Cost-utility analysis of a consensus and evidence-based medication review to optimize and potentially reduce psychotropic drug prescription in institutionalized dementia patients.

BACKGROUND: Growing evidence shows the effects of psychotropic drugs on the evolution of dementia. Until now, only a few studies have evaluated the cost-effectiveness of psychotropic drugs in institutionalized dementia patients. This study aims to assess the cost-utility of intervention performed in the metropolitan area of Barcelona (Spain) (MN) based on consensus between specialized caregivers involved in the management of dementia patients for optimizing and potentially reducing the prescription of inappropriate psychotropic drugs in this population. This analysis was conducted using the Monitoring and Assessment Framework for the European Innovation Partnership on Active and Healthy Ageing (MAFEIP) tool. METHODS: The MAFEIP tool builds up from a variety of surrogate endpoints commonly used across different studies in order to estimate health and economic outcomes in terms of incremental changes in quality adjusted life years (QALYs), as well as health and social care utilization. Cost estimates are based on scientific literature and expert opinion; they are direct costs and include medical visits, hospital care, medical tests and exams and drugs administered, among other concepts. The healthcare costs of patients using the intervention were calculated by means of a medication review that compared patients' drug-related costs before, during and after the use of the intervention conducted in MN between 2012 and 2014. The cost-utility analysis was performed from the perspective of a health care system with a time horizon of 12 months. RESULTS: The tool calculated the incremental cost-effectiveness ratio (ICER) of the intervention, revealing it to be dominant, or rather, better (more effective) and cheaper than the current (standard) care. The ICER of the intervention was in the lower right quadrant, making it an intervention that is always accepted even with the lowest given Willingness to Pay (WTP) threshold value (€15,000). CONCLUSIONS: The results of this study show that the intervention was dominant, or rather, better (more effective) and cheaper than the current (standard) care. This dominant intervention is therefore recommended to interested investors for systematic application.

The Need to Develop Standard Measures of Patient Adherence for Big Data: Viewpoint.

Despite half a century of dedicated studies, medication adherence remains far from perfect, with many patients not taking their medications as prescribed. The magnitude of this problem is rising, jeopardizing the effectiveness of evidence-based therapies. An important reason for this is the unprecedented demographic change at the beginning of the 21st century. Aging leads to multimorbidity and complex therapeutic regimens that create a fertile ground for nonadherence. As this scenario is a global problem, it needs a worldwide answer. Could this answer be provided, given the new opportunities created by the digitization of health care? Daily, health-related information is being collected in electronic health records, pharmacy dispensing databases, health insurance systems, and national health system records. These big data repositories offer a unique chance to study adherence both retrospectively and prospectively at the population level, as well as its related factors. In order to make full use of this opportunity, there is a need to develop standardized measures of adherence, which can be applied globally to big data and will inform scientific research, clinical practice, and public health. These standardized measures may also enable a better understanding of the relationship between adherence and clinical outcomes, and allow for fair benchmarking of the effectiveness and cost-effectiveness of adherence-targeting interventions. Unfortunately, despite this obvious need, such standards are still lacking. Therefore, the aim of this paper is to call for a consensus on global standards for measuring adherence with big data. More specifically, sound standards of formatting and analyzing big data are needed in order to assess, uniformly present, and compare patterns of medication adherence across studies. Wide use of these standards may improve adherence and make health care systems more effective and sustainable.

Consensus and evidence-based medication review to optimize and potentially reduce psychotropic drug prescription in institutionalized dementia patients.

BACKGROUND: Dementia patients often show neuropsychiatric symptoms, known as behavioral and psychological symptoms of dementia (BPSD). These are a common motive for medical consultations, hospitalizations, and nursing home stays. Various studies have suggested that the high prevalence of psychotropic drug use to treat BPSD in institutionalized dementia patients may lead to impaired cognitive capacity, rigidity, somnolence, and other complications during the course of the illness. The aim of this study was to design a consensus-based intervention between care levels to optimize and potentially reduce prescription of psychotropic drugs in institutionalized patients with dementia and assess the changes occurring following its implementation. METHODS: Design: Prospective, quasi-experimental, pre/post intervention, multicenter study. SCOPE: 7 nursing homes associated with a single primary care team. INCLUSION CRITERIA: Institutionalized patients diagnosed with dementia and under treatment with 1 or more psychotropic drugs for at least 3 months. SAMPLE: 240 individuals; mean age, 87 years (SD: 6.795); 75% (180) women. INTERVENTION: Creation of evidence-based therapeutic guidelines for psychotropic drug use in the treatment of BPSD by consensus between reference professionals. Joint review (primary care and geriatric care nursing home professionals) of the medication based on the guidelines and focusing on individual patient needs. Primary variable: Number of psychotropic drugs used per patient. ASSESSMENT: Preintervention, immediate postintervention, and at 1 and 6 months. RESULTS: Overall, the number of psychotropic drugs prescribed was reduced by 28% (from 636 before to 458 after the intervention). The mean number of psychotropic drugs prescribed per patient decreased from 2.71 at baseline to 1.95 at 1 month postintervention and 2.01 at 6 months (p < 0.001 for both time points). Antipsychotics were the drug class showing the highest reduction rate (49.66%). Reintroduction of discontinued psychotropic drugs was 2% at 1 month following the intervention and 12% at 6 months. CONCLUSIONS: A consensus guidelines-based therapeutic intervention with a patient-centered medication review by a multidisciplinary team led to a reduction in prescription of psychotropic drugs in institutionalized dementia patients.

