Programa de seguimiento farmacoterapéutico integral a pacientes crónicos y polimedicados. Programa Piloto en pacientes con Diabetes tipo 2. Resultados / Integral medication review with follow up program to chronic and poymedicated patients. Pilot Program in patients with type 2 Diabetes Mellitus

Introducción: La Farmacia comunitaria vasca tiene una larga tradición de colaboración con la Dirección de Farmacia del Departamento de Salud del Gobier-no Vasco. En mayo de 2017 se firmó un Convenio de colaboración entre el Departamento de Salud y los tres colegios de farmacéuticos vascos “para la puesta en marcha de un Programa piloto de Segui-miento Farmacoterapéutico Integral a pacientes crónicos polimedicados” en el que el farmacéutico comunitario realizaría seguimiento farmacotera-péutico a pacientes con Diabetes tipo2. Método: Se realizó el servicio de seguimiento farmacoterapéutico en farmacias de tres organi-zaciones sanitarias integradas de Alava, Bizkaia y Gipuzkoa. Participaron 18 farmacias con 7 pacien-tes cada una. Criterios de inclusión: paciente con diabetes tipo2 que tomaban 8 o más principios activos de forma continuada. Durante los 12 meses de estudio se analizaron tres puntos: inicio (V1), 6 meses (V2) y al finalizar el estudio (V3).Resultados: De los 127 pacientes inicialmente previstos finalizaron el estudio 87. No se obtuvie-ron diferencias significativas en el valor de HbA1c entre inicio y final. Por el contrario, el número de problemas de salud no controlados disminuyó en un 47% (p=0,001) sin que se modificase el número de medicamentos. Los PRM más frecuentes en V3 fueron el conocimiento insuficiente del medicamen-to (34%) y la falta de adherencia (19%). Mejoraron tanto el conocimiento y la adherencia (p<0,001) como la calidad de vida (p<0,05). Conclusiones: Aunque el programa no ha tenido impacto en el valor de la HbA1c, sí ha contribuido a controlar otros problemas de salud, así como la adherencia, el conocimiento sobre los medicamen-tos y la calidad de vida de los pacientes. (AU)

Introduction: Basque community pharmacy has a long tradition of collaborating with Basque health authorities. In May 2017, a collaboration agreement was signed between the Department of Health and the three Basque Pharmaceutical Associations "for the implementation of a Pilot Program for Medi-cation review with follow up service for chronic polymedicated patients". Method: The medication review with follow up service was carried out in pharmacies of three integrated health organizations in Alava, Bizkaia and Gipuzkoa. 18 pharmacies participated with 7 patients each. Inclusion criteria: patients with type 2 diabetes who were taking 8 or more medicines. During the 12 months of the study, three points were analyzed: baseline (V1), 6 months (V2) and at the end of the study (V3).Results: Of the 127 initially planned patients, 87 completed the study. No significant differences were obtained in the HbA1c value between baseline and the end. In contrast, the number of uncontro-lled health problems decreased by 47% (p=0.001) without changing the number of medications. The most frequent DRPs in V3 were insufficient knowle-dge of the medication (34%) and lack of adherence (19%). Both, knowledge and adherence (p<0.001) and quality of life (p<0.05) improved.Conclusions: Although the program has not had an impact on the value of HbA1c, it has contributed to controlling other health problems, as well as adher-ence, knowledge about medications and the quality of life of patients. (AU)

A communication procedure between community pharmacists and primary care professionals resolves medication errors and other administrative issues.

