatments in chronic patients older than 65 years in primary health care.

BACKGROUND: Different studies have investigated the effects that changes in drug appearance have on the control of chronic diseases and drug safety. The main objective of the proposed study is to evaluate if changes in the appearance of the packaging and presentation of drugs having the same active ingredient are related to a decrease in adherence and an increase in usage errors for chronic treatment using antihypertensive (enalapril and amlodipine) and hypolipidemic agents (simvastatin) in patients ≥65 years old, over a one-year follow-up period. METHODS/DESIGN: We propose a multicentric observational longitudinal cohort study with a one-year follow-up period in 8 primary health care centers (PHCC) in the Community of Madrid. 259 patients who are ≥65 years old, hypertensive and/or dyslipidemic, undergoing treatment with enalapril and/or amlodipine and/or simvastatin, and under formal follow-up of chronic patients in primary health care will be selected by simple random sampling. The main outcome variable will be a final combined variable (adherence and medication usage errors). Other included variables will be: sociodemographic and clinical variables of the patient, degree of disease control, drug taken, number of changes in the appearance of each drug by the pharmacy, and the type and frequency of both avoidable and non-avoidable adverse effects during the follow-up period. A descriptive and a multivariate analysis of the variables will be carried out by means of a logistic regression model, using the final combined variable as the dependent variable (error and/or inadequate usage of the drug), and variables shown to be related to it during the bivariate analysis as the independent variables. DISCUSSION: For drugs of the same active ingredient, the effect that different package appearances and presentation may have on the safety of patients undergoing chronic treatments is unknown under the new legislative framework. There are various initiatives that promote the iso-appearance of drugs: "If they are the same, make them look the same". It is to be expected that older, multi-medicated patients with chronic pathologies will be the ones under a greater risk of suffering from this problem.