ABSTRACT
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.
Subject(s)
Multimorbidity , Polypharmacy , Aged , Chronic Disease , Humans , Primary Health Care/methods , Quality of Life , Randomized Controlled Trials as TopicABSTRACT
OBJETIVO: Analizar la efectividad de una intervención en profesionales sanitarios de atención primaria (AP) en la mejora de resultados de salud de pacientes agudizadores de EPOC (AEPOC). DISEÑO: Observacional, con análisis retrospectivo y prospectivo. Emplazamiento. Distrito Sanitario Málaga-Guadalhorce (DSMG). PARTICIPANTES: Pacientes EPOC agudizados atendidos por los dispositivos móviles de urgencias del DSMG (n = 523; 21% pérdidas). INTERVENCIONES: Formación a los profesionales en la práctica clínica habitual e inclusión de indicadores de proceso de EPOC en objetivos ligado a incentivos. Mediciones principales. Comparación de variables de proceso y de resultado mediante auditoría de la historia clínica. Variable respuesta: diferencia de agudizaciones en 2 periodos analizados. Análisis bivariante y multivariante. RESULTADOS: Edad media 75 (±9,3) años; varones 63,7%, con un IMC de 29,4 (± 7,1); fumadores activos 21%. El FEV1 medio fue del 48,2% (± 18,7). La media de agudizaciones en el primer período fue de 2,86 (± 2,29) y en el segundo, de 1,36 (± 1,56) (p < 0,001). La media de ingresos en el primer y segundo periodos fue 0,56 (± 0,94) y 0,31 (± 0,66) (p < 0,001), respectivamente. La disminución del número de agudizaciones se relacionó de forma directa con haber tenido ≥2 agudizaciones en el primer período, exacerbación revisada en atención primaria y de forma inversa con tener insuficiencia cardiaca y ≥ 2 agudizaciones en el segundo período (coeficiente de determinación R2 = 0,28; p < 0,001). CONCLUSIONES: El número de agudizaciones y de ingresos entre ambos periodos evaluados disminuyó significativamente. Sin embargo, no mejoraron los indicadores de proceso evaluados. Se precisan estudios prospectivos de intervención para establecer la posible relación causal
OBJECTIVE: To examine the impact of an intervention by Primary Care (PC) professionals of a Health District on the clinical outcomes for treating COPD exacerbations using a process and outcome indicators analysis (clinical audit). DESIGN: Observational, retrospective and prospective analysis cross-sectional audit of clinical practice. SETTING: Malaga-Guadalhorce Sanitary District (DSMG). Participants. Patients with COPD exacerbations treated by the extra-hospital emergency services (n = 523; 21% losses). INTERVENTIONS: Professional training in the usual clinical practice and inclusion of process indicators of COPD targets in relation to incentives. Principal measurements. Comparison of external audit results (process and outcomes variables) from medical records and Health Outcomes (exacerbations, admissions). Variable response: Difference in exacerbations and admissions in 2 periods analysed. Bivariate and multivariate analysis. RESULTS: Mean age was 75 (± 9.3), 63.7% males with a BMI of 29.4 (±7.1), and 21% active smokers. Mean FEV1, 48.2% (± 18.7). Mean exacerbations in the first period, 2.86 (± 2.29) and in the second 1.36 (± 1.56) (P <. 001). Mean hospital admissions in the first and second period, 0.56 (±0.94) and 0.31 (± 0.66) (P < .001), respectively. The decrease in the number of exacerbations was directly associated with having ≥ 2 exacerbations in the first period, reviewed in Primary Care, and inversely with heart failure and with having ≥ 2 exacerbations in the second period (R2 = 0.28; P < .001). CONCLUSIONS: The number of exacerbations and admissions decreased significantly in both periods assessed. However, the evaluated process indicators did not improve. Prospective intervention studies are necessary to establish the possible causal relationshi
Subject(s)
Humans , Male , Female , Pulmonary Disease, Chronic Obstructive/epidemiology , Pulmonary Disease, Chronic Obstructive/prevention & control , Primary Health Care/methods , Primary Health Care/trends , Symptom Flare Up , Retrospective Studies , Prospective Studies , Mobile ApplicationsABSTRACT
OBJECTIVE: To examine the impact of an intervention by Primary Care (PC) professionals of a Health District on the clinical outcomes for treating COPD exacerbations using a process and outcome indicators analysis (clinical audit). DESIGN: Observational, retrospective and prospective analysis cross-sectional audit of clinical practice SETTING: Malaga-Guadalhorce Sanitary District (DSMG). PARTICIPANTS: Patients with COPD exacerbations treated by the extra-hospital emergency services (n=523; 21% losses). INTERVENTIONS: Professional training in the usual clinical practice and inclusion of process indicators of COPD targets in relation to incentives. PRINCIPAL MEASUREMENTS: Comparison of external audit results (process and outcomes variables) from medical records and Health Outcomes (exacerbations, admissions). Variable response: Difference in exacerbations and admissions in 2 periods analysed. Bivariate and multivariate analysis. RESULTS: Mean age was 75 (±9.3), 63.7% males with a BMI of 29.4 (±7.1), and 21% active smokers. Mean FEV1, 48.2% (±18.7). Mean exacerbations in the first period, 2.86 (±2.29) and in the second 1.36 (±1.56) (P<.001). Mean hospital admissions in the first and second period, 0.56 (±0.94) and 0.31 (±0.66) (P<.001), respectively. The decrease in the number of exacerbations was directly associated with having ≥2 exacerbations in the first period, reviewed in Primary Care, and inversely with heart failure and with having ≥2 exacerbations in the second period (R2=0.28; P<.001) CONCLUSIONS: The number of exacerbations and admissions decreased significantly in both periods assessed. However, the evaluated process indicators did not improve. Prospective intervention studies are necessary to establish the possible causal relationship.
