Improving medication adherence and effective prescribing through a patient-centered prescription model in patients with multimorbidity.

PURPOSE: This study aimed to assess the impact of the patient-centered prescription (PCP) model in medication adherence and effective prescribing in patients with multimorbidity. METHODS: Uncontrolled before-after study in an intermediate care facility in a mixed urban-rural district. Inpatients aged ≥ 65 years with multimorbidity exposed to polypharmacy before hospital admission were consecutively enrolled. Every patient's treatment plan was analyzed through the PCP model, which includes interventions aimed at improving medication adherence. The primary endpoint was the change in the proportion of adherent patients between pre-admission and after discharge for all regularly scheduled long-term medications, using the proportion of days covered (PDC). Secondary endpoints included the change on mean PDC for all long-term medications, number of long-term medications, proportion of patients with hyperpolypharmacy, medication regimen complexity index (MRCI) score, drug burden index (DBI) score, number of potential inappropriate prescribing (PIP), and proportion of patients with ≥ 2 PIPs. RESULTS: Ninety-three non-institutionalized patients were included (mean age 83.0 ± SD 6.1 years). The proportion of adherent patients increased from 22.1 to 51.9% (P < 0.001). Intervention also improved mean PDC [mean difference (95% CI) 10.6 (7.7, 13.5)] and effective prescribing through a reduction on the number of long-term medications [- 1.3 (- 1.7, - 0.9)], proportion of patients exposed to hyperpolypharmacy (- 16.1%, P < 0.001), MRCI score [- 2.2 (- 3.4, - 1.0)], DBI score [- 0.16 (- 1.8, - 1.3)], number of PIPs [- 1.6 (- 1.8, - 1.3)], and proportion of patients with ≥ 2 PIPs (- 53.7%, P < 0.001). CONCLUSION: Studied intervention provides significant effective prescribing and medication adherence enhancements in non-institutionalized older patients with multimorbidity and polypharmacy.

Therapeutic optimization through goal-oriented prescription in nursing homes.

Background People living in nursing homes are highly vulnerable and frail. Polypharmacy and inappropriate prescription (IP) are also common problems. Objectives The objectives of the study are (i) to study the baseline situation and calculate the frailty index (FI) of the residents, (ii) to assess the results of routine clinical practice to do a pharmacotherapy review (patient-centred prescription (PCP) model) (Molist Brunet et al., Eur Geriatr Med. 2015;6:565-9) and (iii) to study the relationship between IP and frailty, functional dependence, advanced dementia and end-of-life situation. Setting Two nursing homes in the same geographical area in Catalonia (Spain). Method This was a prospective, descriptive and observational study of elderly nursing home residents. Each patient's treatment was analysed by applying the PCP model, which centres therapeutic decisions on the patient's global assessment and individual therapeutic goal. Main outcome measure Prevalence of polypharmacy and IP. Results 103 patients were included. They were characterized by high multimorbidity and frailty. Up to 59.2% were totally dependent. At least one IP was identified in 92.2% of residents. Prior to the pharmacological review, the mean number of chronic medications prescribed per resident was 6.63 (SD 2.93) and after this review it was 4.97 (SD 2.88). Polypharmacy decreased from 72.55% to 52.94% and excessive polypharmacy fell from 18.62% to 5.88%.The highest prevalence of IP was detected in people with a higher FI, in those identified as end-of-life, and also in more highly dependent residents (p < 0.05). Conclusions People who live in nursing homes have an advanced frailty. Establishing individualized therapeutic objectives with the application of the PCP model enabled to detect 92.2% of IP. People who are frailer, are functionally more dependent and those who are end-of-life are prescribed with inappropriate medication more frequently.

