Preventing hospital admissions by reviewing medication (PHARM) in primary care: an open controlled study in an elderly population.

WHAT IS KNOWN AND OBJECTIVE: Limited and conflicting evidence exists on the effect of a multicomponent pharmaceutical care intervention (i.e. medication review, involving collaboration between general practitioners (GPs), pharmacists and patients) on medication-related hospitalizations, survival, adverse drug events (ADEs) and quality of life. We aimed to investigate the effect of a multicomponent pharmaceutical care intervention on these outcomes. METHODS: An open controlled multicentre study was conducted within primary care settings. Patients with a high risk on medication-related hospitalizations based on old age, use of five or more medicines, non-adherence and type of medication used were included. The intervention consisted of a patient interview, a review of the pharmacotherapy and the execution and follow-up evaluation of a pharmaceutical care plan. The patient's own pharmacist and GP carried out the intervention. The control group received usual care and was cared for by a GP other than the intervention GP. The primary outcome of the study was the frequency of hospital admissions related to medication within the study period of 12 months for each patient. Secondary outcomes were survival, quality of life and ADEs. RESULTS AND DISCUSSION: 364 intervention and 310 control patients were included. Less medication-related hospital admissions were found in the intervention group (n = 6; 1·6%) than in the control group (n = 10; 3·2%) but the overall effect was not statistically significant (hazard ratio (HR) 0·50, 95% confidence interval (CI) 0·12-1·59). The secondary outcomes were not statistically significantly different either. The study was underpowered, which may explain the negative results. A post hoc analysis showed that the effect of the intervention was statistically significant for patients with five diseases or more: five diseases, HR 0·28 (95% bootstrap CI: 0·056-0·73) and eight diseases, HR 0·11 (95% CI: 0·013-0·34). WHAT IS NEW AND CONCLUSION: A multicomponent pharmaceutical care intervention does not prevent medication-related hospital admissions. Whether this is true for such interventions in general is unknown, because the PHARM study was underpowered. The intervention may significantly reduce medication-related hospitalizations in patients with five or more comorbidities, but this is only based on a post hoc analysis and thus needs confirmation in large controlled trials.

[Summary of the practice guideline 'Bacterial skin infections' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Bacteriële huidinfecties' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The revised practice guideline 'Bacterial skin infections' developed by the Dutch College of General Practitioners replaces the previous practice guideline from 1998. Most bacterial skin infections can be diagnosed based on the patient history and clinical findings. Skin cultures and serologic analysis (in the case oferythema migrans) are not necessary. Exceptions are made for patients with bacterial skin infection and a high risk of MRSA involvement, or if nasal treatment is indicated for patients with recurring furunculosis. A superficial skin infection can be treated with local therapy. In case of a deep skin infection, oral antibiotics or surgical intervention is recommended. Antibiotic prophylaxis after a tick bite is not recommended. Erysipelas is considered a specific type of cellulitis and is treated as such.

[Summary of the practice guideline 'Urinary incontinence' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Incontinentie voor urine' (eerste herziening) van het Nederlands Huisartsen Genootschap.

Two years after revision of the practice guideline 'Urinary incontinence' from the Dutch College of General Practitioners, it is time for a summary of the most important changes. The use of a bladder diary is recommended. In primary care, a stress test does not provide more information than history taking. Routine urodynamic testing is not indicated for patients presenting to their general practitioner with urinary incontinence. Treatment of stress, urge and mixed incontinence can usually be commenced in primary care; pelvic floor exercises and bladder training are preferred. If bladder training is not effective for urge incontinence, anticholinergic drugs should be considered. The use of oral and vaginal oestrogens and flavoxate is no longer recommended.

[Summary of the practice guideline 'Sore throat' (second revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Acute keelpijn' (tweede herziening) van het Nederlands Huisartsen Genootschap.

