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.

Hydrosurgery as a safe and efficient debridement method in a clinical wound unit.

OBJECTIVE: Hydrosurgical debridement allows removal of non-viable tissue, preserving healthy tissues. This study was designed to analyse whether hydrosurgery, used in a clinical wounds unit, is an effective and safe method that may reduce debridement time. METHODS: Patients' wounds had the following characteristics: wounds with devitalised tissue needing rapid debridement, wounds with cavities, or non-healing wounds. Hydrosurgical debridement uses a pressurised stream of saline (0.9% sodium chloride) and a vacuum around this stream to remove the devitalised tissue of the wound, preserving healthy surrounding tissues. RESULTS: This prospective study comprised of 53 wounds from 39 patients. The wound aetiology included 39.7% arterial insufficiency, 22.6% pressure ulcers (PUs), 15.1% diabetic foot ulcers (DFUs), 9.4% venous leg ulcers (VLUs), and 13.2% from other aetiologies. The percentage of wounds according the size was the following: 32.1% (<10cm2), 43.4% (10-49cm2), 15.1% (50-99cm2), and 9.4% (≥100cm2). Superficial wounds were 43.4% of the total and 56.6% of wounds had cavities. Pain associated with the hydrosurgery was mild to moderate. There were no hydrosurgery-related adverse events. For effective debridement, the required sessions were as follows: one procedure (73.6%), two procedures (18.9%) and three procedures (7.5%). There was a statistical significant direct correlation (r=0.307) between the number of required sessions and wound size. All patients improved in a week (>80% of granulation tissue). CONCLUSION: We demonstrate that hydrosurgery is an effective and rapid debridement method that can be used safely in the outpatient setting.

[Usefulness of echocardiography in heart insufficiency: a prospective study of 100 patients]. / Utilidad de la ecocardiografía en la insuficiencia cardíaca: estudio prospectivo sobre 100 pacientes.

We prospectively evaluated 100 patients with heart failure, grades III and IV of the NYHA who were admitted to our Internal Medicine Service. In all cases a clinical diagnosis previous to the recording of the echocardiogram was made to evaluate the contributions of the latter. In 26 patients the echocardiogram gave information which had not been anticipated from the history and basic studies. This information resulted in a change of diagnosis in 21 cases and in the addition of a diagnosis with therapeutic and/or prognostic implications in 5 cases. It also permitted an approach to pathogenesis in the subgroup with preserved systolic function (36%), which were categorized as having diastolic dysfunction. On the other hand, the echocardiogram permitted the definition of the group of elderly patients, with heart failure and without previously known heart disease, which we considered as having senile heart disease.

[Bacteremia secondary to decubitus ulcer]. / Bacteriemia secundaria a úlceras de decúbito.

We have prospectively evaluated 16 episodes of bacteremia induced by decubitus ulcers. The most commonly isolated microorganisms were Staphylococcus aureus, Proteus mirabilis, Pseudomonas aeruginosa and Bacteroides fragilis. Bacteremia was polymicrobial in 5 cases (31%). Most ulcers were already present at the time of admission, but bacteremia developed within the hospital in 13 patients. In 3 patients, ulcers did not show local features of infection. The initial antibiotic therapy was satisfactory in 13 cases. Mortality rate directly associated with bacteremia was 18%, but the overall mortality rate was 62%. We did not identify data permitting a reliable prediction of the findings of blood culture; therefore, the initial empirical therapy should be active against Staphylococcus aureus, Pseudomonas, enteric Gram-negative bacilli and anaerobes including Bacteroides fragilis.