Optimizing drug therapy in frail patients with type 2 diabetes mellitus.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is closely linked with ageing. In frail diabetic patients, the risks of intensive antidiabetic therapy outweigh the potential benefits. AIMS: To study the prevalence of T2DM in frail elderly patients, to identify inappropriate prescription (IP) of antidiabetic drugs and to study the relationship between patients' frailty index (FI) with polypharmacy and IP. METHODS: This was a prospective, descriptive, observational study of elderly patients. Each patient's antidiabetic treatment was analysed by applying the patient-centred prescription model (PCP), which centres therapeutic decisions on the patient's global assessment and individual therapeutic goal. RESULTS: 210 patients with T2DM were included (25.15% prevalence). They were characterised by high multimorbidity and frailty. 93.3% presented polypharmacy and 51% excessive polypharmacy. IP was identified in 66.2% of patients. A statistically significant relationship was found between the progression in FI degree and IP prevalence (p < 0.05. During the admission, drug therapy regimens were modified in 97.1% of cases with IP (n = 136). DISCUSSION: These results suggest that in clinical practice T2DM treatment is not individualised, but rather is based on the same general recommendations for the population as a whole. CONCLUSIONS: There is a high prevalence of T2DM in the elderly. As the frailty of patients increases, so does the prevalence of IP. The application of PCP model enables drug therapy optimization in frail patients according to their main therapeutic goal, and contributes to provide clinical evidences on the applicability of a set of knowledge areas from the theoretical framework to the daily clinical practice.

Respuesta de los autores: Los acontecimientos adversos a medicamentos originados en el servicio de urgencias y el estudio EVADUR / No disponible

No disponible

Evaluación de los acontecimientos adversos a medicamentos originados en el servicio de urgencias / Evaluation of adverse drug reactions in emergency department practice

OBJETIVO: Determinar la incidencia y caracterizar los acontecimientos adversos a medicamentos (AAM) originados en el servicio de urgencias (SU) de un hospital de tercer nivel. Identificar factores de riesgo asociados a la ocurrencia de AAM y evaluar los errores de medicación (EM) implicados en la aparición de los AAM prevenibles. MÉTODO: Estudio observacional descriptivo de revisión de historias clínicas. Durante 3 meses se seleccionaron pacientes atendidos en el SU que finalmente ingresaron en el centro. La identificación de los AAM se realizó siguiendo una metodología previamente establecida basada en la utilización de señales alertantes (triggers). Se utilizaron los algoritmos de Karch-Lasagna y Hallas para evaluar la causalidad y el cuestionario de Schumock-Thornton para la evitabilidad de los AAM. Todos los posibles AAM fueron validados por dos revisores. RESULTADOS: Se detectaron 31 AAM en los 237 pacientes incluidos, que representan una incidencia del 13%. La mayoría de los AAM presentó una relación de causalidad posible o probable (61% y 29%). El 45% de los AAM fue debido a errores de medicación (EM), que podrían haber sido evitados. Entre los AAM evitables, la principal manifestación fue la alteración de la glucemia atribuida al grupo de antidiabéticos. El principal error implicado fue la falta de prescripción de un medicamento necesario (50%) o la omisión en su administración (21%). En el caso de los AAM inevitables, las principales manifestaciones fueron taquicardia e hiperglicemia asociadas a salbutamol y corticoides respectivamente. Los únicos factores asociados a una mayor prevalencia de AAM fueron el número de fármacos administrados en el SU y la atención en el área de mayor gravedad del SU. CONCLUSIONES: La incidencia de AAM durante la estancia en el SU es elevada y potencialmente prevenible. Estos resultados coinciden con la incidencia descrita en el ámbito hospitalario

OBJECTIVE: To assess the incidence of adverse drug reactions (ADRs) in the emergency department of a tertiary care hospital, to determine the characteristics of the ADRs, to identify related risk factors, and to evaluate medication errors associated with preventable ADRs. METHODS: Descriptive observational study based on data extracted from medical records. Patients admitted to hospital after attendance in the emergency department over a 3-month period were included. ADRs were found following a previously established method to identify ADR clues, or triggers, in patient records. The Karch-Lasagna scale and the Hallas algorithm were used to evaluate causality, and the Schumock-Thornton questionnaire was used to assess ADR preventability. All events that were candidates for classification as ADRs were validated by 2 data collectors. RESULTS: In the records for the 237 patients included, 31 ADRs were detected (incidence, 13%). Most of the ADRs could be assigned a possible (61%) or probable (29%) cause. Forty-five percent of the ADRs were caused by medication errors and could have been prevented. The most common preventable ADRs were hypo- or hyperglycemia related to antidiabetic medication. The most common errors involved failure to prescribe a necessary medication (50%) or failure to administer one (21%). The most common unavoidable ADRs were tachycardia and hyperglycemia related to salbutamol and corticosteroids, respectively. The only factors associated with a higher prevalence of ADRs were the number of drugs administered in the emergency department and admission to the acute-care section of the department. CONCLUSIONS: The incidence of ADRs in this study was high and preventable events were detected. These findings are consistent with evaluations of ADRs in the hospital setting)

