Impact of a Home Telehealth Program After a Hospitalized COPD Exacerbation: A Propensity Score Analysis.

INTRODUCTION: Currently there is lack of data regarding the impact of a home telehealth program on readmissions and mortality rate after a COPD exacerbation-related hospitalization. OBJECTIVE: To demonstrate if a tele-monitoring system after a COPD exacerbation admission could have a favorable effect in 1-year readmissions and mortality in a real-world setting. METHODS: This is an observational study where we compared an intervention group of COPD patients treated after hospitalization that conveyed a telehealth program with a followance period of 1 year with a control group of patients evaluated during one year before the intervention began. A propensity-score analyses was developed to control for confounders. The main clinical outcome was 1-year all-cause mortality or COPD-related readmission. RESULTS: The analysis comprised 351 telemonitoring patients and 495 patients in the control group. The intervention resulted in less mortality or readmission after 12 months (35.2% vs. 45.2%; hazard ratio [HR] 0.71 [95% CI=0.56-0.91]; p=0.007). This benefit was maintained after the propensity score analysis (HR=0.66 [95% CI=0.51-0.84]). This benefit, which was seen from the first month of the study and during its whole duration, is maintained when mortality (HR=0.54; 95% CI=[0.36-0.82]) or readmission (subdistribution hazard ratio [SHR] 0.66; 95% CI=[0.50-0.86]) are analyzed separately. CONCLUSION: Telemonitoring after a severe COPD exacerbation is associated with less mortality or readmissions at 12 months in a real world clinical setting.

Impacto de la anticoagulación en los pacientes con demencia y fibrilación auricular. Resultados del registro CardioCHUVI-FA / Impact of anticoagulation in patients with dementia and atrial fibrillation. Results of the CardioCHUVI-FA registry

INTRODUCCIÓN Y OBJETIVOS: El envejecimiento de la población se asocia con una prevalencia creciente de fibrilación auricular (FA) y demencia. Con este estudio se pretende analizar el impacto de la anticoagulación oral en pacientes ancianos con FA y demencia de grado moderado-grave. MÉTODOS: Estudio retrospectivo unicéntrico que analiza a pacientes de edad ≥ 85 años con diagnóstico de FA entre 2013 y 2018. El impacto de la anticoagulación en la mortalidad, las embolias y las hemorragias se evaluó mediante un análisis multivariado de Cox. En los pacientes con demencia, dicho análisis se complementó con un propensity score matching en función de que se les prescribiera tratamiento anticoagulante o no. RESULTADOS: De los 3.549 pacientes de 85 o más años con FA, 221 presentaban demencia de grado moderado-grave (6,1%), de los que 88 (60,2%) fueron anticoagulados. Durante un seguimiento de 2,8 ±1,7 años, la anticoagulación se asoció con menor riesgo embólico y mayor riesgo hemorrágico tanto en pacientes con demencia (HRembolias=0,36; IC95%, 0,15-0,84; HRhemorragias=2,44; IC95%, 1,04-5,71) como sin demencia (HRembolias=0,58; IC95%, 0,45-0,74; HRhemorragias=1,55; IC95%, 1,21-1,98). Sin embargo, la anticoagulación únicamente se asoció con menor mortalidad en los pacientes sin demencia (HR=0,63; IC95%, 0,53-0,75), no en pacientes con demencia (HR ajustada=1,04; IC95%, 0,63-1,72; p = 0,541; HR después de propensity score matching=0,91; IC95%, 0,45-1,83; p = 0,785). CONCLUSIONES: En pacientes de 85 o más años con demencia moderada-grave y FA, la anticoagulación oral se asoció de manera significativa con menor riesgo de embolias y mayor riesgo hemorrágico, sin encontrarse diferencias en cuanto a mortalidad total

