An Ontology-Based Approach to Improving Medication Appropriateness in Older Patients: Algorithm Development and Validation Study.

Background: Inappropriate medication in older patients with multimorbidity results in a greater risk of adverse drug events. Clinical decision support systems (CDSSs) are intended to improve medication appropriateness. One approach to improving CDSSs is to use ontologies instead of relational databases. Previously, we developed OntoPharma-an ontology-based CDSS for reducing medication prescribing errors. Objective: The primary aim was to model a domain for improving medication appropriateness in older patients (chronic patient domain). The secondary aim was to implement the version of OntoPharma containing the chronic patient domain in a hospital setting. Methods: A 4-step process was proposed. The first step was defining the domain scope. The chronic patient domain focused on improving medication appropriateness in older patients. A group of experts selected the following three use cases: medication regimen complexity, anticholinergic and sedative drug burden, and the presence of triggers for identifying possible adverse events. The second step was domain model representation. The implementation was conducted by medical informatics specialists and clinical pharmacists using Protégé-OWL (Stanford Center for Biomedical Informatics Research). The third step was OntoPharma-driven alert module adaptation. We reused the existing framework based on SPARQL to query ontologies. The fourth step was implementing the version of OntoPharma containing the chronic patient domain in a hospital setting. Alerts generated from July to September 2022 were analyzed. Results: We proposed 6 new classes and 5 new properties, introducing the necessary changes in the ontologies previously created. An alert is shown if the Medication Regimen Complexity Index is ≥40, if the Drug Burden Index is ≥1, or if there is a trigger based on an abnormal laboratory value. A total of 364 alerts were generated for 107 patients; 154 (42.3%) alerts were accepted. Conclusions: We proposed an ontology-based approach to provide support for improving medication appropriateness in older patients with multimorbidity in a scalable, sustainable, and reusable way. The chronic patient domain was built based on our previous research, reusing the existing framework. OntoPharma has been implemented in clinical practice and generates alerts, considering the following use cases: medication regimen complexity, anticholinergic and sedative drug burden, and the presence of triggers for identifying possible adverse events.

OntoPharma: ontology based clinical decision support system to reduce medication prescribing errors.

BACKGROUND: Clinical decision support systems (CDSS) have been shown to reduce medication errors. However, they are underused because of different challenges. One approach to improve CDSS is to use ontologies instead of relational databases. The primary aim was to design and develop OntoPharma, an ontology based CDSS to reduce medication prescribing errors. Secondary aim was to implement OntoPharma in a hospital setting. METHODS: A four-step process was proposed. (1) Defining the ontology domain. The ontology scope was the medication domain. An advisory board selected four use cases: maximum dosage alert, drug-drug interaction checker, renal failure adjustment, and drug allergy checker. (2) Implementing the ontology in a formal representation. The implementation was conducted by Medical Informatics specialists and Clinical Pharmacists using Protégé-OWL. (3) Developing an ontology-driven alert module. Computerised Physician Order Entry (CPOE) integration was performed through a REST API. SPARQL was used to query ontologies. (4) Implementing OntoPharma in a hospital setting. Alerts generated between July 2020/ November 2021 were analysed. RESULTS: The three ontologies developed included 34,938 classes, 16,672 individuals and 82 properties. The domains addressed by ontologies were identification data of medicinal products, appropriateness drug data, and local concepts from CPOE. When a medication prescribing error is identified an alert is shown. OntoPharma generated 823 alerts in 1046 patients. 401 (48.7%) of them were accepted. CONCLUSIONS: OntoPharma is an ontology based CDSS implemented in clinical practice which generates alerts when a prescribing medication error is identified. To gain user acceptance OntoPharma has been designed and developed by a multidisciplinary team. Compared to CDSS based on relational databases, OntoPharma represents medication knowledge in a more intuitive, extensible and maintainable manner.