[Pharmaceutical intervention with parenteral nutrition]. / Intervención farmacéutica en el ámbito de la nutrición parenteral.

OBJECTIVE: Description and analysis of pharmaceutical interventions for patients with parenteral nutrition and an assessment of the degree of acceptance. METHOD: Prospective six-month study. Design of a data collection sheet (with personal data, the indication for parenteral nutrition, hospital area, nutrition type, time and type of intervention, type of notification, acceptance) for recording interventions carried out based on normal activities: complete review of pharmacotherapy and clinical history. RESULTS: A total of 265 interventions were carried out during the study period (1.5 interventions/day) with a mean of 2.1 interventions/patient. The overall degree of acceptance was 83.77%; significant differences were found between type of communication for the intervention (oral and/or written) and the degree of acceptance. CONCLUSIONS: Adding a pharmacist to the care team permits direct intervention in partnership with the doctor, and it is an effective method for preventing and resolving the complications, generally metabolic, that are associated with parenteral nutrition. Using this process for resolving medication-related problems in hospitalised patients, principally in surgical areas, is an addition to the pharmacist's activities in the area of nutritional support.

Intervención farmacéutica en el ámbito de la nutrición parenteral / Pharmaceutical intervention with parenteral nutrition

Objetivo Descripción y análisis de las intervenciones farmacéuticas realizadas en el ámbito de la nutrición parenteral (NP) y valoración del grado de aceptación. Método Estudio prospectivo de 6 meses. Se diseñó una hoja de recogida de datos (datos personales, indicación de NP, sala de hospitalización, tipo de nutrición, momento y tipo de intervención, modo de notificación y aceptación) en la que se registraron las intervenciones realizadas a partir de la actividad diaria: revisión completa de la farmacoterapia y de la historia clínica. Resultados Se realizaron un total de 265 intervenciones en el período de estudio (1,5 intervenciones/día) con una media de 2,1 intervenciones/paciente. El grado global de aceptación fue del 83,77%, fueron significativas las diferencias encontradas entre el tipo de comunicación de la intervención (oral y/o escrita) y el grado de aceptación. Conclusiones La integración del farmacéutico en el equipo asistencial permite una intervención directa con el médico, y es un método eficaz para la prevención y resolución de complicaciones asociadas a la NP, principalmente de tipo metabólico. Utilizar este proceso para resolver problemas relacionados con la medicación en los pacientes ingresados, principalmente en salas quirúrgicas, proporciona una calidad añadida a la actividad del farmacéutico en el área del soporte nutricional (AU)

Objective Description and analysis of pharmaceutical interventions for patients with parenteral nutrition and an assessment of the degree of acceptance. Method Prospective six-month study. Design of a data collection sheet (with personal data, the indication for parenteral nutrition, hospital area, nutrition type, time and type of intervention, type of notification, acceptance) for recording interventions carried out based on normal activities: complete review of pharmacotherapy and clinical history. Results A total of 265 interventions were carried out during the study period (1.5 interventions/day) with a mean of 2.1 interventions/patient. The overall degree of acceptance was 83.77%; significant differences were found between type of communication for the intervention (oral and/or written) and the degree of acceptance (AU)

[Optimising the quality of the unit dose dispensing process through the implementation of the semi-automated Kardex system]. / Optimización de la calidad del proceso de dispensación de medicamentos en dosis unitaria mediante la implantación del sistema semiautomático Kardex.

