Chronic-pharma: New Platform for Chronic Patients Pharmacotherapy Optimization.

We describe the technological development of a web platform named CHRONIC-PHARMA that integrates three prescription support tools for patients with chronic diseases: Anticholinergic Burden Calculator (ABC), LESS-CHRON criteria and TRIGGER-CHRON. They focus on the optimization and evaluation of pharmacotherapy in patients with chronic diseases, resulting in a useful, single platform that can facilitate the review of pharmacotherapy and improve the safety of chronically ill patients. This is achieved by estimating and reducing the anticholinergic risk (ABC), detecting opportunities for deprescribing drugs and monitoring its success (LESS-CHRON criteria), as well as calculating the risk of adverse drug events (TRIGGER-CHRON). The platform is freely accessible online ( https://chronic-pharma.com/ ) as well as through a mobile application, and therefore easily accessible among the healthcare community.

Validating a Trigger Tool for Detecting Adverse Drug Events in Elderly Patients With Multimorbidity (TRIGGER-CHRON).

PURPOSE: The aims of the study were to evaluate the performance of an initial list developed to detect adverse drug events (ADEs) in elderly patients with multimorbidity in clinical practice, to explore the possibility of shortening the list, and to use this tool to study the incidence and characteristics of the ADEs among this population. METHODS: This observational study was conducted at 12 Spanish hospitals. A random sample of five charts from each hospital was selected weekly for retrospective review for a 12-week period. We included patients aged 65 years and older with multimorbidity, hospitalized more than 48 hours. Adverse drug events were detected using a list of 51 triggers previously selected by an expert panel by means of a modified Delphi method. The number of triggers identified and ADEs detected were recorded. The severity and preventability of the ADEs were evaluated. The positive predictive value (PPV) of each trigger was calculated and used to select the most efficient triggers. RESULTS: In 720 charts reviewed, 1430 positive triggers were identified that led to detect 215 ADEs in 178 patients (24.7%), of which 13% were serious. One hundred nineteen ADEs (55.3%) were preventable and mainly related to inadequate treatment monitoring and prescribing errors. Triggers with a PPV of 5% or less were eliminated, resulting in a final list of 32 triggers (TRIGGER-CHRON) with a PPV of 22.1%, which accounted for 98.9% of all ADEs detected and 98.6% of the preventable ADEs. CONCLUSIONS: The shorter final validated TRIGGER-CHRON tool is an efficient list for identifying ADEs in elderly patients with multimorbidity, detecting ADEs in one-fourth of hospitalized patients in internal medicine or geriatric units.

Development of a Trigger Tool to Identify Adverse Drug Events in Elderly Patients With Multimorbidity.

PURPOSE: Elderly patients with multimorbidity are especially vulnerable to adverse drug events (ADEs) and had high prevalence rates. Identifying ADEs is essential for enabling timely interventions that can mitigate the adverse events detected and for developing targeted strategies to prevent their occurrence as well as to monitor implementation. The aim of this study was to develop a set with appropriate triggers for detecting potential ADEs in elderly patients with multimorbidity. METHODS: A modified Delphi methodology was used to reach consensus. Existing triggers for detecting ADEs in adult patients were identified from a literature search in several databases (EMBASE, MEDLINE, Web of Science, Centre for Reviews and Dissemination, and Cochrane Library) and from Institute for Healthcare Improvement published lists. Twelve experts in patient/medication safety or in chronic diseases scored candidate triggers for appropriateness according to 3 criteria (evidence, usefulness for elderly patients, and feasibility of implementation in clinical practice). RESULTS: Seventy-two triggers were initially selected to be evaluated. The final set includes a total of 51 triggers for which the panelists who completed the 2 rounds of evaluation reached agreement. These triggers were organized into 5 modules: 11 as care module triggers, 10 as antidotes/treatment, 11 medication concentrations, 18 abnormal laboratory values, and 1 as emergency department trigger. CONCLUSIONS: A set of triggers for detecting ADEs in elderly patients with multimorbidity have been developed, following the consensus of a panel of experts. Subsequent validation in clinical practice is needed to confirm the accuracy and efficiency of these triggers for this population.

Utility of a trigger tool (TRIGGER-CHRON) to detect adverse events associated with high-alert medications in patients with multimorbidity.

OBJECTIVE: To determine the utility of a tool (TRIGGER-CHRON) for identifying adverse drug events (ADEs) associated with the administration of high-alert medications in elderly patients with multimorbidity and to determine the medications most frequently implicated. METHODS: A retrospective observational study was conducted at 12 Spanish hospitals. A random sample of five medical records from each hospital was selected weekly for review over a 12-week period. We included patients aged 65 and over with multimorbidities, hospitalised for >48 hours. ADEs detected by the 32 TRIGGER-CHRON signals and caused by high-alert medications included on the Spanish HAMC list for chronic patients were selected for analysis. Triggers identified and ADEs detected were recorded. The severity and preventability of the ADEs were evaluated. The positive predictive value (PPV) of each trigger was calculated. RESULTS: On 720 charts reviewed, 908 positive triggers were identified that led to the detection of 158 ADEs caused by at least one high-alert medication on the HAMC list. These ADEs occurred in 139 patients (prevalence 19.3/100 admissions). The majority of ADEs were mild and 59.5% were deemed preventable. The drugs most frequently associated with ADEs were corticosteroids, loop diuretics, opioid analgesics and oral anticoagulants. Fifteen triggers had PPVs ≥20%. Six triggers (serum glucose >110 mg/dL, abrupt cessation of medication, oversedation/lethargy, hypotension, adverse reaction recorded and constipation) accounted for 69.8% of the ADEs identified. CONCLUSIONS: Applying the TRIGGER-CHRON to hospitalised patients with multimorbidity in 12 Spanish centres allowed detection of one adverse event caused by a high-alert drug for every four patients, which were preventable in a large proportion of patients. This confirms the need to establish interventions that reduce harm with these medications. We believe that TRIGGER-CHRON can be a useful tool to measure this harm and to determine the effects of medication safety improvement programmes as they are implemented.

