Outpatient pharmaceutical office: access to medicines in public health

Abstract We evaluated the implementation of the outpatient pharmaceutical office in a teaching hospital regarding the access to medicines available in the Unified Health System - SUS. This is a descriptive-analytical study, based on secondary data analysis of 735 appointments performed by the pharmacist from 2015 to 2017. Of the drugs prescribed to patients attended at the outpatient pharmacist office, 86.39% were listed in the National List of Essential Medicines - RENAME, of which 95.43% belonged to the Specialized Component of Pharmaceutical Assistance. Evaluating the patient's diagnosis against the inclusion criteria of the Clinical Protocols and Therapeutic Guidelines (PCDT), that the most frequent pharmaceutical interventions were: adequacy of the medication request documents (56.4%) and examination requests for pharmacotherapeutic follow up (28.5%). When the prescribed drugs were not included in RENAME/PCDT, the intervention was accepted in 90.3% of the proposals for exchange with available drug in SUS. Still, it was possible to refer the patient to primary care for renewal of continuity of treatment in 95.1% of cases. In conclusion, the role of the clinical pharmacist contributes to the resolution of untreated health problems by promoting access to medicines within the scope of SUS and their rational use in accordance with the PCDT.

A study on diabetes-related self-care plan and its determinants among diabetes patients in a Warangal region, Telangana, India

Abstract The prevalence of epidemiological diseases, including diabetes, has continued to increase because of the adaption of Western culture and the lack of self-care activities among patients with diabetes. Therefore, in this cross-sectional study, we aimed to assess self-care plans and determinants among diabetes outpatients in Warangal. We conducted a prospective observational study among diabetes outpatient clinic in Warangal, India over 6 months from October 2019 to March 2020. We used the expanded Summary of Diabetes Self-Care Activities (SDSCA) questionnaire. A P value of less than < 0.05 was considered statistically significant. Respondents (mean age, 52.3 (standard deviation (SD), 11.01) years) had an overall SDSCA score of 49.18 ± 3.57 (SD). Mean scores for the diet, physical activity, foot care, medication adherence, and blood sugar testing scales were 12.79 (SD, 1.61), 10.24 (SD, 1.77), 15.67 (SD, 1.5), 5.66 (SD, 1.17), and 4.80 (SD, 0.68), respectively. Patients' age, education, disease duration and hemoglobin A1C (HbA1C) levels of <7.5% (P < 0.001)) had significantly higher mean scores for blood sugar testing, diet, physical activity, and adherence (P < 0.001). The employment status is associated with all the domains of Summary of Diabetes Self-Care Activities (P < 0.001). Taken together, our results revealed that patients with diabetes in Warangal had poor self-care planning, highlighting the need for strengthening initiatives that generate awareness regarding diabetes and improving related self-care practices

Pharmacovigilance of thalidomide in the Brazilian Health System and patient safety

In Brazil, thalidomide is manufactured by a public laboratory, distributed by the Unified Health System (SUS), and regulated by the National Health Surveillance Agency (Anvisa). Despite the concerns regarding the adverse effects of thalidomide, few drug utilization studies have been conducted to describe processes and outcomes related to this drug. The aim of this study was to elucidate the issues related to the utilization and control of thalidomide, and patient safety within the scope of SUS. In this cross-sectional study, we evaluated the articulation between an outpatient dermatology service of a referral hospital in infectology, the manufacturer, and Anvisa. Four data sources were used: i) interviews with health professionals; ii) data from the Customer Service of the manufacturer, iii) data on adverse events reported to Anvisa, and iv) adverse events identified in outpatient service. Most health professionals interviewed knew the major thalidomide-related adverse effects. None of them ever reported adverse events to Anvisa or contacted the Customer Service. For over three years, there were 330 calls concerning thalidomide at Customer Service, 7% of which were related to adverse events. During a period of six years, Anvisa was notified of only 15 adverse events. Health professionals were aware of the adverse events associated with thalidomide, but not the necessity to report them. The low number of notifications recorded by Anvisa and the information obtained from Customer Service show that pharmacovigilance remains incipient. A pharmacovigilance system that integrates all the services associated with thalidomide is required to strengthen this activity within the SUS to improve patient safety.

Use of the International Classification of Functioning, Disability and Health Generic-30 Set for the characterization of outpatients: Italian Society of Physical and Rehabilitative Medicine Residents Section Project.