OBJECTIVE: To evaluate the effect of the incorporation of the semi-automated Kardex medication storage and dispensing system on the quality of the filling process of medicine trolleys in unit doses. METHOD: The speed of filling medicine trolleys in unit doses using the Kardex system was analysed retrospectively (n = 33,946 dispensings) and compared with the manual filling system (n = 5,284 dispensings); different filling procedures were used and compared. For each filling system and procedure, we obtained information for the number of dispensings and the time spent carrying this out. The speed of the process was calculated as the number of dispensings per hour. In addition, the drugs contained in the Kardex system were checked and the correspondence between both the actual and the theoretical content was assessed. RESULTS: The speed of the trolley filling process, expressed as the number of dispensings per hour, increased from 394 with the manual system (filling trolleys individually, n = 5,284 dispensings) to 417, 540 and 592 with the Kardex system when trolleys were filled individually (n = 16,530 dispensings), or grouped in two (n = 10,369 dispensings) or in three (n = 7,047 dispensings) respectively, at the start of the filling process. The check of the contents in the Kardex system detected 36% of trays with differences in quantity, one tray with out of date medication and three trays which should in theory have been empty and contained medication. CONCLUSIONS: The Kardex system optimises the speed of trolley filling with regard to the manual system, provided that the trolleys are grouped at the time of starting the preparation. The check of the cabinet contents shows that possibilities of error exist, related to its handling, which can be minimised by incorporating bar codes into the system s replenishment process.

Optimización de la calidad del proceso de dispensación de medicamentos en dosis unitaria mediante la implantación del sistema semiautomático Kardex® / No disponible

Objetivo: Evaluar el impacto de la incorporación del sistema semiautomático del almacenaje y dispensación de medicamentos Kardex® sobre la calidad del proceso de llenado de carros de medicamentos en dosis unitaria. Método: Se analiza retrospectivamente la velocidad de llenado de carros de medicamentos en dosis unitaria utilizando el sistema Kardex® (n = 33.946 dispensaciones) comparativamente conel sistema de llenado manual (n = 5.284 dispensaciones); se utilizan y comparan diferentes procedimientos de llenado. Para cada sistema y procedimiento de llenado se obtiene el número de dispensaciones y el tiempo invertido en realizarlas y se calcula la velocidad de proceso expresada en número de dispensaciones por hora. También, se revisan los medicamentos contenidos en el Kardex® y se evalúa la concordancia entre el contenido real y teórico del mismo.Resultados: La velocidad del proceso de llenado de carros,expresada en número dispensaciones por hora, pasa de 394 con el sistema manual (llenado de carros individual, n = 5.284 dispensaciones)a 417, 540 y 592 con Kardex®, realizando el llenado individual (n = 16.530 dispensaciones), o agrupando los carros de2 en 2 (n = 10.369 dispensaciones) o de 3 en 3 (n = 7.047 dispensaciones), respectivamente, en el momento de iniciar el llenado.La revisión del contenido del Kardex® permite detectar un 36% de cubetas con diferencias en cantidad, una cubeta con (..) (AU)

Objective: To evaluate the effect of the incorporation of the semi-automated Kardex® medication storage and dispensing systemon the quality of the filling process of medicine trolleys in unitdoses.Method: The speed of filling medicine trolleys in unit dosesusing the Kardex® system was analysed retrospectively (n =33,946 dispensings) and compared with the manual filling system(n = 5,284 dispensings); different filling procedures were used and compared. For each filling system and procedure, we obtained information for the number of dispensings and the time spent carryingthis out. The speed of the process was calculated as the number of dispensings per hour. In addition, the drugs contained in the Kardex® system were checked and the correspondence between both the actual and the theoretical content was assessed. Results: The speed of the trolley filling process, expressed as the number of dispensings per hour, increased from 394 with the manual system (filling trolleys individually, n = 5,284 dispensings)to 417, 540 and 592 with the Kardex® system when trolleys were filled individually (n = 16,530 dispensings), or grouped in twos (n= 10,369 dispensings) or in threes (n = 7,047 dispensings)respectively, at the start of the filling process. The check of the contents in the Kardex® system detected 36% of trays with differences in quantity, one tray with out of date medication and threetrays which should in theory have been empty and contained (..) (AU)