Factors Associated With Specialists' Intention to Adopt New Behaviors After Taking Web-Based Continuing Professional Development Courses: Cross-sectional Study.

BACKGROUND: Web-based continuing professional development (CPD) is a convenient and low-cost way for physicians to update their knowledge. However, little is known about the factors that influence their intention to put this new knowledge into practice. OBJECTIVE: We aimed to identify sociocognitive factors associated with physicians' intention to adopt new behaviors as well as indications of Bloom's learning levels following their participation in 5 web-based CPD courses. METHODS: We performed a cross-sectional study of specialist physicians who had completed 1 of 5 web-based CPD courses offered by the Federation of Medical Specialists of Quebec. The participants then completed CPD-Reaction, a questionnaire based on Godin's integrated model for health professional behavior change and with evidence of validity that measures behavioral intention (dependent variable) and psychosocial factors influencing intention (n=4). We also assessed variables related to sociodemographics (n=5), course content (n=9), and course format (eg, graphic features and duration) (n=8). Content variables were derived from CanMEDS competencies, Bloom's learning levels, and Godin's integrated model. We conducted ANOVA single-factor analysis, calculated the intraclass correlation coefficient (ICC), and performed bivariate and multivariate analyses. RESULTS: A total of 400 physicians participated in the courses (range: 38-135 physicians per course). Average age was 50 (SD 12) years; 56% (n=223) were female, and 44% (n=177) were male. Among the 259 who completed CPD-Reaction, behavioral intention scores ranged from 5.37 (SD 1.17) to 6.60 (SD 0.88) out of 7 and differed significantly from one course to another (P<.001). The ICC indicated that 17% of the total variation in the outcome of interest, the behavioral intention of physicians, could be explained at the level of the CPD course (ICC=0.17). In bivariate analyses, social influences (P<.001), beliefs about capabilities (P<.001), moral norm (P<.001), beliefs about consequences (P<.001), and psychomotor learning (P=.04) were significantly correlated with physicians' intention to adopt new behaviors. Multivariate analysis showed the same factors, except for social influences and psychomotor learning, as significantly correlated with intention. CONCLUSIONS: We observed average to high behavioral intention scores after all 5 web-based courses, with some variations by course taken. Factors affecting physicians' intention were beliefs about their capabilities and about the consequences of adopting new clinical behaviors, as well as doubts about whether the new behavior aligned with their moral values. Our results will inform design of future web-based CPD courses to ensure they contribute to clinical behavior change.

An exploratory identification of biological markers of chronic musculoskeletal pain in the low back, neck, and shoulders.

OBJECTIVES: This study was an in-depth exploration of unique data from a nationally representative sample of adults living in the United States to identify biomarkers associated with musculoskeletal pain. METHODS: We performed secondary analyses of 2003-2004 NHANES data. After a first screening of 187 markers, analyses of 31 biomarkers were conducted on participants aged ≥20 years identified in all counties using the 2000 Census Bureau data (n = 4,742). To assess the association of each biomarker with each pain outcome (acute, subacute and chronic low back, neck, and shoulder pain), analyses were carried out using multivariable logistic regression with adjustments for sex, age and body mass index. Biomarkers were considered as continuous variables and categorized at the median of their distributions. RESULTS: Pain at any site for ≥24 hours during the past month was reported by 1,214 participants. Of these, 779 mentioned that the pain had lasted for ≥3 months ("chronic pain"). α-carotene, ascorbic acid, ß-carotene, mercury and total protein had a statistically significant, inverse association with ≥2 chronic pain sites. Acrylamide, alkaline phosphatase, cadmium, cotinine, glycidamide, homocysteine, retinol, triglycerides and white blood cell count were positively associated with ≥2 chronic pain sites. Few biological markers were associated with acute and subacute pain. CONCLUSIONS: This study identified some biomarkers that were strongly and consistently associated with musculoskeletal pain. These results raise new hypotheses and could have tremendous implications for advancing knowledge in the field. Research on musculoskeletal pain needs to put more effort on the biological dimension of the biopsychosocial model of pain.

Evaluation of a prenatal screening decision aid: A mixed methods pilot study.