BACKGROUND: The International Classification of Functioning, Disability and Health (ICF) Generic-30 Set (previously referred to as Rehabilitation Set) is a minimal set of ICF categories for reporting and assessing functioning and disability in clinical populations with different health conditions along the continuum of care. Recently, the Italian Society of Physical and Rehabilitation Medicine (SIMFER) developed an Italian modification of the simple and intuitive descriptions (SID) of these categories. This study was the first one to implement the use of the SID in practice. AIM: The main aims of this study are: 1) to implement the use of the ICF in clinical practice and research among Italian Residents in PRM, and 2) to verify if the SID made the application of ICF Generic 30 Set more user-friendly than the original descriptions; 3) to examine the prevalence of functioning problems of patients accessing Rehabilitation Services to serve as reference for the development of an ICF-based clinical data collection tool. DESIGN: Multicenter cross-sectional study. SETTING: Italian Physical Medicine and Rehabilitation (PRM) outpatient rehabilitation services. POPULATION: Patients referring to Italian PRM outpatient rehabilitation services and Italian Residents in PRM. METHODS: Each School of Specialization involved, randomly, received the ICF Generic-30 Set with the original descriptions or with the SID. Residents collected over a 4-month period (April-July 2016) patients data related to the ICF Generic-30 Set categories. Moreover, the residents self-assessed their difficulty in using the ICF Generic-30 Set with the original descriptions or with the SID, through a Numeric Rating Scale (NRS). RESULTS: Ninety-three residents collected functioning data of 864 patients (mean aged 57.7±19.3) with ICF Generic-30 Set: 304 with the original descriptions and 560 with SID. The difficulty in using the ICF Generic-30 Set with SID was rated as lower than using the original descriptions (NRS 2.8±2.5 vs. 3.5±3.1; P<0.001). The most common disease was the back pain (9.6%) and the most common altered ICF categories were b280 (76.3%) and b710 (72.9%). CONCLUSIONS: This multicenter cross-sectional study shown that the ICF Generic-30 Set is a valuable instrument for reporting and assessing functioning and disability in clinical populations with different health conditions and along the continuum of care and that SID facilitate the understanding of the ICF categories and therefore their use in clinical practice. CLINICAL REHABILITATION IMPACT: By increasing the knowledge of ICF among Italian PRM residents, this national survey makes an important step towards the system-wide implementation of ICF in the Italian healthcare system.

Desenvolvimento e validação de indicadores para avaliação da qualidade do acompanhamento farmacoterapêutico / Development and validation of indicators for quality assessment of medication management

Um dos elementos para melhoria da qualidade dos serviços farmacêuticos clínicos é medir a qualidade do cuidado prestado e os indicadores podem ser usados nesta avaliação. O presente trabalho teve como objetivos identificar estudos sobre indicadores de qualidade para serviços farmacêuticos clínicos e desenvolver e validar um instrumento de indicadores para avaliação dos serviços de acompanhamento farmacoterapêutico prestados para pacientes ambulatoriais. Para tanto, uma busca abrangente da literatura foi conduzida nas bases de dados PubMed/Medline, Scopus, Lilacs e DOAJ por esses estudos. Os instrumentos apresentados pelos estudos foram avaliados em relação à qualidade das propriedades psicométricas. A seguir, foi desenvolvido um instrumento de indicadores-chave de desempenho. O grupo de pesquisa estabeleceu sete indicadores possíveis para avaliação de especialistas da área através de duas rodadas da técnica Delphi para validação de conteúdo. Ainda, farmacêuticos foram convidados a participar por meio de um questionário para validação de construto e confiabilidade do instrumento. A busca bibliográfica identificou 3.276 registros, dos quais 12 estudos completaram os critérios de inclusão. No geral, o maior número de estudos foi baseado em pesquisas para avaliar a satisfação dos pacientes e usou a revisão da literatura combinada com opinião de especialistas para o desenvolvimento do instrumento. Todos os estudos apresentaram algumas propriedades psicométricas do instrumento. A consistência interna e a validade de conteúdo foram os critérios mais relatados dos estudos, e nenhum deles apresentou o critério de estabilidade. Onze (68,8%) especialistas participaram da primeira rodada da técnica Delphi e nove (81,8%) especialistas completaram as 2 rodadas. Um novo indicador foi desenvolvido após a avaliação do painel de especialistas na primeira rodada. No geral, a validade de conteúdo e construto foi alcançada para o instrumento final. Os resultados desta tese apontam que os instrumentos dos estudos identificados na revisão sistemática apresentaram propriedades psicométricas, porém de forma incompleta ou não satisfatória. Ainda, um instrumento com seis indicadores foi desenvolvido e validado para o Serviço de Acompanhamento Farmacoterapêutico prestado para pacientes ambulatoriais