Mejora de calidad del área de pacientes externos mediante participación del paciente y metodología Lean

Objetivo: Mejorar la calidad del proceso de dispensación y atenciónfarmacéutica a pacientes externos mediante la participación del pacientey la aplicación de la metodología Lean y analizar los resultados obtenidos en cuanto a eficiencia e impacto en la satisfacción de los pacientes.Método: Estudio observacional, prospectivo y unicéntrico. Se creó ungrupo de trabajo con los diferentes profesionales implicados en la atención al paciente externo para aplicar la metodología Lean y detectaroportunidades de mejora. Para conocer la experiencia del paciente seutilizó la técnica del grupo focal. El impacto en la satisfacción de lospacientes se midió mediante encuestas de satisfacción que se enviaron através del correo electrónico en diciembre de 2019 (antes de implantarlas principales medidas) y en diciembre de 2020.Resultados: Teniendo en cuenta la perspectiva de los pacientes yde los profesionales sanitarios, se identificaron más de 30 acciones demejora de las que se priorizaron 9, relacionadas fundamentalmente concambios estructurales y de circuitos. Se consiguió mejorar significativamente los tiempos de espera (el 35% de los pacientes esperaban másde 30 minutos frente al 4,5% en el análisis realizado después de lasintervenciones). Los aspectos que mostraron diferencias estadísticamentesignificativas en las encuestas entre los dos periodos fueron el tiempo de espera y la satisfacción global, en ambos casos el grado de satisfacciónfue superior una vez implantadas las acciones de mejora. (AU)

Objective: To improve the quality of the dispensing process and pharmaceutical care in the Outpatient Pharmacy through patient participationand Lean methodology, and to analyse the results obtained in terms ofefficiency and patient satisfaction.Method: Prospective observational single-centre study. A working groupwas organized with the health care staff involved in outpatient care toapply Lean methodology and detect improvement opportunities. Weused a focus group technique to understand the patients’ experience. Theimpact on patient satisfaction was measured through a mass survey mailed out in December 2019 (before introducing the main measures) and inDecember 2020.Results: More than 30 improvement actions were identified after surveying the opinions of the patients and health care staff involved. Nineactions were prioritized, which were mainly related to structural andcircuit changes. Waiting times significantly improved (35% of patientswaited for more than 30 minutes before the improvement actions vs4.5% afterward). The results showed that waiting times and overall satisfaction significantly improved in the period between the two surveys. Inboth cases, the degree of satisfaction was higher after introducing theimprovement actions. (AU)

Improvement of outpatient pharmacy through patient participation and Lean methodology.

OBJECTIVE: To improve the quality of the dispensing process and  pharmaceutical care in the Outpatient Pharmacy through patient participation and Lean methodology, and to analyse the results obtained in  terms of efficiency and patient satisfaction. METHOD: Prospective observational single-centre study. A working group was  organized with the health care staff involved in outpatient care to apply Lean  methodology and detect improvement opportunities. We used a focus group  technique to understand the patients' experience. The impact on patient  satisfaction was measured through a mass survey mailed out in December  2019 (before introducing the main measures) and in December 2020. RESULTS: More than 30 improvement actions were identified after surveying the opinions of the patients and health care staff involved. Nine actions were prioritized, which were mainly related to structural and circuit changes. Waiting times significantly improved (35% of patients waited for more than 30 minutes before the improvement actions vs 4.5% afterward). The results showed that waiting times and overall  satisfaction significantly improved in the period between the two surveys. In both cases, the degree of satisfaction was higher after introducing the improvement actions. CONCLUSIONS: We analysed the situation of our Outpatient Service and designed the most appropriate improvement actions according to the resources available. This initiative was achieved through patient  participation (via a focus group and mass surveys), the participation of health  care staff, and the application of Lean methodology.