Intervenciones para la mejora de la adherencia al tratamiento en pacientes pluripatológicos: resumen de revisiones sistemáticas / Interventions for improving adherence to treatment in patients with multiple pathologies: overview of systematic reviews

Objetivo: Evaluar la evidencia disponible respecto a la eficacia de intervenciones destinadas a mejorar la adherencia al tratamiento que sean aplicables a pacientes pluripatológicos (PP). Diseño: Revisión de revisiones sistemáticas. Fuentes de datos: Se consultaron (septiembre de 2013): Pubmed, EMBASE, the Cochrane Library, CRD y WoS para detectar intervenciones para la mejora de la adherencia en PP, o en su defecto, pacientes con patologías definitorias de pluripatología o polimedicados. Selección de estudios: Se incluyeron revisiones sistemáticas de ensayos clínicos con PP o de características similares. Estas debían comparar la eficacia de cualquier intervención destinada a mejorar el cumplimiento del tratamiento autoadministrado prescrito con la práctica habitual u otra intervención. Extracción de datos: Se extrajo información sobre la población en estudio, la intervención ensayada y la eficacia de la misma en términos de mejora de la adherencia. Resultados: Se recuperaron 566 artículos de los que se seleccionaron 9 revisiones sistemáticas. Ninguna se centraba específicamente en PP. Sí consideraban pacientes con múltiples patologías crónicas, patologías definitorias de pluripatología o polimedicados. La eficacia global de las intervenciones fue modesta, no observándose diferencias relevantes entre las intervenciones de carácter conductual, educativo o combinado. Algunos componentes de estas intervenciones como son el asesoramiento al paciente o las estrategias de simplificación posológica parecen ser herramientas eficaces en la mejora de la adherencia en este grupo poblacional. Conclusiones: Existe una gran heterogeneidad de intervenciones orientadas a la mejora de la adherencia de eficacia modesta, no habiendo sido diseñadas para una población de PP (AU)

Objective: To assess the available scientific evidence regarding the efficacy of interventions aimed to enhance medication adherence in patients with multiple chronic conditions (PMCC). Design: Overview of systematic reviews. Data sources: The following databases were consulted (September 2013): Pubmed, EMBASE, the Cochrane Library, CRD and WoS to identify interventions aimed to enhance medication adherence in PMCC, or otherwise, patients with chronic diseases common in the PMCC, or polypharmacy. Study selection: Systematic reviews of clinical trials focused on PMCC or similar were included. They should compare the efficacy of any intervention aimed to improve compliance to prescribed and self-administered medications with clinical practice or other interventions. Data extraction: Information about the study population, nature of intervention and efficacy in terms of improved adherence was extracted. Results: 566 articles were retrieved of which 9 systematic reviews were included. None was specifically focused on PMCC but considered patients with chronic diseases common in the PMCC, patients with more than one chronic disease and polypharmacy. The overall effectiveness of interventions was modest without relevant differences between behavioural, educational and combined interventions. Some components of these interventions including patient counselling and regimen simplification appear to be effective tools in improving adherence in this population group. Conclusion: There is a large heterogeneity of interventions aimed to improve adherence with modest efficacy, none in PMCC (AU)

[Interventions for improving adherence to treatment in patients with multiple pathologies: overview of systematic reviews]. / Intervenciones para la mejora de la adherencia al tratamiento en pacientes pluripatológicos: resumen de revisiones sistemáticas.

OBJECTIVE: To assess the available scientific evidence regarding the efficacy of interventions aimed to enhance medication adherence in patients with multiple chronic conditions (PMCC). DESIGN: Overview of systematic reviews. DATA SOURCES: The following databases were consulted (September 2013): Pubmed, EMBASE, the Cochrane Library, CRD and WoS to identify interventions aimed to enhance medication adherence in PMCC, or otherwise, patients with chronic diseases common in the PMCC, or polypharmacy. STUDY SELECTION: Systematic reviews of clinical trials focused on PMCC or similar were included. They should compare the efficacy of any intervention aimed to improve compliance to prescribed and self-administered medications with clinical practice or other interventions. DATA EXTRACTION: Information about the study population, nature of intervention and efficacy in terms of improved adherence was extracted. RESULTS: 566 articles were retrieved of which 9 systematic reviews were included. None was specifically focused on PMCC but considered patients with chronic diseases common in the PMCC, patients with more than one chronic disease and polypharmacy. The overall effectiveness of interventions was modest without relevant differences between behavioural, educational and combined interventions. Some components of these interventions including patient counselling and regimen simplification appear to be effective tools in improving adherence in this population group. CONCLUSION: There is a large heterogeneity of interventions aimed to improve adherence with modest efficacy, none in PMCC.