The second version of the practice guideline 'Sore throat' has been updated from the 1999 version. --Infections of the throat generally cure spontaneously within 7 days. In most cases the sore throat is caused by a virus. Group A beta-haemolytic streptococci (GABHS) are the most important bacterial cause ofa sore throat. --In diagnostics, the main focus is placed on evaluating how sick the patient is in general. --In adolescents who have had a sore throat for more than 7 days, the possibility of mononucleosis infectiosa should be borne in mind. This diagnosis can be verified by a test for IgM against Epstein-Barr-virus. --Additional investigations to detect GABHS are not recommended. --Prescribing antibiotics is only recommended for patients who have a severe throat infection or an increased risk of complications. Pheneticillin or phenoxymethylpenicillin remains first choice. --Referral for tonsillectomy should meet the following criteria: 5 or more episodes of sore throat per year or 3 or more episodes per year in the last 2 years.

[Summary of the practice guideline 'Asthma in adults' (second revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'astma bij volwassenen' (tweede herziening) van het Nederlands Huisartsen Genootschap.

The practice guideline 'Asthma in adults' from the Dutch College of General Practitioners was revised on the basis of the developments over the last years. The most important modifications are as follows: - 'Asthma with persistent obstruction' was replaced by the double diagnosis 'Asthma and COPD'. - The prednisone test to distinguish asthma from chronic obstructive pulmonary disease (COPD) is no longer recommended. - Spirometry is currently preferred for the diagnosis of asthma. An increase of the forced expiratory volume in 1 second (FEV1) of > or = 12% compared with baseline or in case of a smaller lung volume (FEV1 < 1.67 liters) of > or = 200 ml (therefore, no longer > or = 9% of the predicted value) supports the diagnosis 'asthma'. - As of 2007, the guidelines from the Dutch College of General Practitioners for COPD and asthma in adults are divided into two separate practice guidelines: the practice guideline 'COPD' and the practice guideline 'Asthma in adults'.

[Summary of the practice guideline 'Urolithiasis' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Urinesteenlijden' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The Dutch College of General Practitioners has revised the practice guideline 'Urolithiasis'. In the acute phase, violent colic pain is treated with diclophenac or morphine. In the post-acute phase, imaging diagnostics are performed. Initially this is ultrasound examination and, ifindicated, an x-ray of the abdomen and at a later stage, a CT scan. The recommendation to consider the use oftamsulosin in the post acute phase is new. This alpha-1 blocking agent can enhance expulsion of the stone and contribute to the relief of pain.

[Summary of the practice guideline 'Children with fever' (Second Revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Kinderen met koorts' (tweede herziening) van het Nederlands Huisartsen Genootschap.

In the second revision of the practice guideline 'Children with fever' from the Dutch College of General Practitioners, due to its greater reliability rectal measurement of the body temperature above measurement with an ear thermometer is recommended in the case of children younger than 3 months, where the classical signs of infectious diseases are often less apparent. The practice guideline distinguishes between alarm signs which can be recognised by the parents and alarm symptoms which can be diagnosed by the physician during a physical examination. In children younger than 2 years who are feverish with no apparent cause, the urine should be examined at the first consultation. An X-ray of the thorax of a child with fever is only necessary if pneumonia is suspected. As it is not possible at an early stage to identify serious cases among children who are feverish without an apparent cause, these children should be re-examined within 24-48 hours. Children with fever who are younger than 3 months should be referred to a paediatrician. A typical febrile seizure is harmless, nevertheless an underlying meningitis should be excluded.

[Summary of the practice guideline 'Viral hepatitis and other liver diseases' (second revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Virushepatitis en andere leveraandoeningen' (tweede herziening) van het Nederlands Huisartsen Genootschap.