One of the elements of quality improvement of medication management services is measuring the quality of care and key performance indicators (KPIs) can be used in this assessment. The study is aimed to identify quality indicators instruments in pharmaceutical care services and to develop and validate KPI instrument for medication management services provided for outpatients. For this, comprehensive literature search was performed in databases PubMed/Medline, Scopus, and Lilacs. The psychometric quality of the instruments was determined. In addition, a key performance indicators instrument was developed. A working group established 7 possible KPIs for assessment of the expert panel through an internet based 2-round Delphi approach. An internet questionnaire was developed for pharmacists in order to construct validity and reliability of the instrument. The literature search yielded 3,276 records, of which 12 studies satisfied the inclusion criteria. Overall, the greatest number of studies were based surveys to assess patients' satisfaction and used literature review combined with expert's opinion for the instrument development. All studies presented some psychometrics properties of the instrument. Internal consistency and content validity were the most reported criteria of the studies and none of them presented stability. Eleven (68.8%) experts participated in the Delphi round 1 and nine (81.8%) experts completed the 2 Delphi rounds. A new KPI was develop after expert panel assessment in the first round. Overall, content and construct validity were reached for final instrument. The results of this thesis point out that instrument of the studies identified in the systematic review presented some psychometrics properties, but did not describe them satisfactorily. In addition, a set of six key performance indicators was developed and validated for medication management services provided for outpatients

Markov Model of the Outpatient Classification System Morbidity Related Groups (MRG).

BACKGROUND: Benchmarking and guidance of outpatient physicians in Germany are almost always based on one year data. This also holds true for morbidity related groups, a classification system applied in northern Germany since 2017. A study of the markov properties of prescription based grouping algorithms is reported here. RESULTS: There is a strongly connected graph for almost all components and the resulting markov chain has a unique stationary solution. CONCLUSIONS: Target values based on the status quo of prescription behavior can provide stable guidelines for outpatient physicians. Every set of partitions converging like MRG should be considered for controlling measures.

Morbidity Related Groups (MRG) for Epidemiological Analysis in Outpatient Treatment.

Each patient in outpatient treatment is assigned per quarter and corresponding physician to a case group that is strongly related to the morbidity (Morbidity Related Group, MRG). MRG is defined by the drug group on a four character level in the international anatomic-therapeutic-chemical (ATC) classification with the largest costs as an indicator for the severity of the drug treatment. Using severity levels we get a risk adjustment with respect to age and polypharmacy as an indicator for multimorbidity and treatment intensity. By application of MRG groups we generate a patient type classification in relation to physicians and a distance structure of the medical disciplines.

Axial low back pain: one painful area--many perceptions and mechanisms.

Axial low back pain can be considered as a syndrome with both nociceptive and neuropathic pain components (mixed-pain). Especially neuropathic pain comprises a therapeutic challenge in practical experience and may explain why pharmacotherapy in back pain is often disappointing for both the patient and the therapist. This survey uses epidemiological and clinical data on the symptomatology of 1083 patients with axial low back pain from a cross sectional survey (painDETECT). Objectives were (1) to estimate whether neuropathic pain contributes to axial low back pain and if so to what extent. (2) To detect subgroups of patients with typical sensory symptom profiles and to analyse their demographic data and co-morbidities. (3) To compare patients with and without prior intervertebral disc surgery (IVD). Neuropathic pain components could be detected in 12% of the entire cohort. Cluster analyses of these patients revealed five distinct subgroups of patients showing a characteristic sensory profile, i.e. a typical constellation and combination of symptoms. All subgroups occurred in relevant numbers and some showed distinct neuropathic characteristics while others showed nociceptive features. Post-IVD-surgery patients showed a tendency to score more "neuropathic" than patients without surgery (not statistically significant). Axial low back pain has a high prevalence of co-morbidities with implication on therapeutic aspects. From these data it can be concluded that sensory profiles based on descriptor severity may serve as a better predictor for therapy assessment than pain intensity or sole diagnosis alone. Standardized phenotyping of pain symptoms with easy tools may help to develop an individualized therapy leading to a higher success rate in pharmacotherapy of axial low back pain.