OBJECTIVES: The aim of this study was to implement a communication procedure, with agreed-upon protocols, to resolve daily medication errors and other administrative issues that require communication between community pharmacists (CPs) and primary healthcare professionals (PHCPs). METHODS: A 6-month pilot study followed by a year-length principal study was carried out in the Donostialdea Integrated Healthcare Organisation (IHO). Afterwards, the project was extended to other IHOs. The CPs identified medication errors or other administrative issues that required communication with PHCPs, contacting the customer service staff by telephone for urgent problems and by email for non-urgent problems. KEY FINDINGS: In total, 49 community pharmacies participated in the study. A total of 1179 medication errors and other administrative issues were detected, and over 90% of problems were solved in less than 24 h (n = 1079, 91.5%). Email was the more frequently used communication method (n = 874, 74.1%), and the most prevalent problems were due to absent (n = 766, 65.0%) and expired (n = 226, 19.2%) electronic prescriptions. Most of the participants were satisfied with the programme. CONCLUSION: The present communication procedure between CPs and PHCPs is an efficient tool to resolve a variety of challenges that occur in community pharmacies.

Exploración de las opiniones de agentes implicados sobre la integración entre la farmacia comunitaria y los equipos de atención primaria / Stakeholder views of the integration of community pharmacy and primary health care teams

Introducción: Dado el aislamiento existente entre los farmacéuticos comunitarios y los miembros de los equipos de atención primaria en nuestro país, se diseñó este estudio para explorar las opiniones de profesionales de la salud de Osakidetza y de farmacia comunitaria, sobre la posibilidad de inte-gración de ambos colectivos. Método: Se diseñó un estudio cualitativo utilizan-do el Grupo Focal como método de obtención de información con análisis temático del contenido. La reunión tuvo lugar en el Centro de Salud de Gros (OSI Donostialdea). Participaron diferentes profesionales tanto de Osakidetza (n=6) como de la farmacia comunitaria (n=2). Todo el proceso de la reunión grupal y su informe, se realizó siguiendo los Standards for Reporting Qualitative Research (SRQR). Resultados: La Farmacia tiene como elementos fuertes su frecuentación, cercanía y facilidad de ac-ceso viéndose como un recurso no suficientemente aprovechado. A pesar de la dificultad conceptual de integrar un colectivo privado con otro público, se entendía la necesidad de acercamiento inter-profesional a través de una integración funcional, proceso que por su complejidad será lento y largo. Se debe comenzar con los programas locales ya existentes, proyectos pequeños, con objetivos concretos e indicadores medibles y mejorando la comunicación interprofesional y el conocimiento mutuo. Se analizaron las barreras a superar y los agentes implicados que deberían participar en cualquier proyecto futuro de integración siguiendo un modelo de diseño compartido.Conclusiones: Parece importante integrar funcio-nalmente la Farmacia comunitaria en Osakidetza – SVS.(AU)

Introduction: Due to the lack of integration of com-munity pharmacy and primary health care teams a study was designed to explore the views of stake-holders in the Basque health care system (Osakide-tza) on the integration of community pharmacy and primary healthcare teams.Method: A qualitative study, using focus group technique was used. The group met in the Gros health care center (IHO Donostialdea). There were 6 participants from the Basque primary health care system and 2 from community pharmacy. The whole focus group process followed the “Standards for Reporting Qualitative Research (SRQR”) and data generated was thematic content analysis.Results: The group identified the inherent strengths of community pharmacy as accessibility, geograph-ical distribution and frequency of visits by patients. Pharmacy was seen as a resource that was not optimally used. Despite the philosophical dilemma posed by the integration of a private (community pharmacy) and public (salaried health care profes-sionals) sector, there was seen a need for interpro-fessional collaboration, via functional integration due to the complexities and length of time required. The starting point was identified as existing rela-tively small local programs with specific objectives and measurable outcomes that increase commu-nication and build mutual confidence. The content analysis indicated a number of barriers and iden-tified potential stakeholders that should codesign any future potential integration program.Conclusions: There was general support for the integration of community pharmacy in the primary care system however this was tempered with sig-nificant barriers which would suggest a lengthy and complex process.(AU)

Servicio de identificación de discrepancias en el uso de los medicamentos en el entorno comunitario / Medication discrepancy identification service in community setting