The revised Dutch College of General Practitioners' practice guideline 'Viral hepatitis and other liver diseases' offers advice in the diagnosis and management of viral hepatitis A, B and C and other liver diseases. The guideline is important for general practitioners as well as specialists in internal medicine and gastroenterology. The emphasis is on the management of chronic hepatitis B en C, because the prevalence of these diseases has increased in the Netherlands and, in addition, the treatment options for chronic hepatitis have improved. Consequently, timely recognition and adequate referral of patients with chronic hepatitis B or hepatitis C have become more important. However, many patients with a chronic liver disease have no symptoms. Therefore, the general practitioner should be aware that a patient visiting the practice with fatigue and malaise could have a liver disease if he or she belongs to a high-risk group or has had high-risk contacts. If the general practitioner repeatedly finds increased liver transaminase values during routine examination of asymptomatic patients, additional diagnostic tests should be performed. Further tests should focus on viral hepatitis as well as on non-alcoholic fatty liver disease and non-alcoholic steatohepatitis or, depending on the history-taking, liver damage due to excessive alcohol, medication or drug use.

[Summary of the practice guideline 'Influenza and influenza vaccination' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Influenza en influenzavaccinatie' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The first revision of the guideline 'Influenza and influenza vaccination' from the Dutch College of General Practitioners contains the new indications for influenza vaccination. The most important revisions are: the minimum age has been lowered from 65 to 60 years, the indication for furunculosis patients and their families has been removed, and vaccination is recommended to healthcare professionals who have regular and intensive contact with patients. The purpose of vaccinating healthcare professionals against influenza is to reduce the transmission of the influenza virus to patients at very high risk of complications from influenza and reduce sick leave among healthcare professionals. The use of antiviral agents should only be considered for patients with a very high risk of complications from influenza.

[Summary of the practice guideline 'Asthma in children' (second revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'astma bij kinderen' (tweede herziening) van het Nederlands Huisartsen Genootschap.

A number of important changes have been made in the second revision of the guideline 'Asthma in children' from the Dutch College of General Practitioners. In children under the age of 6 years, the symptoms stuffiness and recurrent cough are no longer considered part of the symptomatic diagnosis of asthma. Wheezing has become the key symptom of asthma. In children aged 6 years or more, spirometry is the optimal method for both diagnosis and monitoring. This method is preferred over peak flow measurement. Inhalation allergies should be investigated in children under the age of 6 years because the presence of an inhalation allergy may influence the management approach. Starting asthma medication in children under the age of 6 years should always be considered a therapeutic trial, and its effect should always be evaluated. The prescription of allergen-resistant mattresses and bed coverings is only effective when it is one component of a set of allergen reduction measures. At this time, the Dutch Health Council recommends influenza vaccination in children with asthma.

[Summary of the practice guideline 'Acne' (second revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Acne' (tweede herziening) van her Nederlands Huisartsen Genootschap.

The 1999 practice guideline 'Acne vulgaris' from the Dutch College of General Practitioners has been revised. Benzoyl peroxide and local retinoids are first choice in local treatment of acne. When treatment with oral antibiotics is indicated, doxycycline is first choice. Use of minocycline is not recommended in general practice. It is recommended that both local and oral antibiotics are always combined with local benzoyl peroxide or a local retinoid. Oral contraceptives are only recommended in women with acne who also desire contraception. Use of oral contraceptives containing cyproterone acetate is no longer recommended in women with acne, because they are not more effective than other oral contraceptives. Treatment with oral isotretinoin may be given by the general practitioner, as long as the treatment guidelines are carefully followed.

[Summary of the practice guideline 'Otitis externa' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Otitis externa' (eerste herziening) van het Nederlands Huisartsen Genootschap.

* The practice guideline 'Otitis externa', first developed by the Dutch College of General Practitioners in 1995, has been revised and updated. * It is no longer recommended to perform a KOH test on material collected from the auditory canal in patients with otitis externa. * Eardrops that contain both acid and corticosteroids are preferred over eardrops that contain acid only. * Suitable options include acidic eardrops with hydrocortisone 1% FNA and acidic eardrops with triamcinolone acetonide 0.1% FNA at a dose of 3 drops thrice daily. * The guideline contains a detailed discussion of the ototoxicity of eardrops in patients with tympanic membrane perforation. * Management of these patients, however, remains unchanged: the preferred approach is aluminium acetotartrate eardrops 1.2% FNA.