BACKGROUND: We developed a decision aid (DA) to help pregnant women and their partners make informed decisions about prenatal screening for trisomy. We aimed to determine its usefulness for preparing for decision-making and its acceptability among end-users. METHODS: In this mixed-methods pilot study, we recruited participants in three prenatal care settings in Quebec City. Eligible women were over 18 and more than 16 weeks pregnant or had given birth recently. We asked them about the usefulness of the DA using an interview grid based on the Technology Acceptance Model. We performed descriptive statistics and deductive analysis. RESULTS: Thirty-nine dyads or individuals participated in the study. Mean usefulness score was 86.2 ± 13. Most participants found the amount of information in the DA just right (79.5%), balanced (89.7%), and very useful (61.5%). They were less satisfied with the presentation and the values worksheet and suggested different values clarification methods. CONCLUSION: Rigorous pilot tests of DAs with patients are an important stage in their development before the more formal assessments that precede scaling up the DA in clinical practice. PRACTICE IMPLICATIONS: The next version of the DA will integrate the suggestions of end-users for better decision-making processes about prenatal screening for trisomy.

Impact of Fasting Status on the Use of Klotho as a Biomarker.

BACKGROUND: Klotho is a protein secreted physiologically in humans. It acts like a hormone that regulates many biological processes. It is also a novel serological biomarker that is increasingly used as a predictive factor for several physiological and psychological conditions. Surprisingly, there is no consensus about the fasting state of the patient who is tested for klotho. Most studies are done on fasting patients, although others are done without concern about fasting status. There is a lack of evidence about this variable in klotho serological testing. Performing fasting tests on patients can be deleterious and can affect compliance. We investigated the effect of fasting status on klotho serological value. METHODS: We conducted an observational study in which klotho serology was evaluated in a fasting state and 2 h after a meal. In total, 35 participants came to the laboratory without having eaten for 10 h. Blood samples were taken on arrival at our laboratory and 2 h after eating a standardized meal. RESULTS: The mean age of our participants was 32.7 years old. There were 13 men and 22 women. In the fasting state, the klotho value was 1060.5 pg/mL (SD: 557.5 pg/mL). At 2 h after the meal, the klotho value was 1077.5 pg/mL (SD: 576.9 pg/mL). Statistical tests showed no difference before and after a meal in our study (P = 0.2425). CONCLUSIONS: Our results suggest that it is not necessary to perform klotho serology in a fasting state.

Postoperative outcomes in surgical COVID-19 patients: a multicenter cohort study.

BACKGROUND: Data on postoperative outcomes of the COVID-19 patient population is limited. We described COVID-19 patients who underwent a surgery and the pandemic impact on surgical activities. METHODS: We conducted a multicenter cohort study between March 13 and June 192,020. We included all COVID-19 patients who underwent surgery in nine centres of the Province of Québec, the Canadian province most afflicted by the pandemic. We also included concomitant suspected COVID-19 (subsequently confirmed not to have COVID-19) patients and patients who had recovered from it. We collected data on baseline characteristics, postoperative complications and postoperative mortality. Our primary outcome was 30-day mortality. We also collected data on overall surgical activities during this first wave and during the same period in 2019. RESULTS: We included 44 COVID-19 patients, 18 suspected patients, and 18 patients who had recovered from COVID-19 at time of surgery. Among the 44 COVID-19 patients, 31 surgeries (71%) were urgent and 16 (36%) were major. In these patients, pulmonary complications were frequent (25%) and 30-day mortality was high (15.9%). This mortality was higher in patients with symptoms (23.1%) compared to those without symptoms (5.6%), although not statistically significant (p = 0.118). Of the total 22,616 cases performed among participating centres during the study period, only 0.19% had COVID-19 at the time of surgery. Fewer procedures were performed during the study period compared to the same period in 2019 (44,486 cases). CONCLUSION: In this Canadian cohort study, postoperative 30-day mortality in COVID-19 patients undergoing surgery was high (15.9%). Although few surgeries were performed on COVID-19 patients, the pandemic impact on surgical activity volume was important. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04458337 .

Web-Based Training for Nurses on Shared Decision Making and Prenatal Screening for Down Syndrome: Protocol for a Randomized Controlled Trial.