Introducción: Los errores de medicación constituyen la causa evitable más común de los efectos adversos relacionados con la medicación y suponen una carga importante para la salud pública. El servicio de identificación de discrepancias en el entorno comunitario puede ser una estrategia útil para detectar estos errores en el ámbito comunitario. Hasta el momento, pocos estudios han analizado el papel del farmacéutico comunitario en la detección de discrepancias en el uso de los medicamentos. Objetivo: Desarrollar y estandarizar un procedimiento normalizado de trabajo para la detección de discrepancias en el uso de los medicamentos en el entorno comunitario. Métodos: El diseño del procedimiento se ha basado en estudios previamente publicados sobre el tema y teniendo en cuenta las Buenas Prácticas en Farmacia Comunitaria en España publicadas por el Consejo General de Colegios Oficiales de Farmacéuticos. Resultados: Se presenta un procedimiento del servicio de detección de discrepancias en el uso de medicamentos en el entorno comunitario y un diagrama de flujo que recoge los aspectos más importantes del procedimiento de forma visual. Conclusión: El documento recoge un procedimiento estandarizado para que el farmacéutico comunitario pueda detectar las discrepancias que existen en los medicamentos del paciente en su práctica diaria.(AU)

Introduction: Medication errors are the most common preventable causes of medication-related adverse effects and a major public health burden. The medication discrepancy identification service could be a useful strategy to detect those errors at the community level in the patient's day-to-day life, without requiring a transition of care. Up to now, few studies have studied the role of the community pharmacist in detecting medication discrepancies. Objective: To develop a standarized working procedure for the detection of medication discrepancies in the community setting. Methods: The design of the procedure has been carried out based on studies previously published and taking into account the Good Practices in Community Pharmacy in Spain published by the General Council of Official Pharmacists Association. Results: A procedure of the service for detecting medication discrepancies in the community setting is presented, summarized ina flow diagram that collects visually the most important aspects of the procedure. Conclusion: The document includes a standardized procedure for the community pharmacist to detect the discrepancies that exist in the medications of patient's day-to-day life.(AU)

El papel del farmacéutico comunitario en la detección y disminución de los errores de medicación: revisión sistemática exploratoria / The Role of the Community Pharmacist in Detecting and Decreasing Medication Errors: A Scoping Review

INTRODUCCIÓN: Los errores de medicación se encuentran entre las 10 principales causas de muerte en el mundo y en su mayoría son prevenibles. Los servicios profesionales farmacéuticos asistenciales (SPFA) tratan de garantizar un uso más seguro, efectivo y eficiente de los medicamentos, y por ello los farmacéuticos comunitarios pueden contribuir a reducir errores de la medicación a nivel de atención primaria. Este trabajo pretender ofrecer un marco de evidencia sobre las iniciativas llevadas a cabo por farmacéuticos comunitarios, a nivel estatal, para identificar, reducir o eliminar los errores de medicación en los diferentes puntos de la cadena terapéutica y plantear una revisión, de los puntos críticos de la cadena terapéutica y clasificar los SPFA. MÉTODO: Revisión sistemática exploratoria de bases de datos internacionales y estatales para obtener estudios publicados sobre la intervención del farmacéutico en la detección, reducción o eliminación de los errores de medicación. RESULTADOS: Se han recopilado 39 iniciativas que se han clasificado en 7 puntos críticos de la cadena terapéutica: (I) 7 en dispensación, (II) 4 en validación o revisión del tratamiento, (III) 3 en transición asistencial, (IV) 18 en monitorización del tratamiento, (V) 4 en educación a pacientes y (VI) 3 en indicación. CONCLUSIONES: Los SPFA llevados a cabo a nivel estatal demuestran que sirven para identificar y resolver los errores de medicación y se plantea una nueva clasificación de los 7 puntos de la cadena terapéutica que se identifican como críticos para la farmacia comunitaria y los relaciona con los SPFA que intervienen en cada uno de los puntos