Objetivo: Mejorar la calidad del proceso de dispensación y atención farmacéutica a pacientes externos mediante la participación del  paciente y la aplicación de la metodología Lean y analizar los resultados  obtenidos en cuanto a eficiencia e impacto en la satisfacción de los pacientes. Método: Estudio observacional, prospectivo y unicéntrico. Se creó un grupo de  trabajo con los diferentes profesionales implicados en la atención al  paciente externo para aplicar la metodología Lean y detectar oportunidades de  mejora. Para conocer la experiencia del paciente se utilizó la técnica del grupo  focal. El impacto en la satisfacción de los pacientes se midió mediante  encuestas de satisfacción que se enviaron a través del correo electrónico en  diciembre de 2019 (antes de implantar las principales medidas) y en diciembre  de 2020.Resultados: Teniendo en cuenta la perspectiva de los pacientes y de los  profesionales sanitarios, se identificaron más de 30 acciones de mejora de las  que se priorizaron 9, relacionadas fundamentalmente con cambios  estructurales y de circuitos. Se consiguió mejorar significativamente los  tiempos de espera (el 35% de los pacientes esperaban más de 30 minutos  frente al 4,5% en el análisis realizado después de las intervenciones). Los  aspectos que mostraron diferencias estadísticamente significativas en las  encuestas entre los dos periodos fueron el tiempo de espera y la satisfacción  global, en ambos casos el grado de satisfacción fue superior una vez  implantadas las acciones de mejora.Conclusiones: La participación del paciente, a través del grupo focal y  encuestas masivas, unido a la participación de los profesionales sanitarios implicados en el proceso, a través de la metodología Lean, ha permitido analizar la realidad de nuestro servicio y diseñar las acciones de  mejora más adecuadas en función de los recursos disponibles.

Dose banding of intravenous ganciclovir: Banding scheme proposal and audit of toxicity and efficiency.

WHAT IS KNOWN AND OBJECTIVE: Dose banding is a strategy to optimize processing without reducing patient safety. Prescribed doses are rounded up or down to predetermined standard doses. Although it has been mostly used in chemotherapy, other drugs are suitable for this strategy, such as the antiviral ganciclovir. The aim of this work is to assess the safety and efficiency of a dose-rounding system for intravenous ganciclovir. METHODS: Dose bands were established for a maximum of 10% variation from the individualized dose. The number of annual preparations that expired before use and the number of ganciclovir vials saved were documented as indicators of efficiency. Toxicity was assessed comparing haematological parameters before and after ganciclovir treatment in a sample of patients who received doses above the theoretical dose (n = 121) and in the rest of the cohort (n = 129). RESULTS AND DISCUSSION: Five ganciclovir standard doses were established. It was shown that the bulk of the preparations (83.7%) had a maximum variation between the exact dose prescribed and the adjusted dose of ±10%. Three years after its implementation, a mean of 2848 annual preparations were compounded. The average percentage of annual expired preparations was lower than 1% of the total compounded doses, and the dose-rounding system allowed for saving 699 manufactured ganciclovir vials annually. There was no significant difference between haemoglobin and leucocyte levels measured before and after ganciclovir treatment in both groups. WHAT IS NEW AND CONCLUSION: Ganciclovir dose banding allows for efficient management of preparations without an increased risk of acute haematological side effects.

Selection of interventions aimed at improving medication adherence in patients with multimorbidity.

OBJECTIVES: To select interventions aimed at improving medication adherence in patients with multimorbidity by means of a standardised methodology. METHODS: A modified Delphi methodology was used to reach consensus. Interventions that had demonstrated their efficacy in improving medication adherence in patients with multimorbidity or in similar populations were identified from a literature search of several databases (PubMed, EMBASE, the Cochrane Library, Center for Reviews and Dissemination, and Web of Science). 11 experts in medication adherence and/or chronic disease scored the selected interventions for appropriateness according to three criteria: strength of the evidence that supported each intervention, usefulness in patients with multimorbidity, and feasibility of implementation in clinical practice. The final set of interventions was selected according to appropriateness and agreement based on the Delphi methodology. RESULTS: 566 articles were retrieved in the literature search. Nine systematic reviews were included. 33 interventions were initially selected for evaluation by the panellists. Consensus after two Delphi rounds was reached on 16 interventions. Five interventions were categorized as educational, six as behavioural and five were related to other aspects of interest. CONCLUSIONS: The interventions selected following a comprehensive and standardized methodology, could be used to improve medication adherence in patients with multimorbidity.