[Summary of the practice guideline 'Smoking cessation' from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Stoppen met roken' van het Nederlands Huisartsen Genootschap.

In general practice important health gain is obtainable by encouraging patients to stop smoking with support from the general practitioner. The practice guideline 'Smoking cessation' differentiates between smokers who are motivated to stop smoking, smokers who are considering smoking cessation, and smokers who are unmotivated to stop smoking. It is important to offer smokers, who are motivated to stop, intensive support at the right moment. Medicinal support in the way of nicotine replacement therapy, nortriptyline or bupropion is, ifpossible, recommended in motivated smokers who smoke at least 10 cigarettes daily.

[Summary of the practice guideline 'Pelvic inflammatory disease' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Pelvic inflammatory disease' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The 1995 guideline on pelvic inflammatory disease (PID) has been updated. The general practitioner should consider PID whenever a woman of childbearing age complains of lower abdominal pain; the diagnosis should then be based on 5 criteria: (a) non-acute lower abdominal pain; (b) pain on upward movement or adnexal tenderness during vaginal touch; (c) painful or swollen adnexae; (d) ESR > or = 15 mm in the 1st hour or a temperature > 38 degree C, and (e) no indications for other diseases, such as appendicitis or an extra-uterine pregnancy. In case of diagnostic doubt, a gynaecologist must be consulted. Rapid treatment with antibiotics diminishes symptoms, shortens the course of disease, and may prevent complications such as infertility or extra-uterine pregnancy. Treatment should be started with ofloxacin and metronidazole. Due to the increasing antibiotic resistance of Neisseria gonorrhoeae, when there are indications for this pathogen the medicinal treatment should immediately be directed at it by means of cefotaxim, doxycycline and metronidazole. In his or her information to the patient, the general practitioner should devote attention to the major role of sexually transmissible micro-organisms and give advice, if necessary, regarding high-risk behaviour.

[Summary of the practice guideline 'Hearing impairment' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Slechthorendheid' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The Dutch College of General Practitioners recently issued a revised version of the practice guideline 'Hearing impairment'. The modification of the screening for hearing impairment, which now takes place in neonates, has resulted in a much lower number of false-positive diagnoses of perceptive hearing loss than under the previous version of the practice guideline. The expanded diagnostic possibilities for adults, whether or not implemented by the patients themselves, demand an active approach from the general practitioner towards patients with impaired hearing. This guideline helps general practitioners to select patients that will truly benefit from a hearing aid and that will also be more likely to use one. The general practitioner can play an important role by stimulating patients to be referred for a hearing aid.

[Summary of the practice guideline 'Atopic dermatitis' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Constitutioneel eczeem' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The 1996 practice guideline on atopic dermatitis from the Dutch College of General Practitioners has been updated. For diagnosing atopic dermatitis, the use of Williams' criteria is recommended. Testing for food allergy is only useful in case of children under the age of 2 who have other food-related allergic complaints together with dermatitis. In the treatment of atopic dermatitis, keeping the skin in good condition with emollients is essential; furthermore, topical corticosteroids are the therapy of first choice. In case of a severe exacerbation of atopic dermatitis, starting with a class 3 corticosteroid is preferred. In case of frequent recurrences, 'pulse-therapy' is indicated: topical corticosteroids on 2-4 consecutive days per week as maintenance therapy. The role of preparations from tar is marginal. The use of the topical immunomodulators tacrolimus and pimecrolimus in general practice is discouraged.