BACKGROUND: Pregnant women often find it difficult to choose from among the wide variety of available prenatal screening options. To help pregnant women and their partners make informed decisions based on their values, needs, and preferences, a decision aid and a web-based shared decision making (SDM) training program for health professionals have been developed. In Canada, nurses provide maternity care and thus can train as decision coaches for prenatal screening. However, there is a knowledge gap about the effectiveness of SDM interventions in maternity care in nursing practice. OBJECTIVE: This study aims to assess the impact of an SDM training program on nurses' intentions to use a decision aid for prenatal screening and on their knowledge and to assess their overall impressions of the training. METHODS: This is a 2-arm parallel randomized trial. French-speaking nurses working with pregnant women in the province of Quebec were recruited online by a private survey firm. They were randomly allocated (1:1 ratio) to either an experimental group, which completed a web-based SDM training program that included prenatal screening, or a control group, which completed a web-based training program focusing on prenatal screening alone. The experimental intervention consisted of a 3-hour web-based training hosted on the Université Laval platform with 4 modules: (1) SDM; (2) Down syndrome prenatal screening; (3) decision aids; and (4) communication between health care professionals and the patient. For the control group, the topic of SDM in Module 1 was replaced with "Context and history of prenatal screening," and the topic of decision aids in Module 3 was replaced with "Consent in prenatal screening." Participants completed a self-administered sociodemographic questionnaire with close-ended questions. We also assessed the participants' (1) intention to use a decision aid in prenatal screening clinical practice, (2) knowledge, (3) satisfaction with the training, (4) acceptability, and (5) perceived usefulness of the training. The randomization was done using a predetermined sequence and included 40 nurses. Participants and researchers were blinded. Intention to use a decision aid will be assessed by a t test. Bivariate and multivariate analysis will be performed to assess knowledge and overall impressions of the training. RESULTS: This study was funded in 2017 and approved by Genome Canada. Data were collected from September 2019 to late January 2020. This paper was initially submitted before data analysis began. Results are expected to be published in winter 2020. CONCLUSIONS: Study results will inform us on the impact of an SDM training program on nurses' intention to use and knowledge of decision aids for prenatal screening and their overall impressions of the training. Participant feedback will also inform an upgrade of the program, if needed. TRIAL REGISTRATION: ClinicalTrials.gov NCT04162288; https://clinicaltrials.gov/ct2/show/NCT04162288. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17878.

Decision Regret among Informal Caregivers Making Housing Decisions for Older Adults with Cognitive Impairment: A Cross-sectional Analysis.

Background. Informal caregivers are regularly faced with difficult housing decisions for older adults with cognitive impairment. They often regret the decision they made. We aimed to identify factors associated with decision regret among informal caregivers engaging in housing decisions for cognitively impaired older adults. Methods. We performed a secondary analysis of cross-sectional data collected from a cluster-randomized trial. Eligible participants were informal caregivers involved in making housing decisions for cognitively impaired older adults. Decision regret was assessed after caregivers' enrollment in the study using the Decision Regret Scale (DRS), scored from 0 to 100. We used a conceptual framework of potential predictors of regret to identify independent variables. We performed multilevel analyses using a mixed linear model by estimating fixed effects (ß) and 95% confidence intervals (CIs). Results. The mean (SD) DRS score of 296 informal caregivers (mean [SD] age, 62 [12] years) was 12.4 (18.4). Factors associated with less decision regret were having a college degree compared to primary education (ß [95% CI]: -11.14 [-18.36, -3.92]), being married compared to being single (-5.60 [-10.05, -1.15]), informal caregivers' perception that a joint process occurred (-0.14 [-0.25, -0.02]), and older adults' not having a specific housing preference compared to preferring to stay at home (-4.13 [-7.40, -0.86]). Factors associated with more decision regret were being retired compared to being a homemaker (7.74 [1.32, 14.16]), higher burden of care (0.14 [0.05, 0.22]), and higher decisional conflict (0.51 [0.34, 0.67]). Limitations. Our analysis may not illustrate all predictors of decision regret among informal caregivers. Conclusions. Our findings will allow risk-mitigation strategies for informal caregivers at risk of experiencing regret.

The stigma of low opioid prescription in the hospitalized multimorbid elderly in Italy.

The primary aim of this study was to evaluate the prevalence of opioid prescriptions in hospitalized geriatric patients. Other aims were to evaluate factors associated with opioid prescription, and whether or not there was consistency between the presence of pain and prescription. Opioid prescriptions were gathered from the REgistro POliterapie Societa` Italiana di Medicina Interna (REPOSI) data for the years 2008, 2010 and 2012. 1,380 in-patients, 65+ years old, were enrolled in the first registry run, 1,332 in the second and 1,340 in the third. The prevalence of opioid prescription was calculated at hospital admission and discharge. In the third run of the registry, the degree of pain was assessed by means of a numerical scale. The prevalence of patients prescribed with opioids at admission was 3.8% in the first run, 3.6% in the second and 4.1% in the third, whereas at discharge rates were slightly higher (5.8, 5.3, and 6.6%). The most frequently prescribed agents were mild opioids such as codeine and tramadol. The number of total prescribed drugs was positively associated with opioid prescription in the three runs; in the third, dementia and a better functional status were inversely associated with opioid prescription. Finally, as many as 58% of patients with significant pain at discharge were prescribed no analgesic at all. The conservative attitude of Italian physicians to prescribe opioids in elderly patients changed very little between hospital admission and discharge through a period of 5 years. Reasons for such a low opioid prescription should be sought in physicians' and patients' concerns and prejudices.