INTRODUCTION: Medication errors, mostly preventable, are among the top 10 causes of death worldwide. Commu¬nity pharmacists provide professional pharmacy services (PPS) to ensure safer, more effective and efficient use of medications, being professionals who should be included in strategies to reduce medication errors at the primary care level. This work aims to offer an evidence framework on the initiatives carried out by community pharmacists, in Spain, to identify, reduce or eliminate medication errors at different points in the therapeutic chain and propose a classification of the critical points of the therapeutic chain to classify PPS. METHOD: Scoping review of international and national databases to obtain published studies where the community pharmacists provide an intervention to detect, reduce or eliminate of medication errors. RESULTS: 39 records have been compiled and have been classified in 7 critical points of the therapeutic chain: (I) 7 in dispensation, (II) 4 in validation/review of the treatment, (III) 3 in healthcare transition, (IV) 18 in treatment monitor¬ing, (V) 4 in education to patients and (VI) 3 in minor ailments service. CONCLUSIONS: The PPS carried out at the state level demonstrate that they serve to identify and resolve medication errors and a new classification of the critical points of the therapeutic chain that exist in the community pharmacy is proposed, and it relates to the PPS that are involved in each point

The medication discrepancy detection service: A cost-effective multidisciplinary clinical approach / Servicio de detección de discrepancias de la medicación: un estudio multidisciplinar y coste-efectivo

OBJECTIVE: To estimate the effectiveness of a Medication Discrepancy Detection Service (MDDS), a collaborative service between the community pharmacy and Primary Care. DESIGN: Non-controlled before-and-after study. SETTING: Bidasoa Integrated Healthcare Organisation, Gipuzkoa, Spain. PARTICIPANTS: The service was provided by a multidisciplinary group of community pharmacists (CPs), general practitioners (GPs), and primary care pharmacists, to patients with discrepancies between their active medical charts and medicines that they were actually taking. Outcomes: The primary outcomes were the number of medicines, the type of discrepancy, and GPs' decisions. Secondary outcomes were time spent by CPs, emergency department (ED) visits, hospital admissions, and costs. RESULTS: The MDDS was provided to 143 patients, and GPs resolved discrepancies for 126 patients. CPs identified 259 discrepancies, among which the main one was patients not taking medicines listed on their active medical charts (66.7%, n = 152). The main GPs' decision was to withdraw the treatment (54.8%, n = 125), which meant that the number of medicines per patient was reduced by 0.92 (9.12 ± 3.82 vs. 8.20 ± 3.81; p < .0001). The number of ED visits and hospital admissions per patient were reduced by 0.10 (0.61 ± .13 vs 0.52 ± 0.91; p = .405 and 0.17 (0.33 ± 0.66 vs. 0.16 ± 0.42; p = .007), respectively. The cost per patient was reduced by (Euro)444.9 ((Euro)1003.3 ± 2165.3 vs. (Euro)558.4 ± 1273.0; p = .018). CONCLUSION: The MDDS resulted in a reduction in the number of medicines per patients and number of hospital admissions, and the service was associated with affordable, cost-effective ratios

OBJETIVOS: Estimar la efectividad del servicio de detección de discrepancias de la medicación, un servicio de colaboración entre la farmacia comunitaria y la atención primaria. DISEÑO: Estudio de intervención antes-después, sin grupo control. Emplazamiento: Organización Sanitaria Integrada de Bidasoa, Gipuzkoa, España. PARTICIPANTES: El servicio fue ofrecido por un grupo multidisciplinar que incluía farmacéuticos comunitarios (FC), médicos de atención primaria (MAP) y farmacéuticos de atención primaria a pacientes que presentaban discrepancias entre la medicación prescrita en la hoja de tratamiento activo y lo que realmente estaban tomando. Mediciones principales: Las variables principales del estudio fueron el número de medicamentos, tipo de discrepancia y la decisión del MAP. Las variables secundarias fueron tiempo invertido por el farmacéutico, visitas al servicio de urgencias, ingresos hospitalarios y los costes. RESULTADOS: El servicio se ofreció a 143 pacientes, y el MAP resolvió las discrepancias de un total de 126 pacientes. El FC identificó 259 discrepancias de las cuales la mayoría fue que el paciente no estaba tomando un medicamento prescrito (66,7%, n = 152). En la mayoría de los casos, la decisión del MAP fue suspender el tratamiento (54,8%, n = 125); el número de medicamentos que tomaba el paciente se redujo en un 0,92 (9,12 ± 3,82 vs. 8,20 ± 3,81; p < 0,0001). El número de visitas al hospital y los ingresos hospitalarios se redujeron en 0,10 (0,61 ± 0,13 vs. 0,52 ± 0,91; p = 0,405) y 0,17 puntos (0,33 ± 0,66 vs. 0,16 ± 0,42; p = 0,007), respectivamente. El coste por paciente se redujo en 444,9 (Euro) (1.003,3 ± 2.165,3 vs. 558,4 (Euro) ± 1.273,0; p = 0,018). CONCLUSIÓN: El servicio redujo el número de medicamentos que tomaba el paciente e ingresos hospitalarios y esto se relacionó con unos ratios de coste-efectividad positivos