Modelo de Prescripción Centrado en la Persona para mejorar la adherencia terapéutica en pacientes con multimorbilidad / Patient-Centered Prescription Model to improve therapeutic adherence in patients with multimorbidity

Según los estudios disponibles, la eficacia de las intervenciones para mejorar la adherencia terapéutica en pacientes con multimorbilidad es limitada e inconsistente; por ello, debemos definir nuevos modelos de intervención que incorporen como elementos clave la atención centrada en la persona, el abordaje interdisciplinar y la orientación a la mejora de la adecuación terapéutica. En este sentido, el Modelo de Prescripción Centrado en la Persona ha demostrado su capacidad para adecuar la prescripción a las necesidades de pacientes con complejidad clínica. Para ello, incorpora cuatro etapas consecutivas: 1) valoración centrada en el paciente; 2) valoración centrada en el diagnóstico; 3) valoración centrada en el fármaco, y 4) propuesta de plan terapéutico. Proponemos, a través de un caso práctico, una adaptación del Modelo de Prescripción Centrado en la Persona como estrategia para mejorar la adherencia terapéutica. Para ello, en la primera etapa del modelo hemos incorporado una herramienta para la valoración multidimensional de la adherencia adaptada transculturalmente al español. Posteriormente, proponemos un conjunto de intervenciones a aplicar en las tres etapas restantes del modelo. Dichas intervenciones han sido identificadas en un resumen de revisiones sistemáticas y posteriormente seleccionadas mediante la metodología Delphi. Todos estos elementos han sido considerados adecuados en pacientes con multimorbilidad por la solidez de su evidencia, su utilidad potencial en la población diana y la factibilidad de su aplicación en la práctica clínica. La aproximación propuesta pretende sentar las bases de un modelo de cambio respecto al abordaje de la adherencia en el paciente con multimorbilidad

To date, interventions to improve medication adherence in patients with multimorbidity have shown modest and inconsistent efficacy among available studies. Thereby, we should define new approaches aimed at improving medication adherence tailored to effective prescribing, with a multidisciplinary approach and patient-centered. In this regard, the Patient-Centered Prescription Model has shown its usefulness on improving appropriateness of drug treatments in patients with clinical complexity. For that, this strategy addresses the following four steps: 1) Patient-Centered assessment; 2) Diagnosis-Centered assessment; 3) Medication-Centered assessment; and 4) Therapeutic Plan. We propose through a clinical case an adaptation of the Patient-Centered Prescription Model to enhance both appropriateness and medication adherence in patients with multimorbidity. To this end, we have included on its first step the Spanish version of a cross-culturally adapted scale for the multidimensional assessment of medication adherence. Furthermore, we suggest a set of interventions to be applied in the three remaining steps of the model. These interventions were firstly identified by an overview of systematic reviews and then selected by a panel of experts based on Delphi methodology. All of these elements have been considered appropriate in patients with multimorbidity according to three criteria: strength of their supporting evidence, usefulness in the target population and feasibility of implementation in clinical practice. The proposed approach intends to lay the foundations for an innovative way in tackling medication adherence in patients with multimorbidity

Patient-Centered Prescription Model to improve therapeutic adherence in patients with multimorbidity.

To date, interventions to improve medication adherence in patients with multimorbidity have shown modest and inconsistent efficacy among  available studies. Thereby, we should define new approaches aimed at improving medication adherence tailored to effective prescribing, with a multidisciplinary approach and patient-centered.In this regard, the Patient-Centered Prescription Model has shown its usefulness on improving appropriateness of drug treatments in patients with clinical complexity. For that, this strategy addresses the following four steps: 1) Patient-Centered assessment; 2) Diagnosis-Centered assessment; 3) Medication-Centered assessment; and 4) Therapeutic Plan.We propose through a clinical case an adaptation of the Patient-Centered Prescription Model to enhance both appropriateness and medication adherence in patients with multimorbidity. To this end, we have  included on its first step the Spanish version of a cross-culturally adapted scale  for the multidimensional assessment of medication adherence. Furthermore, we suggest a set of interventions to be applied in the three remaining steps of  the model. These interventions were firstly identified by an overview of systematic reviews and then selected by a panel of experts based on Delphi methodology.All of these elements have been considered appropriate in patients with multimorbidity according to three criteria: strength of their supporting  evidence, usefulness in the target population and feasibility of implementation in clinical practice.The proposed approach intends to lay the foundations for an innovative way in  tackling medication adherence in patients with multimorbidity.