Prevalence of dementia in the oldest old: the Monzino 80-plus population based study.

BACKGROUND: Epidemiological studies commonly include too few of the oldest old to provide accurate prevalence rates of dementia in older age groups. Estimates of the number of those affected, necessary for healthcare planning, are thus flawed. The objective is to estimate the prevalence of dementia and levels of dementia severity in a very large population of oldest old and to investigate the relation between age and dementia prevalence in the extreme ages. METHODS: The Monzino 80-plus is a population-based study among residents 80 years or older in Varese province, Italy. Dementia cases were identified using a one-phase design. The survey was conducted in the participant's place of residence, whether home or institution. Both participants and informants were interviewed. Information was available for 2504 of the 2813 residents (89%). RESULTS: In all, 894 individuals (714 women and 180 men) met the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) criteria for dementia, for a standardized prevalence of 25.3% (95% confidence interval [CI]: 23.4, 27.2%), 28.5% (95% CI: 26.2, 30.9) in women and 18.6% (95% CI: 15.2, 21.9) in men. Age-specific prevalence estimates of dementia increased with age from 15.7% at age 80 to 84 years to 65.9% at age 100 years and higher. For women, prevalence continued to rise after age 100 years, from 64.8% at age 100 to 101 years to 76.1% at age 102 to 107 years. After age 85 years prevalence rates tended to rise linearly, on average 2.6% per year in women and 1.8% in men. About 80% of the cases were moderate or severe. The frequency of mild dementia decreased and that of severe dementia increased with age. CONCLUSION: One-quarter of 80-plus year olds are affected by dementia, mostly moderate or severe. Prevalence rates of dementia do not level off, but continue to rise gradually even in the extreme ages.

The drug prescription network: a system-level view of drug co-prescription in community-dwelling elderly people.

Networks are well suited to display and analyze complex systems that consist of numerous and interlinked elements. This study aimed at: (1) generating a series of drug prescription networks (DPNs) displaying co-prescription in community-dwelling elderly people; (2) analyzing DPN structure and organization; and (3) comparing various DPNs to unveil possible differences in drug co-prescription patterns across time and space. Data were extracted from the administrative prescription database of the Lombardy Region in northern Italy in 2000 and 2010. DPNs were generated, in which each node represents a drug chemical subclass, whereas each edge linking two nodes represents the co-prescription of the corresponding drugs to the same patient. At a global level, the DPN was a very dense and highly clustered network, whereas at the local level it was organized into anatomically homogeneous modules. In addition, the DPN was assortative by class, because similar nodes (representing drugs with the same anatomic, therapeutic, and pharmacologic annotation) connected to each other more frequently than expected, indicating that similar drugs are often co-prescribed. Finally, temporal changes in the co-prescription of specific drug sub-groups (for instance, proton pump inhibitors) translated into topological changes of the DPN and its modules. In conclusion, complementing more traditional pharmaco-epidemiology methods, the DPN-based method allows appreciatiation (and representation) of general trends in the co-prescription of a specific drug (e.g., its emergence as a heavily co-prescribed hub) in comparison with other drugs.

Electrocardiographic monitoring for new prescriptions of quetiapine co-prescribed with acetylcholinesterase inhibitors or memantine from 2005 to 2009. A population study on community-dwelling older people in Italy.