INTRODUCTION AND OBJECTIVES: Population aging is associated with an increased prevalence of atrial fibrillation (AF) and dementia. This study aimed to analyze the impact of oral anticoagulation in elderly patients with AF and moderate-severe dementia. METHODS: We conducted a single-center retrospective study analyzing patients aged ≥ 85 years with a diagnosis of AF between 2013 and 2018. The impact of anticoagulation on mortality, embolisms, and bleeding events was assessed by multivariate Cox analysis. In patients with dementia, this analysis was complemented by propensity score matching, depending on whether the patients were prescribed anticoagulant treatment or not. RESULTS: Of the 3549 patients aged ≥ 85 years with AF, 221 had moderate-severe dementia (6.1%), of whom 88 (60.2%) were anticoagulated. During a follow-up of 2.8 ±1.7 years, anticoagulation was associated with lower embolic risk and higher bleeding risk both in patients with dementia (hazard ratio [HR]embolisms, 0.36; 95%CI, 0,15-0.84; HRbleeding, 2.44; 95%CI, 1.04-5.71) and in those without dementia (HRembolisms, 5.58; 95%CI, 0.45-0.74; HRbleeding, 1.55, 95%CI, 1.21-1.98). However, anticoagulation was associated with lower mortality only in patients without dementia (HR, 0.63; 95%CI, 0.53-0.75) and not in those with dementia (adjusted HR, 1.04; 95%CI, 0.63-1.72; P=.541; HR after propensity score matching 0.91, 95%CI, 0.45-1.83; P=.785). CONCLUSIONS: In patients aged ≥ 85 years with moderate-severe dementia and AF, oral anticoagulation was significantly associated with a lower embolic risk and a higher bleeding risk, with no differences in total mortality

Pooling for SARS-CoV-2 control in care institutions.

BACKGROUND: Workers and residents in Care Homes are considered at special risk for the acquisition of SARS-CoV-2 infection, due to the infectivity and high mortality rate in the case of residents, compared to other containment areas. The role of presymptomatic people in transmission has been shown to be important and the early detection of these people is critical for the control of new outbreaks. Pooling strategies have proven to preserve SARS-CoV-2 testing resources. The aims of the present study, based in our local experience, were (a) to describe SARS-CoV-2 prevalence in institutionalized people in Galicia (Spain) during the Coronavirus pandemic and (b) to evaluate the expected performance of a pooling strategy using RT-PCR for the next rounds of screening of institutionalized people. METHODS: A total of 25,386 Nasopharyngeal swab samples from the total of the residents and workers at Care Homes in Galicia (March to May 2020) were individually tested using RT-PCR. Prevalence and quantification cycle (Cq) value distribution of positives was calculated. Besides, 26 pools of 20 samples and 14 pools of 5 samples were tested using RT-PCR as well (1 positive/pool). Pooling proof of concept was performed in two populations with 1.7 and 2% prevalence. RESULTS: Distribution of SARS-CoV-2 infection at Care Homes was uneven (0-60%). As the virus circulation global rate was low in our area (3.32%), the number of people at risk of acquiring the infection continues to be very high. In this work, we have successfully demonstrated that pooling of different groups of samples at low prevalence clusters, can be done with a small average delay on Cq values (5 and 2.85 cycles for pools of 20 and 5 samples, respectively). CONCLUSIONS: A new screening system with guaranteed protection is required for small clusters, previously covered with individual testing. Our proposal for Care Homes, once prevalence zero is achieved, would include successive rounds of testing using a pooling solution for transmission control preserving testing resources. Scale-up of this method may be of utility to confront larger clusters to avoid the viral circulation and keeping them operative.

Impact of malnutrition in the embolic-haemorrhagic trade-off of elderly patients with atrial fibrillation.