Role of two clusters of male alcoholics in treatment retention.

AIMS: This study aimed to classify alcohol-dependent outpatients on the basis of clinical factors and to verify if the resulting types show different treatment retention. METHODS: The sample comprised 332 alcoholics that were enrolled in three different pharmacological trials carried out at São Paulo University, Brazil. Based on four clinical factors - problem drinking onset age, familial alcoholism, alcohol dependence severity, and depression - K-means cluster analysis was performed by using the average silhouette width to determine the number of clusters. A direct logistic regression was performed to analyze the influence of clusters, medication groups, and Alcoholics Anonymous (AA) attendance in treatment retention. RESULTS: Two clusters were delineated. The cluster characterized by earlier onset age, more familial alcoholism, higher alcoholism severity, and less depression symptoms showed a higher chance of discontinuing the treatment, independently of medications used and AA attendance. Participation in AA was significantly related to treatment retention. DISCUSSION: Health services should broaden the scope of services offered to meet heterogeneous needs of clients, and identify treatment practices and therapists which improve retention. Information about patients' characteristics linked to dropout should be used to make treatment programs more responsive and attractive, combining pharmacological agents with more intensive and diversified psychosocial interventions.

Relationship between urinary tract infection categorization and pathogens' antimicrobial susceptibilities.

BACKGROUND: Urinary tract infections (UTIs) can be hard to treat and treatment plans need to include accurate categorization such as uncomplicated or complicated UTI, or catheterized or uncatheterized UTI. We investigated the antibiotic susceptibilities of representative uropathogens in UTI categories. METHODS: We isolated uropathogens and analyzed their antimicrobial susceptibilities according to UTI categorization such as: (1) urology outpatients, urology inpatients, or other department inpatients; (2) uncomplicated or complicated UTIs; (3) upper or lower UTIs, and (4) non-catheterized or catheterized UTIs. RESULTS: Escherichia coli, Enterococcus faecalis, and Pseudomonas aeruginosa were representative uropathogens. Susceptibilities to levofloxacin (LVFX) in E. coli in urology outpatients (p = 0.0179), those to ceftadizime in E. coli in other department inpatients (p = 0.0327), and those to LVFX in E. faecalis in complicated UTI (p = 0.0137) significantly decreased in these 3 years compared with the previous 3 years. Susceptibilities of upper UTI to LVFX in E. coli were significantly lower in the recent 4 years compared to lower UTI (p = 0.0452) and those of catheterized UTI to LVFX in E. faecalis were significantly lower than in non-catheterized UTI (p = 0.0153). CONCLUSIONS: Data demonstrated different tendencies of uropathogens' antibiotic susceptibilities according to UTI categorizations and they could be useful for planning UTI treatments.

Predicting patient deterioration in youth mental health services: community mental health vs. managed care settings.

OBJECTIVE: To examine differences across a community mental health system and a private managed care system in the accuracy of a warning system designed to identify youth at risk for deterioration in mental health services. DESIGN: Longitudinal outcome data from the Youth Outcome Questionnaire (Y-OQ) were examined using multilevel modeling for 2,310 youth ages 4-17 who received outpatient treatment. RESULTS: The warning system correctly identified 69% of cases that ultimately ended in deterioration in the community mental health setting, compared to 61% in the managed care setting. The overall hit rate (overall accuracy in classifying cases as deteriorators/non-deteriorators) was the same in the two settings (75%). CONCLUSIONS: Results are consistent with previous research demonstrating that patient-focused warning systems can be reasonably accurate in identifying youth cases at risk for treatment failure.

The comorbidity of anger symptoms with personality disorders in psychiatric outpatients.