Según los estudios disponibles, la eficacia de las intervenciones para mejorar la  adherencia terapéutica en pacientes con multimorbilidad es limitada e  inconsistente; por ello, debemos definir nuevos modelos de intervención que  incorporen como elementos clave la atención centrada en la persona, el abordaje interdisciplinar y la orientación a la mejora de la adecuación terapéutica.En este sentido, el Modelo de Prescripción Centrado en la Persona ha  demostrado su capacidad para adecuar la prescripción a las necesidades de  pacientes con complejidad clínica. Para ello, incorpora cuatro etapas consecutivas: 1) valoración centrada en el paciente; 2) valoración  centrada en el diagnóstico; 3) valoración centrada en el fármaco, y 4) propuesta de plan terapéutico.Proponemos, a través de un caso práctico, una adaptación del Modelo de Prescripción Centrado en la Persona como estrategia para mejorar la  adherencia terapéutica. Para ello, en la primera etapa del modelo hemos  incorporado una herramienta para la valoración multidimensional de la  adherencia adaptada transculturalmente al español. Posteriormente,  proponemos un conjunto de intervenciones a aplicar en las tres etapas restantes del modelo. Dichas intervenciones han sido identificadas en un resumen de  revisiones sistemáticas y posteriormente seleccionadas mediante la metodología  Delphi. Todos estos elementos han sido considerados adecuados en pacientes  con multimorbilidad por la solidez de su evidencia, su utilidad potencial en la población diana y la factibilidad de su aplicación en la práctica clínica. La  aproximación propuesta pretende sentar las bases de un modelo de cambio respecto al abordaje de la adherencia en el paciente con multimorbilidad.

Traducción y adaptación transcultural al español del cuestionario ARMS para la medida de la adherencia en pacientes pluripatológicos / Spanish translation and cross-cultural adaptation of the ARMS-scale for measuring medication adherence in polypathological patients

Objetivo: Traducir y adaptar transculturalmente el cuestionario ARMS al español para medir la adherencia en pacientes pluripatológicos. Diseño: Traducción, adaptación transcultural y análisis de la comprensibilidad mediante entrevistas cognitivas. Emplazamiento: Hospital de segundo nivel. Mediciones: 1) Traducción directa e inversa seguidas de una síntesis y adaptación transcultural mediante metodología cualitativa para garantizar la equivalencia conceptual, semántica y de contenido entre el cuestionario original y su versión española. 2) Análisis de la comprensibilidad de la versión española del cuestionario mediante entrevistas cognitivas en una muestra de pacientes pluripatológicos no institucionalizados. Resultados: Se obtuvo la versión española del cuestionario ARMS (ARMS-e). La dificultad global de los traductores responsables de la traducción directa e inversa para encontrar una expresión conceptualmente equivalente entre los dos idiomas fue baja. El análisis de la comprensibilidad, realizado en una muestra aleatoria de 40 pacientes pluripatológicos no institucionalizados ingresados en un servicio de medicina interna de un hospital de segundo nivel, mostró una excelente comprensibilidad. Conclusiones: El cuestionario ARMS-e es una versión adaptada al español del cuestionario ARMS que es adecuada para la medida de la adherencia en pacientes pluripatológicos. Su estructura facilita un abordaje multidimensional de la falta de adherencia permitiendo individualizar posibles intervenciones en función de las barreras detectadas en cada paciente (AU)