AIMS: Nutrition is an important determinant of health above the age of 80 years. Malnutrition in the elderly is often underdiagnosed. The aim of this study was to report the prevalence and prognostic value of malnutrition in patients ≥80 years old with atrial fibrillation (AF) with and without anticoagulant therapy. METHODS AND RESULTS: We assessed the nutritional status of 4724 octogenarian patients with diagnoses of AF in a single centre from Spain between 2014 and 2017 with the CONUT score. Malnutrition was confirmed in 2036 patients (43.1%). Anticoagulation prescription was more frequent in patients with good nutrition than in those malnourished (79.5% vs. 71.7%, P < 0.001). The impact of malnutrition on mortality was evaluated by Cox regression, whereas its association with ischaemic stroke and major bleeding was studied through competing risk analysis. After multivariate adjusting, malnutrition was associated with mortality [hazard ratio (HR) 1.36, 95% confidence interval (CI) 1.24-1.49], stroke [sub-distribution HR (sHR) 1.37, 95% CI 1.10-1.69], and major bleeding (sHR 1.29, 95% CI 1.02-1.64). In anticoagulated patients, the embolic-haemorrhagic trade-off event was virtually neutral for those who had normal nutritional status [average daily rates (ADRs) for stroke and bleeding: 4.70 and 4.69 per 100 000 patients/day, respectively; difference = +0.01 per 100 000 patients/day; P = 0.99] and negative for those with malnutrition (ADR for stroke and bleeding: 5.38 and 7.61 per 100 000 patients/day, respectively; difference = -2.23 per 100 000 patients/day; P = 0.07). CONCLUSION: Malnutrition is very common in octogenarian patients with AF, being a clinical predictor for poor prognosis. For anticoagulated patients, malnutrition was associated with a negative embolic-haemorrhagic balance.

Impact of anticoagulation in patients with dementia and atrial fibrillation. Results of the CardioCHUVI-FA registry.

INTRODUCTION AND OBJECTIVES: Population aging is associated with an increased prevalence of atrial fibrillation (AF) and dementia. This study aimed to analyze the impact of oral anticoagulation in elderly patients with AF and moderate-severe dementia. METHODS: We conducted a single-center retrospective study analyzing patients aged ≥ 85 years with a diagnosis of AF between 2013 and 2018. The impact of anticoagulation on mortality, embolisms, and bleeding events was assessed by multivariate Cox analysis. In patients with dementia, this analysis was complemented by propensity score matching, depending on whether the patients were prescribed anticoagulant treatment or not. RESULTS: Of the 3549 patients aged ≥ 85 years with AF, 221 had moderate-severe dementia (6.1%), of whom 88 (60.2%) were anticoagulated. During a follow-up of 2.8 ±1.7 years, anticoagulation was associated with lower embolic risk and higher bleeding risk both in patients with dementia (hazard ratio [HR]embolisms, 0.36; 95%CI, 0.15-0.84; HRbleeding, 2.44; 95%CI, 1.04-5.71) and in those without dementia (HRembolisms, 0.58; 95%CI, 0.45-0.74; HRbleeding, 1.55, 95%CI, 1.21-1.98). However, anticoagulation was associated with lower mortality only in patients without dementia (HR, 0.63; 95%CI, 0.53-0.75) and not in those with dementia (adjusted HR, 1.04; 95%CI, 0.63-1.72; P=.541; HR after propensity score matching 0.91, 95%CI, 0.45-1.83; P=.785). CONCLUSIONS: In patients aged ≥ 85 years with moderate-severe dementia and AF, oral anticoagulation was significantly associated with a lower embolic risk and a higher bleeding risk, with no differences in total mortality.

Standardization Consensus of a Hospital Drug Database: An Efficient Tool.