OBJECTIVES: Although many psychiatric disorders are "emotional" disorders, no disorders exist for which dysfunctional anger is a necessary feature. This study examined whether dysfunctional anger could be considered a diagnosis independent from Personality Disorders. DESIGN: We analyzed data on 1,158 psychiatric outpatients who underwent a semi-structured interview for Axis II disorders and ascertained the co-occurrence of dysfunctional anger and Personality Disorders. RESULTS: The overlap between dysfunctional anger and all Personality Disorders was low. Data analyses showed dysfunctional anger was not well accounted for by Axis II diagnoses. CONCLUSIONS: Dysfunctional anger can be viewed by researchers and clinicians as an independent diagnostic entity. The implications of these results for the diagnosis and treatment of patients with anger symptoms is discussed.

Reduction of cardiovascular risk in patients with metabolic syndrome in a community health center after a pharmaceutical care program of pharmacotherapy follow-up

The objective of this study was to determine the impact of a pharmaceutical care (PC) program in a sample of public outpatients with metabolic syndrome (MS) who were being treated in Brazil's health system; the patients were randomized into PC or standard care. The pharmacotherapy follow-up (PF) was performed in a total of 120 patients with type 2 diabetes for 6 months. Adherence to treatment (measured with the Morisky test), negative outcomes associated with medication (NOM) and anthropometric and biochemical parameters were measured before and after PF. The Framingham scoring method was used to estimate changes in 10-year coronary heart disease risk scores in all patients. Ninety-six of 120 patients had characteristics of MS and were randomized into two groups (G): the control group (CG: 36) and the intervention group (IG: 38). Among the MS patients, 100% were taking a glucose-lowering drug; many were also taking anti-hypertensive drugs (CG: 72%; IG: 73%), and some patients were also taking hypolipemic drugs (CG: 12.0%; IG: 14.7%). Only 20.7% of the IG patients were considered adherent to their prescribed drugs. In the CG, an increase of coronary heart disease (CHD) risk (22±2 to 26±3; p<0.05) was observed, while in the IG, there was a reduction in CHD risk (22±2 to 14±2%; p<0.01). The PC program administered to patients with MS monitored through the primary healthcare services of the Brazilian public health system improved patient health, resulting in clinical improvements and a decrease in cardiovascular risk in IG patients over a period of ten years.

O objetivo deste estudo foi o de determinar o impacto de um Programa de atenção Farmacêutica (AF) em uma amostra de pacientes ambulatoriais de Sistema Público de Saúde do Brasil portadores de Síndrome Metabólica, randomizados em AF ou atenção à saúde usual. Realizou-se o seguimento farmacoterapêutico com 120 pacientes com diabetes tipo 2 durante seis meses. Avaliou-se o nível de aderência ao tratamento (teste Morisky), resultados clínicos negativos associados a medicamentos (RNM), parâmetros bioquímicos e antropométricos, antes e após o seguimento. O método de Framingham foi usado para calcular as variações no risco de doenças coronarianas em 10 anos em todos os pacientes. Dos 120 pacientes, 96 tiveram características de SM e foram então randomizados em dois grupos (G): Controle (GC: 36) e Intervenção (GI: 38). Entre os pacientes com SM, 100% faziam uso de medicamentos para diminuir a glicose, anti-hipertensivos (GC: 72%; GI: 73%) e hipoglicemiantes (GC: 12.0%; GI: 14.7%). Apenas 20,7% do GI foram considerados aderentes aos fármacos prescritos. No GC foi observado aumento do risco de Doença Arterial Coronariana (DAC) (22±2 para 26±3; p<0,05), enquanto no GI foi observado redução (22±2 para 14±2%; p<0,01). O Programa de AF para pacientes com SM monitorados na atenção primária do Sistema de Saúde Pública brasileiro melhora o funcionamento do serviço resultando na melhoria clínica dos pacientes com redução do risco de doença cardiovascular em um período de dez anos.

Perfil dos usuários do posto de saúde da família do bairro Humaitá, Tubarão – SC / Profile of users of users of the Humaitá Family care station in Tubarão, Santa Catarina