The medication discrepancy detection service: A cost-effective multidisciplinary clinical approach.

OBJECTIVE: To estimate the effectiveness of a Medication Discrepancy Detection Service (MDDS), a collaborative service between the community pharmacy and Primary Care. DESIGN: Non-controlled before-and-after study. SETTING: Bidasoa Integrated Healthcare Organisation, Gipuzkoa, Spain. PARTICIPANTS: The service was provided by a multidisciplinary group of community pharmacists (CPs), general practitioners (GPs), and primary care pharmacists, to patients with discrepancies between their active medical charts and medicines that they were actually taking. OUTCOMES: The primary outcomes were the number of medicines, the type of discrepancy, and GPs' decisions. Secondary outcomes were time spent by CPs, emergency department (ED) visits, hospital admissions, and costs. RESULTS: The MDDS was provided to 143 patients, and GPs resolved discrepancies for 126 patients. CPs identified 259 discrepancies, among which the main one was patients not taking medicines listed on their active medical charts (66.7%, n=152). The main GPs' decision was to withdraw the treatment (54.8%, n=125), which meant that the number of medicines per patient was reduced by 0.92 (9.12±3.82 vs. 8.20±3.81; p<.0001). The number of ED visits and hospital admissions per patient were reduced by 0.10 (0.61±.13 vs 0.52±0.91; p=.405 and 0.17 (0.33±0.66 vs. 0.16±0.42; p=.007), respectively. The cost per patient was reduced by €444.9 (€1003.3±2165.3 vs. €558.4±1273.0; p=.018). CONCLUSION: The MDDS resulted in a reduction in the number of medicines per patients and number of hospital admissions, and the service was associated with affordable, cost-effective ratios.

Community pharmacist interventions to improve adherence to lipid lowering medication and their influence on clinical outcomes: A systematic review and meta-analysis.

INTRODUCTION: Non-adherence is a major problem among patients with chronic diseases. Community pharmacists are ideally positioned to detect non-adherence and to provide patient-centred interventions. OBJECTIVE: To conduct a systematic review of the impact of community pharmacist interventions on patient adherence to lipid lowering medication (LLM) prescriptions and clinical outcomes. SEARCH METHOD: Five databases (MEDLINE, Cochrane Library, Science Direct, Scopus, and Web of Knowledge) were searched systematically to identify relevant reports published by December 2019. Study quality was assessed with the Cochrane risk of bias (RoB 2.0) tool. SELECTION CRITERIA: Controlled trials in which community pharmacists conducted an intervention to improve patient adherence to LLM and clinical outcomes were evaluated. MAIN RESULTS: Five studies (2408 participants) were included in the qualitative analysis. Four studies (n = 2266) were pooled in the meta-analysis. Participants in the intervention group (IG) had better adherence than those in the control group (CG) [odds ratio (OR) = 1.67; 95% confidence interval (CI) 1.38-2.02; P < 0.001; I2 = 54%]. Better adherence rates were obtained when adherence was measured with validated questionnaires than when medication-possession ratio (MPR) measurements were used. Total cholesterol (TC) levels were not included in the meta-analysis due to data variability among the studies. CONCLUSIONS: Pharmacist-led intervention can improve LLM adherence, but its influence on clinical outcomes, including lipid level control, remains to be clarified.