PURPOSE: The aims of this study are to analyse, in community-dwelling people aged 65+ living in Italy's Lombardy Region, electrocardiographic (ECG) monitoring for new users of the atypical antipsychotic quetiapine co-prescribed with acetylcholinesterase inhibitors (AChEIs) or memantine and to find independent predictors of ECG monitoring before and after the starting of this prescription. METHODS: The Lombardy Region's administrative health database was used to retrieve prescriptions of ECG exams as well as prevalence rates of subjects aged 65+ who were prescribed such psychotropic drugs from 2005 to 2009. Multivariable analyses were adjusted for age, sex, number of drugs, treatment with beta-blockers, digoxin, verapamil or diltiazem, any antiarrhythmic drug and antidepressants. RESULTS: Overall 2,623 community-dwelling older people started therapy with quetiapine, co-prescribed with AChEIs or memantine, during these 5 years. At least one ECG was performed in 714 cases (27.2 %) in the 6 months before-and in 398 cases (15.2 %) within 3 months after-the starting of this prescription. ECG monitoring was performed both before and after starting quetiapine in only 160 cases (6.1 %). At multivariable analyses, number of drugs taken, beta-blocker and antiarrhythmic drug use were found to be independent correlates of ECG monitoring whereas female sex was associated with a lower probability of receiving an ECG within 3 months after the initiation of quetiapine (odds ratio 0.78, 95 % CI 0.62-0.98). CONCLUSIONS: ECG monitoring for new prescriptions of quetiapine in older people suffering from behavioural and psychological symptoms in dementia was actually performed infrequently, independently of the age of drug users, especially in women. Our results support the need for greater awareness within the medical community of the importance of such ECG monitoring.

Prognostic value of estimated glomerular filtration rate in hospitalized elderly patients.

A multicenter observational study, REPOSI (REgistro POliterapie Società Italiana di Medicina Interna), was conducted to assess the prognostic value of glomerular filtration rate (eGFR) on in-hospital mortality, hospital re-admission and death within 3 months, in a sample of elderly patients (n = 1,363) admitted to 66 internal medicine and geriatric wards. Based on eGFR, calculated by the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula, subjects at hospital admission were classified into three groups: group 1 with normal eGFR (≥60 ml/min/1.73 m(2), reference group), group 2 with moderately reduced eGFR (30-59 ml/min/1.73 m(2)) and group 3 with severely reduced eGFR (<30 ml/min/1.73 m(2)). Patients with the lowest eGFR (group 3) on admission were more likely to be older, to have a greater cognitive and functional impairment and a high rate of comorbidities. Multivariable logistic regression analysis showed that severely reduced eGFR at the time of admission was associated with in-hospital mortality (OR 3.00; 95% CI 1.20-7.39, p = 0.0230), but not with re-hospitalization (OR 0.97; 95% CI 0.54-1.76, p = 0.9156) or mortality at 3 months after discharge (OR 1.93; 95% CI 0.92-4.04, p = 0.1582). On the contrary, an increased risk (OR 2.60; 95% CI 1.13-5.98, p = 0.0813) to die within 3 months after discharge was associated with decreased eGFR measured at the time of discharge. Our study demonstrates that severely reduced eGFRs in elderly patients admitted to hospital are strong predictors of the risk of dying during hospitalization, and that this measurement at the time of discharge helps to predict early death after hospitalization.

Caregivers' perceptions of the therapeutic benefits of drug treatments for dementia.

BACKGROUND AND AIMS: To collect opinions, perceptions, and expectations on the therapeutic benefits of drug treatment for dementia and the impact on the care of the patient in a large sample of caregivers. Only few studies deal with this topic in a small number of participants. METHODS: This used an ad-hoc online questionnaire to collect the opinions of caregivers of patients with dementia and assess their expectations and perceptions of the therapeutic benefits of drug treatments. The questionnaire was accessible for nearly 4 months on the Federazione Alzheimer Italia website and had three sections: (1) information on the patient with dementia; (2) information on the caregiver's perception of the therapeutic benefits of drug treatments; (3) information on caregivers. To evaluate the relationship between the caregiver's expectations of the therapeutic benefits of dementia treatments and some characteristics of the patients and the caregivers, we used the Chi-square test. RESULTS: During the access time, 439 questionnaires were filled, and 369 were validated for inclusion in the analysis; of these, 329 also had information on caregivers. The expectations of drug treatment effects were not statistically significantly influenced by any variables considered about the patients or the caregivers. Caregivers' beliefs about the effectiveness of dementia treatment, their expectations and changes in their lives were clear. CONCLUSIONS: This study addresses a gap in knowledge about caregivers' experiences and their views of drug treatments, and highlights the need for a pharmaceutical treatment that helps to resolve the symptoms and outcomes of dementia.

Antipsychotics prescription and cerebrovascular events in Italian older persons.