Introdução: A cobertura do SUS foi ampliada com a associação feita entre o Programa de Agentes Comunitários e a Estratégia de Saúde da Família, visandoaumentar a área de abrangência e levar melhores condições de saúde à população. Objetivo: Este estudo visou analisar e descrever o perfil dos usuários da Unidade Básica de Saúde doHumaitá do município de Tubarão, Santa Catarina. Métodos: foi desenvolvido através de uma análise transversal, com uma amostra de 105 pacientes,selecionados por demanda. A coleta dos dados foi feita no período de julho a setembro de 2007, sendo aplicadoum questionário semi-estruturado no próprio posto. Resultados: Houve uma prevalência do gênero feminino (73,3%), com 88,6% da população local adscrita natural de Tubarão e faixa etária entre 40 e 59 anos. A maioria dos entrevistados tem tempo de estudo superior a 11 anos e baixa renda mensal. A maioria não encontroudificuldades na marcação de consultas, carência de vagas, longo tempo de espera. Os usuários relataramestar satisfeitos quanto à relação médico-paciente e a resolutividade.Conclusão: O Posto de Saúde da Família Humaitá, segundo nosso estudo, já superou vários obstáculos, apresentando facilidade à marcação de consultas (95,2%), alta resolutividade (96,2%%) e satisfação do público-alvo (62,9% total e 37,1% parcial). Além disso, a população apresenta taxa de escolaridade superior aos estudos comparativos.

Background: The coverage of the Unique System of Health (SUS) was expanded with the union between the community agents and health family programs, aiming to increase the performance area and bring better health conditions to the population. Objective: This study sought to analyze and describe the profile of users of the Humaitá family care station in Tubarão, Santa Catarina. Methods: Was developed a cross-section studyanalysis, performed with a sample of 105 patients, selected by demand. The collection of data was done between July-September 2007 and applied a semistructured questionnaire on the station. Results: Prevalence was significantly higher for female gender (73,3%), with 88,6% of registered local population from Tubarão between 40-59 years old. Most of interviewed that answered the questionnaire havemore than 11 years of study and low-income monthly. The majority didn’t find problems to get an appointment, lacks of consultations or long time of wait. The users reported being satisfied about resolubility and doctorpatient relationship. Conclusions: The Humaitá Health Station, according our study, has already overcame several obstacles,presenting easy to get an appointment (95,2%), high resolubility (96,2%) and satisfaction of the local public (62,9% overall; 37,1% partial). Besides, the education rates of the local population are better than comparatives studies.

2009 OPPS rule is good news for EDs.

For once, the final Outpatient Prospective Payment System payment rule issued by the Centers for Medicare & Medicaid Services generally has been praised by emergency medicine observers. There are, however, some new wrinkles you should be aware of, because they could save - or cost - you money: A separate coding category has been established for EDs that are not open 24/7. The payment rates are lower than those in full-time EDs, except for Level 5 visits. Imaging procedures have been grouped into five milies," and multiple tests on the same patient within the same family will be reimbursed as if only a single test was performed. Visits coded for "trauma response with critical care" will be reimbursed at a rate nearly three times as high as last year's rate.

Triangulating patient and clinician perspectives on clinically important differences in health-related quality of life among patients with heart disease.

OBJECTIVE: To use triangulation methodology to better understand clinically important differences (CIDs) in the health-related quality of life (HRQoL) of patients with heart disease. DATA SOURCES/STUDY SETTING: We used three information sources: a nine-member expert panel, 656 primary care outpatients with coronary artery disease (CAD) and/or congestive heart failure (CHF), and the 46 primary care physicians (PCPs) treating these outpatients. From them, we derived CIDs for the Modified Chronic Heart Failure Questionnaire (CHQ) and the Medical Outcomes Study Short Form 36-Item Health Status Survey, Version 2 (SF-36). STUDY DESIGN: The expert physician panel employed Delphi and consensus methods to obtain CIDs. The outpatients received bimonthly HRQoL interviews for 1 year that included the CHQ and SF-36, as well as retrospective assessments of HRQoL changes. Their PCPs assessed changes in the patient's condition at follow-up clinic visits that were linked to HRQoL assessments to determine change over time. DATA COLLECTION/EXTRACTION METHODS: Patient- and PCP-assessed changes were categorized as trivial (no change), small, moderate, or large improvements or declines. Moderate or large changes in HRQoL reflect the added risk or investment associated with some treatment modifications. Estimates for each categorization were calculated by finding the mean change scores within anchored change classifications. PRINCIPAL FINDINGS: The small CID for the CHQ domains was consistently one to two points using the patient-assessed change categorizations, but small CIDs varied greatly for the SF-36. PCP-assessed changes differed substantially from patient estimates for both the CHQ and SF-36, while the panel-derived estimates were generally larger than those derived from patients. CONCLUSIONS: Triangulation methodology provides a framework for securing a deeper understanding of each informant group's perspective on CIDs for these patient-reported outcome measures. These results demonstrate little consensus and suggest that the derived estimates depend on the rater and assessment methodology.