[Summary of the practice guideline 'Vaginal discharge' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Fluor vaginalis' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The 1996 practice guideline of the Dutch College of General Practitioners (NHG) on vaginal discharge has been updated. Most women who visit their doctor with complaints about vaginal discharge do not have an increased risk of a sexually-transmitted disease. Investigations into vaginal discharge comprise history taking, physical examination and microscopic analysis in the laboratory of the general practitioner. Additional investigation into Chlamydia, gonorrhoea and Trichomonas infection is only necessary if the patient history reveals an increased risk of a sexually-transmitted disease. A Candida infection or bacterial vaginosis should only be treated if the patient experiences bothersome complaints. Treatment of a Candida infection consists of a vaginally applied imidazole compound. Bacterial vaginosis can be treated with oral administration of metronidazole. Patients with vaginal fluor can be examined and, if necessary, treated by their general practitioner. Referral to a gynaecologist is rarely necessary.

[Summary of the practice guideline 'The red eye' (first revision) of the Dutch College of General Practitioners (NHG)]. / Samenvatting van de standaard 'Het rode oog' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The revised NHG-guideline 'The red eye' provides recommendations for the diagnosis and therapy in patients with a red eye. In the presence of pain, decreased visual acuity and photophobia (alarm symptoms) should be considered as sight threatening conditions. In most instances a red eye results from conjunctivitis. The complaint of (an) early morning glued eye(s) makes a bacterial origin of acute infectious conjunctivitis more likely. Itching and a history of infectious conjunctivitis make the probability of bacterial involvement less likely. The type of discharge does not help to adequately distinguish bacterial from viral conjunctivitis. Since an infectious conjunctivitis is a self-limiting condition, no treatment is necessary as a rule. Antibiotic treatment is only rational if conjunctivitis is (most probably) caused by bacteria. It has to be considered only if a patient suffers from much discomfort, if complaints do not begin to decline after 3 days and in patients with preexisting corneal defects. Because of widespread resistance to fusidic acid this should in principle not be prescribed for treatment of conjunctivitis; chloramphenicol is still the drug of choice. During revision of the guideline discussions concentrated on 2 aspects: the position of slit lamp biomicroscopy in general practice and giving a patient with keratoconjunctivitis photoelectrica the remainder of a 'minim' with anaesthetic eye drops. Regarding both topics it was decided not to change the recommendations of the former version of the guideline: the use of slit lamp biomicroscopy remains optional for general practitioners and it remains permitted to give the remainder of a 'minim' with anaesthetic eye drops to a patient with keratoconjunctivitis photoelectrica.

[Summary of the practice guideline 'Thyroid disorders' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Schildklieraandoeningen' (eerste herziening) van het Nederlands Huisartsen Genootschap.

--The practice guideline 'Thyroid disorders' developed by the Dutch College of General Practitioners replaces the practice guideline 'Functional thyroid disorders' from 1996. Recommendations for palpable thyroid disorders have been added. --Hypothyroidism can often be treated by the general practitioner. The guideline offers specific recommendations for substitution therapy based on the 'start low, go slow'-principle. --Pharmacological treatment of hyperthyroidism is described as an optional activity for general practitioners. --A conservative approach is taken to the treatment of subclinical thyroid dysfunction. The development of symptoms may justify treatment initiation. --Cooperation has improved harmonisation of this practice guideline with the Netherlands Association for Internal Medicine's practice guideline 'Functional thyroid disorders' and the Dutch Institute for Healthcare Improvement's practice guideline 'Thyroid carcinomas'.

[Summary of the practice guideline 'allergic and non-allergic rhinitis' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Allergische en niet-allergische rhinitis' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The practice guideline 'Allergic and non-allergic rhinitis' of the Dutch College ofGeneral Practitioners has been revised based on developments that have occurred in recent years. The most important modifications are: Impermeable covers for beddings are advised only for patients with serious complaints despite the use of medication and other mite-avoidance measures, and patients with allergic rhinitis with asthma. The indication for the use ofa corticosteroid nasal spray is broadened. There is more evidence for the efficacy ofa nasal spray with antihistamines. The indication for cromoglycate has been restricted. Two major unsolved points of discussion concerned the effectiveness of sublingual immunotherapy and the link between asthma and allergic rhinitis.