Aim: Translate the ARMS scale into Spanish ensuring cross-cultural equivalence for measuring medication adherence in polypathological patients. Design: Translation, cross-cultural adaptation and pilot testing. Location: Secondary hospital. Measurements: (i) Forward and blind-back translations followed by cross-cultural adaptation through qualitative methodology to ensure conceptual, semantic and content equivalence between the original scale and the Spanish version. (ii) Pilot testing in non-institutionalized polypathological patients to assess the instrument for clarity. Results: The Spanish version of the ARMS scale has been obtained. Overall scores from translators involved in forward and blind-back translations were consistent with a low difficulty for assuring conceptual equivalence between both languages. Pilot testing (cognitive debriefing) in a sample of 40 non-institutionalized polypathological patients admitted to an internal medicine department of a secondary hospital showed an excellent clarity. Conclusions: The ARMS-e scale is a Spanish-adapted version of the ARMS scale, suitable for measuring adherence in polypathological patients. Its structure enables a multidimensional approach of the lack of adherence allowing the implementation of individualized interventions guided by the barriers detected in every patient (AU)

[Spanish translation and cross-cultural adaptation of the ARMS-scale for measuring medication adherence in polypathological patients]. / Traducción y adaptación transcultural al español del cuestionario ARMS para la medida de la adherencia en pacientes pluripatológicos.

AIM: Translate the ARMS scale into Spanish ensuring cross-cultural equivalence for measuring medication adherence in polypathological patients. DESIGN: Translation, cross-cultural adaptation and pilot testing. LOCATION: Secondary hospital. MEASUREMENTS: (i)Forward and blind-back translations followed by cross-cultural adaptation through qualitative methodology to ensure conceptual, semantic and content equivalence between the original scale and the Spanish version. (ii)Pilot testing in non-institutionalized polypathological patients to assess the instrument for clarity. RESULTS: The Spanish version of the ARMS scale has been obtained. Overall scores from translators involved in forward and blind-back translations were consistent with a low difficulty for assuring conceptual equivalence between both languages. Pilot testing (cognitive debriefing) in a sample of 40 non-institutionalized polypathological patients admitted to an internal medicine department of a secondary hospital showed an excellent clarity. CONCLUSIONS: The ARMS-e scale is a Spanish-adapted version of the ARMS scale, suitable for measuring adherence in polypathological patients. Its structure enables a multidimensional approach of the lack of adherence allowing the implementation of individualized interventions guided by the barriers detected in every patient.

Design and validation of a predictive model for 1-year hospital admission in HIV patients on antiretroviral treatment.

OBJECTIVES: To develop and validate a model for predicting the risk of hospital admission within 1 year in the HIV population under antiretroviral treatment. METHODS: We conducted a retrospective observational study. Patients receiving antiretroviral treatment for at least 1 year who were followed by the pharmacy service in a Spanish-speaking hospital between January 2008 and December 2012 were included. Demographics, and clinical and pharmacotherapy variables, were included in the model design. To find prognostic factors for hospital admission a multivariate logistic regression model was created after performing a univariate analysis. Model validity was determined by the shrinkage method and the model discrimination by Harrell's C-index. RESULTS: 442 patients were included in the study. The variables 'CD4 count <200 (cells/µL)', 'drug/alcohol use', 'detectable viral load (>50 copies/mL)', 'number of previous admissions', and 'number of drugs different from antiretroviral treatment' were the independent predictors of risk of hospital admission. Probabilities predicted by the model showed an R2=0.98 for the development sample and an R2=0.86 for the validation sample. The Harrell's C index for the development and validation data were 0.82 (95% CI 0.77 to 0.87) and 0.80 (95% CI 0.73 to 0.88), respectively. CONCLUSIONS: The model developed in this study may be useful in daily practice for identifying HIV patients at high risk of 1-year hospital admission.

Influence of treatment complexity on adherence and incidence of blips in HIV/HCV coinfected patients.