BACKGROUND: Although the electronic prescribing software is the same for all hospitals of a regional health service, each has its own drug database, which it is responsible for maintaining. The aim of this study was to develop a consensus to standardize the hospital drug database of the electronic prescribing software, and to apply this tool to the electronic prescribing system of an oncology outpatient clinic of a Spanish tertiary-level hospital. Additionally, we sought to analyze the impact of the implemented actions on the health care services provided. METHODS: This was a prospective study carried out over a period of 15 months by a group of pharmacists representing all Organizational Integrated Management Systems of a regional health service, and coordinated by the General Subdirectorate of Pharmaceuticals. RESULTS: A total of 500 drugs and 500 active pharmaceutical ingredients included in the hospital drug database were standardized to implement the electronic prescribing system in the oncology outpatient clinic. The implementation of such standardization process yielded a 70% decrease in medication errors. In the satisfaction survey concerning the usefulness of the tall-man letters implemented in the electronic prescribing system, the interviewed doctors reported the highest levels of satisfaction. CONCLUSIONS: The creation of consensus documents to standardize the hospital drug database served to unify the information available in the regional hospital pharmacy services of an autonomous community. In addition, the implementation of the electronic prescribing system in the oncology outpatient clinic of a tertiary-level hospital resulted in a decrease in the number of medication errors.

Vitamin K Antagonists and Direct Oral Anticoagulants in Nonagenarian Patients With Atrial Fibrillation.

OBJECTIVES: Nonagenarian patients are underrepresented in clinical trials that have evaluated oral anticoagulation in patients with atrial fibrillation (AF). The aim of this study was to assess the pronostic impact of oral anticoagulation in patients with AF age ≥90 years. DESIGN: Retrospective multicenter study of nonagenarian patients with AF. SETTING AND PARTICIPANTS: A total of 1750 nonagenarian inpatients and outpatients with nonvalvular AF between January 2013 and December 2018 in 3 Spanish health areas were studied. METHODS: Patients were divided into 3 groups based on antithrombotic therapy: nonoral anticoagulants (30.5%), vitamin-K antagonists (VKAs; 28.6%), and direct oral anticoagulants (DOACs; 40.9%). During a mean follow-up of 23.6 ± 6.6 months, efficacy outcomes (death and embolic events) were evaluated using a Cox regression analysis and safety outcomes (bleeding requiring hospitalization) by competing-risk regression. Results were complemented with a propensity score matching analysis. RESULTS: During follow-up, 988 patients died (56.5%), 180 had embolic events (10.3%), and 186 had major bleeding (10.6%). After multivariable adjustment, DOACs were associated with a lower risk of death and embolic events than nonanticoagulation [hazard ratio (HR) 0.75, 95% confidence interval (CI)] 0.61‒0.92), but VKAs were not (HR 0.87, 95% CI 0.72‒1.05). These results were confirmed after propensity score matching analysis. For bleeding, both DOACs and VKAs proved to be associated with a higher risk (HR for DOAC 1.43; 95% CI 0.97‒2.13; HR for VKA 1.94; 95% CI 1.31‒2.88), although findings for DOACs were not statistically significant (P = .074). For intracranial hemorrhage (ICH), only VKAs-not DOACs-presented a higher risk of ICH (HR 4.43; 95% CI 1.48‒13.31). CONCLUSIONS AND IMPLICATIONS: In nonagenarian patients with AF, DOACs led to a reduction in mortality and embolic events in comparison with nonanticoagulation. This reduction was not observed with VKAs. Although both DOACs and VKAs increased the risk of bleeding, only VKAs were associated with higher ICH rates.

Pharmacotherapeutic Reports as Tools for Detecting Discrepancies in Continuity of Care.

BACKGROUND: The care transition is the time when more medication errors occur. The aim of this study is to analyze the usefulness of a pharmacotherapeutic report model at hospital discharge to prevent medication errors and to simplify pharmacotherapy during a patient's transition from the hospital to primary care. METHODS: Prospective study including patients diagnosed with chronic obstructive pulmonary disease who were admitted to a short-stay unit or an emergency room. Relevant variables were extracted from the patients' clinical history and SPSS software was used to carry out the statistical analysis. Direct costs were also calculated. RESULTS: 79.3% of patients were polymedicated, 15.5% of patients were identified as nonadherent to the treatment, 12.1% were users of alternative therapies, and 10.3% had been prescribed drugs that could be monitored. In 32.8% of the reports, reference was made to the primary care pharmacists with a view to resolve any pharmacotherapeutic discrepancies. A total of 132 discrepancies were identified, the majority being related to medicinal requirements (necessary/unnecessary medication). The major cause of drug-related problems (DRPs) were prescription errors. The drugs that were mainly involved in the onset of DRPs belonged to the R group, and the degree of simplification of the pharmacotherapy was 7.6%. The total cost avoided with the reconciliation was 200€/patient. CONCLUSION: A continuity program was implemented based on the drafting of a pharmacotherapeutic report, which allowed for detecting discrepancies and updating the patients' pharmacotherapeutic history, resulting in financial savings after its implementation.