Effect of health professional intervention on adherence to statin use according to the cause of patient non-adherence.

Background Non-adherence is a problem that particularly affects those with chronic diseases. Studying causes for not following the treatment is necessary to choose the best intervention to improve non-adherence. Objective Analyze how the intentionality of non-adherence modulates the effects of professional intervention in patients with hypercholesterolemia. Setting: Community pharmacies and primary care centres in Spain. Methods A 6-month randomized controlled trial was conducted in 46 community pharmacies and 50 primary care centres in Spain. Adherence to statin therapy was measured with the Morisky-Green-Levine test. Non-adherence was classified based on the intentionality. Results 746 Patients were recruited for the study (465 non-adherent and 281 adherent). Of those, 237 were randomly assigned to the intervention group and 228 to the non-intervention group. The 56.5% of non-adherent patients were classified as unintentional non-adherents and 43.5% as intentional non-adherents. More patients in the intervention group finished being adherent compared with the non-intervention group (+ 17.2% for intentional non-adherents and + 27.4% for unintentional non-adherence). The percentage of patients in the intervention group who completed the study as adherent was higher among those who previously had unintentional non-adherence (66.4%) compared to those with intentional non- adherence (55.3%) (p < 0.001). Conclusion Intervention provided to patients with unintentional non-adherence was more effective than intervention provided to patients with intentional non- adherence.

Tailored interventions by community pharmacists and general practitioners improve adherence to statins in a Spanish randomized controlled trial.

OBJECTIVE: To evaluate the impact of health professionals' intervention on adherence to statins, the influence on total cholesterol levels, and lifestyle patterns in patients with hypercholesterolemia and analyze the differences according to the center of recruitment. STUDY SETTING: Forty-six community pharmacies and 50 primary care centers of Spain. STUDY DESIGN: Randomized controlled trial design (n = 746). Patients were assigned into adherent (ADH) or nonadherent group depending on their initial adherence to statins. Nonadherent patients were randomly assigned to intervention (INT) or nonintervention (NOINT) group. Patients enrolled in the INT group received an intervention depending on the cause of nonadherence. Patients in the ADH and NOINT groups received usual care. Intention-to-treat (ITT) analysis was performed with multiple imputation to replace the missing data. DATA COLLECTION: Adherence, total cholesterol levels, and lifestyle behaviors. FINDINGS: The odds of becoming adherent during the 6 months was higher in the INT group compared to the NOINT group (OR = 1,49; 95% CI: 1.30-1.76; P < 0.001), especially in the community pharmacy group (OR = 2.34; 95% CI: 1.81-3.03; P < 0.001). Adherent patients showed lower values of total cholesterol compared with nonadherent patients at baseline (ADH: 200.3 mg/dL vs NOADH: 216.7 mg/dL; P < 0.001) and at the endpoint (ADH: 197.3 mg/dL vs NOADH: 212.2 mg/dL; P < 0.001). More patients enrolled in the INT group practices exercise at the end of the study (INT: +26.6 percent; P = 0.002), and a greater number of patients followed a diet to treat hypercholesterolemia (+30.2 percent; P < 0.001). CONCLUSIONS: The intervention performed by health professionals, especially by community pharmacists, improved adherence to statins by hypercholesterolemic patients, and this improvement in adherence was accompanied by a reduction in total cholesterol levels and a healthier lifestyle.

Defining and characterising age-friendly community pharmacies: a qualitative study.