[Adequacy of treatment for osteoporosis in primary prevention. Quantitative and qualitative study]. / Adecuación del tratamiento de la osteoporosis en prevención primaria. Estudio cuantitativo y cualitativo.

OBJECTIVE: Quantitative study: To assess the prevalence of inadequacy of treatment for osteoporosis in primary prevention (OPP) in women aged 60-74years. Qualitative study: To evaluate the diagnostic and treatment criteria of the OPP and it's variability in primary care physicians (PC) and specialists. MATERIAL AND METHODS: Quantitative study: observational, cross-sectional and retrospective study. POPULATION: women aged 60-74years with active treatment for OPP (n=424) in May 2012. Inadequacy if they had ≤2 risk factors with a DXA or DXA T-score ≥-2.4. Qualitative study: Delphi technique (15items) and two rounds of consultation. PERIOD: March-April 2014. POPULATION: PC physicians, rheumatologists and orthopaedic surgeons (n=251). Random sampling. RESULTS: Quantitative study: degree of inadequacy is 63.4%. In 43.2% isn't mention a diagnosis of osteoporosis. In 82.3% there isn't mention of risk factors. TREATMENT: bisphosphonate 40.3% and calcium +vitaminD 47.9%. Qualitative study: 23% respond to the first round, and of these 67% the second round. Items with higher agreement were the important of the evaluation of risk factors for diagnosis and bisphosphonates for treatment. Items with fewer consensuses were using the FRAX and densitometry and treatment with only calcium +vitaminD. CONCLUSIONS: The percentage of inadequacy is high. The degree of registration in medical history is low. The Delphi method is useful for detecting discrepancies between recommendations of clinical practice guidelines and results.

Primary Care Records of Chronic-Disease Patient Adherence to Treatment.

The goal of managing adherence (AD) is to achieve better medication use by patients in order to maximize benefits and reduce risks. With the aim of improving treatment adherence by patients, we carried out a descriptive study to obtain information related to adherence management in primary care. Inclusion criteria were as follows: patients that had at least one record of any treatment adherence assessment variable. For those that had more than one recorded variable, we analyzed consistency across test results. For the comparative analysis of adherence records, patients were categorized into three groups on the basis of the healthcare unit that recorded the data: case management (CM), home care (HC), and primary care team (PCT). A total of 32,137 subjects met inclusion criteria; 79.56% of subjects were older than 65. As for the analysis of assessment records across care units, 69.73% of CM patients, 67.17% of HC patients, and 2.33% of PCT patients had adherence assessment records. CM units made a significantly greater number of records than HC units. We observed low adherence at a rate of 49.3% in the CM group, 31.91% in the HC group, and 17.58% in the PCT group. When more than one adherence variable was recorded, analysis revealed inconsistent test results or recorded variables in 9.06% of PCT cases, 14.83% of HC cases, and 20.47% of CM cases. The inconsistencies observed in records of adherence assessment and management across different care units reveal the huge variability that exists in managing and selecting a tool to assess adherence.

Persistence as a Robust Indicator of Medication Adherence-Related Quality and Performance.

Medication adherence is a priority for health systems worldwide and is widely recognised as a key component of quality of care for disease management. Adherence-related indicators were rarely explicitly included in national health policy agendas. One barrier is the lack of standardised adherence terminology and of routine measures of adherence in clinical practice. This paper discusses the possibility of developing adherence-related performance indicators highlighting the value of measuring persistence as a robust indicator of quality of care. To standardise adherence and persistence-related terminology allowing for benchmarking of adherence strategies, the European Ascertaining Barriers for Compliance (ABC) project proposed a Taxonomy of Adherence in 2012 consisting of three components: initiation, implementation, discontinuation. Persistence, which immediately precedes discontinuation, is a key element of taxonomy, which could capture adherence chronology allowing the examination of patterns of medication-taking behaviour. Advances in eHealth and Information Communication Technology (ICT) could play a major role in providing necessary structures to develop persistence indicators. We propose measuring persistence as an informative and pragmatic measure of medication-taking behaviour. Our view is to develop quality and performance indicators of persistence, which requires investing in ICT solutions enabling healthcare providers to review complete information on patients' medication-taking patterns, as well as clinical and health outcomes.