Meta-analyses have found conflicting evidence on the link between antipsychotics and cerebrovascular events (CVEs). The primary aim of this study was to evaluate the association between any antipsychotic prescription and CVEs in Italian elderly; second, to compare the effect of typical and atypical antipsychotics on CVEs; and third, to investigate the effect of antipsychotics on CVEs in the subgroup of persons coprescribed with acetylcholinesterase inhibitors (AChEIs). Administrative claims from community-dwelling people aged 65 to 94 years living in Northern Italy were analyzed using a retrospective case-control design, from 2003 to 2005. The primary outcome measure was a hospital discharge diagnosis of CVEs during 2005. Four age-, sex-, and local health unit-matched control subjects were identified for each case. Antihypertensive drugs, anticoagulants, platelet inhibitors, antidiabetic drugs, lipid-lowering drugs, and AChEI were used as covariates in conditional logistic regression models testing the odds ratio (OR) for CVEs due to antipsychotics use. Three thousand eight hundred fifty-five cases of CVEs were identified and matched with 15,420 control subjects. In multiadjusted models, the association of any antipsychotics, typical or atypical with CVEs, was not significant. When antipsychotics were categorized according to the number of boxes prescribed during the observational period, being prescribed with at least 19 boxes of typical antipsychotics was significantly associated with CVEs (OR, 2.4; 95% confidence interval, 1.08-5.5). An interaction was found between any antipsychotic and AChEI coprescription on CVEs (OR, 0.46; 95% confidence interval, 0.23-0.92). In conclusion, only typical antipsychotics were associated with an increased odd of CVEs, but the association was duration dependent. Persons prescribed simultaneously with AChEI and antipsychotics may be at a lower risk of CVEs.

Prophylaxis of venous thromboembolism in elderly patients with multimorbidity.

Pharmacological thromboprophylaxis (TP) is known to reduce venous thromboembolism (VTE) in medical inpatients, but the criteria for risk-driven prescription, safety and impact on mortality are still debated. We analyze data on elderly patients with multimorbidities admitted in the year 2010 to the Italian internal medicine wards participating in the REPOSI registry to investigate the rate of TP during the hospital stay, and analyze the factors that are related to its prescription. Multivariate logistic regression, area under the ROC curve and CART analysis were performed to look for independent predictors of TP prescription. Association between TP and VTE, bleeding and death in hospital and during the 3-month post-discharge follow-up were explored by logistic regression and propensity score analysis. Among the 1,380 patients enrolled, 171 (15.2 %) were on TP during the hospital stay (162 on low molecular weight heparins, 9 on fondaparinux). The disability Barthel index was the main independent predictor of TP prescription. Rate of fatal and non-fatal VTE and bleeding during and after hospitalization did not differ between TP and non-TP patients. In-hospital and post-discharge mortality was significantly higher in patients on TP, that however was not an independent predictor of mortality. Among elderly medical patients there was a relatively low rate of TP, that was more frequently prescribed to patients with a higher degree of disability and who had an overall higher mortality.

New prescriptions of spironolactone associated with angiotensin-converting-enzyme inhibitors and/or angiotensin receptor blockers and their laboratory monitoring from 2001 to 2008: a population study on older people living in the community in Italy.

PURPOSE: To analyse, in older community-dwelling people living in Italy's Lombardy region, 8-year trends in new users of spironolactone co-prescribed with angiotensin-converting-enzyme inhibitors (ACE-Is) and/or angiotensin receptor blockers (ARBs); blood test monitoring; and independent predictors of appropriate blood test monitoring. METHODS: The region's administrative health database from 2001 to 2008 was used to retrieve yearly frequencies of subjects aged 65+ who started this co-prescription. Multivariate analyses were adjusted for age, sex, local health unit, treatment with beta-blockers, drugs for diabetes, and polypharmacy (i.e., exposure to five or more different drugs). RESULTS: Only new users of spironolactone co-prescribed with ARBs increased from 2001 to 2008 (P < 0.001). In the 6 months before starting the co-prescriptions 96 to 100% of patients measured serum creatinine (mean 99.3%), sodium (97.3%) and potassium (98.6%). Within 3 months of starting the co-prescriptions 96 to 99% of patients measured serum sodium (mean 97.3%) and potassium (98.6%), but on average only 48% of them (range 43 to 53%) measured serum creatinine, with an increase over time (odds ratio [change in regression per year] = 1.03, 95% CI 1.02-1.05, P < 0.001). At multivariate analysis polypharmacy was found to be the only independent predictor of such creatinine monitoring (P < 0.001). CONCLUSIONS: Our results support the need for greater awareness within the medical community of the potential renal toxicity of the association of spironolactone with ACE-Is and/or ARBs. Adequate short-term monitoring of serum creatinine in all older community-dwelling people who receive such co-prescription is necessary in order to ensure safe usage of these medications.