Telephone consultation in primary care.

Purpose The purpose of this paper is to describe and analyze a teleconsultation modality based on a simple telephone call, using either landline or mobile phone, made available to more than two million people. Telecommunication systems are an increasingly common feature in modern healthcare. However, making teleconsultations available to the entire population covered by a public health system is a challenging goal. Design/methodology/approach This retrospective longitudinal observational study analyzed how this modality was used at the primary care level in Galicia, a region in the Northwest of Spain, in 2014 and 2015, focusing on demand, gender and age preferences, rural vs urban population and efficiency. Findings Of 28,472,852 consultations requested in this period, 9.0 percent were telephone consultations. Women requested more telephone consultations (9.9 percent of total consultations) than men (7.7 percent of total consultations). The highest demand occurred for the over 85 age group for both men and women. In both years, 2014 and 2015, the number of telephone consultations per inhabitant was higher in urban (0.53 and 0.69) than in rural areas (0.34 and 0.47). In 10.9 percent of cases, the telephone consultations required further face-to-face consultation. Originality/value Conventional voice telephone calls can efficiently replace conventional face-to-face consultations in primary healthcare in roughly 10 percent of cases. Women are more likely than men to use primary care services in both face-to-face and telephone consultation modalities. Public healthcare systems should consider implementing telephone consultations to deliver their services.

Recommendations for treatment with IMRT for prostate and head-neck cancer. Axencia de Avaliación de Tecnoloxías Sanitarias de Galicia.

Intensity-modulated radiation therapy (IMRT) is an advanced form of radiotherapy for the treatment of cancer that allows, on one hand, to administer a more homogeneous dose to the patients on the volume to irradiate (which would increase the local control of the disease), and on the other hand, to diminish the toxicity in the organs at risk. This type of treatment is based on imaging techniques, on computer dosimetry programs, and on more precise immobilization accessories. Before delivering IMRT it is necessary to establish a protocol that includes the different phases of the treatment process, that is, the obtaining of anatomical data, beam definition, calculation, dose distribution, and treatment performance and control. In this article we present the basic standards for the IMRT treatment for prostate and head-neck cancer agreed upon a consensus meeting. The follow-up of the recommendations settled down in this document will help in the establishment of a standardized clinical practice -assuring the quality- and a better evaluation of the results of the clinical intervention.

Recommendations for treatment with IMRT for prostate and head-neck cancer

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Intensity-modulated radiation therapy (IMRT) isan advanced form of radiotherapy for the treatmentof cancer that allows, on one hand, to administer amore homogeneous dose to the patients on the volumeto irradiate (which would increase the localcontrol of the disease), and on the other hand, to diminishthe toxicity in the organs at risk. This type oftreatment is based on imaging techniques, on computerdosimetry programs, and on more precise immobilizationaccessories. Before delivering IMRT itis necessary to establish a protocol that includes thedifferent phases of the treatment process, that is, theobtaining of anatomical data, beam definition, calculation,dose distribution, and treatment performanceand control.In this article we present the basic standards for theIMRT treatment for prostate and head-neck canceragreed upon a consensus meeting. The follow-up ofthe recommendations settled down in this documentwill help in the establishment of a standardizedclinical practice -assuring the quality- and abetter evaluation of the results of the clinical intervention