[Interactions between herbals medicines and drugs in chronic patients with complexity in primary care.] / Interacciones entre plantas medicinales y medicamentos en pacientes crónicos complejos en atención primaria.

OBJECTIVE: Taking medicinal herbs (MH) is frequent in patients and can cause interactions with others medications. Consumption of MH could be high in chronic patients with complexity (CPC) and produce interactions with drugs and knowledge about these drugs in primary health care (PC) professionals about these interactions is low. The aim was to measure the prevalence of potencial interactions between HM and drugs in CPC and evaluate the degree of knowledge of PC professionals. METHODS: Descriptive observational study in a population of CPC assigned to two PC teams. We investigated MH consumption through interviews and review potential drug interactions. We evaluated the degree of professionals knowledge through a survey designed for the study. A descriptive analysis was carried out. The Student-t test for paired data was used to compare the means.The statistical significance was established at p<0.05. RESULTS: The survey was distributed among 179 patients, mean age 76.9 years old (DE 9.7), 54.6% women. 62.57% (112) take MH. We detected 88 potentially relevant interactions in 51 patients (45.54%). Of the 219 professionals interviewed 51.1% consider that their knowledge about MH were low and 64,4% thought that was important to know the mH consumption of their patients. CONCLUSIONS: We detected a high prevalence of MH consumption in CPC and interactions between herbs medicinal and drugs. Lack of knowledge of PC health professionals is important. It's necessary to record this consumption in the medical history and improve the knowledge of professionals about MH to detect possible interactions, reduce the associated risk and improve the quality of care.

OBJETIVO: El consumo de plantas medicinales (PM) es frecuente en pacientes y puede causar interacciones con otros medicamentos. El consumo de PM puede ser alto en pacientes crónicos complejos (PCC) y producir interacciones con su medicación y el conocimiento sobre estos fármacos en profesionales sanitarios de Atención Primaria (AP) es bajo. El objetivo del estudio fue medir prevalencia de interacciones potenciales entre PM y medicamentos en PCC y evaluar grado de conocimiento de los profesionales de AP. METODOS: Estudio observacional descriptivo en una población de PCC asignados a dos equipos de AP. Se evaluaron el consumo de PM mediante entrevistas y se revisaron las interacciones potenciales con su medicación. Se evaluó el grado de conocimiento de los profesionales mediante una encuesta diseñada para el estudio. Se realizó un análisis descriptivo, La comparación de medias se realizó con la prueba t de Student. La significación estadística se estableció en p<0,05. RESULTADOS: La encuesta se distribuyó entre 179 pacientes, con una edad media de 76,9 años (DE 9,7), 54,6% mujeres. El 62,57% (112) consumieron PM. Detectamos 88 interacciones potencialmente relevantes en 51 pacientes (45,54%). De los 219 profesionales entrevistados el 51,1% consideraron que sus conocimientos sobre PM eran bajos y 64,4% pensaron que era importante conocer el consumo de PM de sus pacientes. CONCLUSIONES: Detectamos una alta prevalencia del consumo de PM en PCC y de interacciones entre PM y medicamentos. La falta de conocimientos de los profesionales sanitarios es importante. Es necesario registrar en la historia clínica este consumo y mejorar el conocimiento de los profesionales de AP sobre PM para detectar posibles interacciones, disminuir el riesgo asociado y mejorar la calidad asistencial.

A retrospective cohort study of risk factors for mortality among nursing homes exposed to COVID-19 in Spain.

Long-term care (LTC) facilities have shown remarkably high mortality rates during the coronavirus disease 2019 (COVID-19) outbreak in many countries1, and different risk factors for mortality have been identified in this setting2-5. Using facilities as the unit of analysis, we investigated multiple variables covering facility characteristics and socioeconomic characteristics of the geographic location to identify risk factors for excess mortality from a comprehensive perspective. Furthermore, we used a clustering approach to detect patterns in datasets and generate hypotheses regarding potential relationships between types of nursing homes and mortality trends. Our retrospective analysis included 167 nursing homes providing LTC to 8,716 residents during the COVID-19 outbreak in Catalonia (northeast Spain). According to multiple regression analysis, COVID-19-related and overall mortality at the facility level were significantly associated with a higher percentage of patients with complex diseases, lower scores on pandemic preparedness measures and higher population incidence of COVID-19 in the surrounding population. When grouping nursing homes into eight clusters based on common features, we found higher mortality rates in four clusters, mainly characterized by a higher proportion of residents with complex chronic conditions or advanced diseases, lower scores on pandemic preparedness, being located in rural areas and larger capacity, respectively.