BACKGROUND: The addition of antihepatitis C therapy to highly active antiretroviral treatment (HAART) in human immunodeficiency virus (HIV)/hepatitis C virus (HCV) coinfected patients leads to an increase in the treatment complexity that may result in decreased adherence. Blips, defined as intermittent episodes of detectable low-level HIV viremia, may be an indication of poor adherence to HAART. OBJECTIVES: To (a) determine the influence of adding anti-HCV therapy to HAART on complexity index, adherence, and incidence of blips and (b) determine complexity index and adherence in patient subgroups based on anti-HCV therapy. METHODS: We conducted a prospective 2-center observational study. HIV/HCV coinfected patients under antiretroviral treatment who started anti-HCV bi-therapy or triple therapy between January 2011 and December 2013 were included. Patients were excluded if they were virologically uncontrolled (HIV viral load greater than 50 copies RNA/mL) or if they had changed antiretroviral treatment in the 6 months prior to the introduction of anti-HCV therapy. Data were collected before and after the addition of anti-HCV therapy to HAART. The main variables were complexity index, incidence of blips, and adherence. The complexity index was based on a score that utilized the number of pills per day, dosing schedule, dosage form, and any specific instructions linked to use of the drug. Blips were defined as a detectable HIV-RNA level ( greater than 50 copies/mL but no more than 1,000 copies/mL) occurring between 2 negative assays. Medication adherence was assessed using electronic pharmacy refill records. The threshold for optimal adherence was defined at 95% and above. Differences in the variables collected were assessed before and after the addition of anti-HCV therapy to HAART.R ESULTS: A total of 66 patients were included in the study. Based on the complexity index, the median value before and after the addition of anti-HCV therapy to HAART was 4.2 (interquartile range [IQR] = 3.5-5.5) and 11.5 (IQR = 10.4-13.4), respectively. The median difference between both complexity indices was 6.9 (95% CI = 6.9-7, P less than 0.001). After introducing the anti-HCV therapy into HAART, the number of adherent patients decreased from 50 (75.8%) to 45 (68.2%, P greater than 0.05), and 12 (18.2%) patients presented blips (P less than 0.001). Subgroup analysis based on anti-HCV therapy showed that patients on boceprevir or telaprevir therapy had a higher complexity index, 16.8 (IQR = 6.0-18.4), compared with patients on bi-therapy anti-HCV, 11.3 (IQR = 10.3-12). The median difference was 6.0 (95% CI = 5.0-7.2, P less than 0.001). The number of adherent patients decreased only in patients on bi-therapy from 42 (79.2%) to 37 (69.8%, P greater than 0.05). CONCLUSIONS: Adding anti-HCV therapy to antiretroviral treatment significantly increases treatment complexity and the incidence of blips. The introduction of anti-HCV therapy is also associated with a decrease in the number of adherent patients. The regimen complexity calculation may be useful for identifying patients who need more care from health care professionals or are at risk for failure to comply with treatment regimens.

High quantity but limited quality in healthcare applications intended for HIV-infected patients.

OBJECTIVE: The aim of this study was to evaluate, through the creation of a specific questionnaire, the information quality in mobile applications (apps) aimed at human immunodeficiency virus (HIV)-infected patients. We also established a quality rating and identified the main strengths and weaknesses of this kind of health app. MATERIALS AND METHODS: Smartphone apps specifically related to HIV/acquired immunodeficiency syndrome (AIDS) were searched. We conducted a key word search with the terms "HIV," "AIDS," and "acquired immune deficiency syndrome" in the Apple™ (Cupertino, CA) App Store and the Android™ Google™ (Mountain View, CA) Play Store. A questionnaire was developed based on the different quality recommendations for health apps up to December 2012. The recommendations consulted were as follows: the Happtique Health App Certification Program, the Food and Drug Administration (Mobile Medical Applications), and recommendations for the design, use, and evaluation of health apps of the Agency of Health Quality in Andalusia. A group of 17 experts assessed the importance of the different sections by using a Delphi method. RESULTS: In total, 41 health apps were analyzed. Only one app (2.4%), called in Practice HIV, approached class A. The remaining were classed as follows: 2 (4.9%) class B, 1 (2.4%) class C, 5 (12.2%) class D and E, and 27 (65.9%) class F (not exceeding minimum criteria). The design and the relevance were highlighted among the strengths. The main areas for improvement are provision of services and confidentiality in addition to privacy policies. CONCLUSIONS: The quality of the revised apps is limited. Only one app complied with the excellence criteria, and over 50% of the apps did not exceed minimum quality standards. The worst rated aspects were political advertising and logical security.