Subgrouping outpatients of an environmental medicine unit using SCL-90-R and cluster analysis.

Between 1999 and 2003 all consecutive outpatients of the environmental medicine unit of the Charité hospital in Berlin were invited to participate in a study on environmentally related disorders. One hundred and sixty-nine of the patients completed a psychosocial questionnaire which comprised SCL-90-R and 14 other tests. When compared with clinical controls, SCL-90-R mean scores of the environmental patients (EP) were found to lie in between those of inpatients of a psychosomatic clinic and melanoma aftercare patients; but they were, with exception of the somatisation dimension, much closer to the latter. Application of the TwoStep Cluster component of SPSS resulted in three subgroups with high, moderate and low scores which were significantly different (p<0.001) although separation was incomplete (87% correct identification; cross-validated discriminant analysis). With all subgroups, scores for somatisation, depression and obsessive compulsion were highest and those for phobic anxiety and psychoticism were lowest. SCL-90-R scores correlated well with results of the Freiburg Personality Inventory, Whiteley Index of hypochondriasis, the short form health questionnaire (SF-36), and the Composite International Diagnostic Interview (CIDI). Hierarchical grouping (average linkage between groups), performed with involvement of SCL-90-R data from literature, resulted in a dendrogram with three distinct groups and three outliers. EP with low SCL-90-R scores were assigned to a group which comprised also general populations (USA, Germany), allergy patients, and melanoma controls. Those with moderate SCL-90-R scores were placed in a group together with chronic pain patients, and 26 'environmentally ill' subjects. The third subgroup of EP formed a cluster with our psychosomatic controls, psychosomatic patients from another study, depressed people, and patients undergoing psychotherapy. The three outliers of the dendrogram, however, were SCL-90-R profiles obtained from persons with toxic waste exposure, neurotoxic workplace exposure or with solvent-induced chronic toxic encephalopathy.

[Out-patients unit--recapitulation of five-year activity]. / Oddzial Dziennego Pobytu--podsumowanie 5-letniej dzialalnosci.

Authors make recapitulation of out-patients unit activity. This unit is a part of Department Physiotherapy, Rheumatology and Rehabilitation University of Medical Sciences in Poznan. Numbers of treated patients in following years, most frequent reasons of treatment and preferences of treatment among patients are given. Finally, authors put particular accent on still growing up interest in this form of rehabilitation activity.

Inappropriate drug use by Portuguese elderly outpatients--effect of the Beers criteria update.

OBJECTIVE: To characterize the use of medicines and to evaluate the inappropriateness of drugs in elderly outpatient population. SETTING: Twelve community pharmacies in different districts of Lisbon-Portugal. METHOD: Observational cross-sectional survey, in a sample of 213 elderly outpatients (age>or=65-years-old) presenting a prescription with two or more drugs, for their own use. MAIN OUTCOME MEASURES: Drug use pattern and prevalence of potentially inappropriate medication. RESULTS: We have studied 213 outpatients, who were taking a total of 1,543 drugs, with an average of 7.23 per patient. The drugs were distributed mainly in the following 3 ATC (Anatomical Therapeutic Chemical Classification) classes: C (cardiovascular system), N (nervous system) and A (alimentary tract). Using the 1997 Beers Explicit criteria, 75 occurrences of inappropriate medicines were detected in 59 patients (27.7%), while with the 2003 Beers Explicit criteria we detected 114 cases of inappropriate medication in 82 patients (38.5%). The occurrence of inappropriate medicines was significantly associated with the consumption of a high number of drugs. According to the ATC Classification, more than one half of the cases of inappropriateness were related with long acting benzodiazepines and with ticlopidine. The 2003 version detected a significantly higher prevalence of inappropriate drug use having potentially adverse outcomes of high severity. CONCLUSIONS: The application of the updated Beers criteria lead to higher rates of potentially inappropriate medication, and especially those responsible for more severe adverse outcomes. The results suggest that there is a need for interventions to improve instructions for safe drug use in the elderly patients and to decrease the number of medications whenever it is possible. This study suggests a high prevalence of potentially inappropriate drug use by the elderly patients of Lisbon region, Portugal.