INTRODUCTION: The Global Network of Age-friendly Cities is a project promoted by the World Health Organization as a response to demographic ageing and urbanization process. San Sebastian, Spain, is one of these Age-friendly Cities and community pharmacies of the city joined the initiative. OBJECTIVE: To define and implement the Age-friendly Pharmacy concept to promote active ageing, optimize the contribution of community pharmacies of San Sebastian to the friendliness of the city and to the improvement of quality of life of the ageing population. METHOD: A bottom-up participative approach was undertaken. A focus group was conducted to determine elderly people's opinions and expectations of community pharmacy. The information obtained was analysed using content analysis and validated for reliability, usefulness and applicability through three expert groups of community pharmacy owners and staff. KEY FINDINGS: Fifteen requirements were agreed, covering four main areas: relationships, pharmacy layout, pharmaceutical services and communication of services. Initially, 18 community pharmacies committed to become Age-friendly Pharmacies by pledging to these requirements and the Official Pharmacist Association of Gipuzkoa supported pharmacies in the implementation of the initiative. CONCLUSION: This study suggests that there is demand for a patient-centred community pharmacy to support older people, in which pharmaceutical care services are required. The 18 Age-friendly Pharmacies together with the Official Pharmacist Association of Gipuzkoa have publicly committed to actively work on social and patient-centred care to meet the needs of the ageing population.

Association of lifestyle, inflammatory factors, and dietary patterns with the risk of suffering a stroke: A case-control study.

BACKGROUND: Lifestyle, including dietary patterns, could involve specific factors participating in inflammation that confer a higher risk of suffering a stroke. However, little attention has been apparently given to habitual food consumption in patients suffering a cerebrovascular event. OBJECTIVE: To assess the influence of dietary habits as well as other lifestyle-related variables on the risk of suffering a stroke. DESIGN: A case-control study was designed. Fifty-one cases (age: 59.1 ± 9.1y.o; BMI; 30.8 ± 3.4 kg/m2) and 51 controls (age: 61.1 ± 9.1y.o; BMI; 30.4 ± 3.6 kg/m2) were enrolled in the study. Anthropometric and body composition variables were measured. Dietary information was obtained from a validated food frequency questionnaire. Physical activity and lifestyle-related factors were assessed. Blood samples were drawn. RESULTS: Patients suffering a stroke showed higher prevalence of diabetes (30 vs. 7.7%; P = 0.020) and hypertension (74.5 vs. 40.3%; P < 0.001) and were less physically active (36.7 vs. 66.6%; P = 0.024) than controls. Patients registered worse glucose and lipid profiles, higher levels of hepatic biomarkers, and higher blood cell counts than controls. Stroked patients showed lower adherence to a statistically derived healthy dietary pattern than controls (23.5 vs. 42.3%; P = 0.017). A logistic regression model was built up considering hypertension, diabetes, smoking, physical activity, adherence to a 'healthy dietary pattern' and C-reactive protein concentration. The final model strongly associated with the risk of suffering a stroke (R2: 44.6%; Pmodel < 0.0001). CONCLUSION: Lifestyle variables such as physical activity, smoking habit, and a dietary pattern including foods with low inflammatory potential play an important role in the reduction of the risk of suffering a stroke.

Cost analysis and cost-benefit analysis of a medication review with follow-up service in aged polypharmacy patients.

BACKGROUND: Drug related problems have a significant clinical and economic burden on patients and the healthcare system. Medication review with follow-up (MRF) is a professional pharmacy service aimed at improving patient's health outcomes through an optimization of the medication. OBJECTIVE: To ascertain the economic impact of the MRF service provided in community pharmacies to aged polypharmacy patients comparing MRF with usual care, by undertaking a cost analysis and a cost-benefit analysis. METHODS: The economic evaluation was based on a cluster randomized controlled trial. Patients in the intervention group (IG) received the MRF service and the comparison group (CG) received usual care. The analysis was conducted from the national health system (NHS) perspective over 6 months. Direct medical costs were included and expressed in euros at 2014 prices. Health benefits were estimated by assigning a monetary value to the quality-adjusted life years. One-way deterministic sensitivity analysis was undertaken in order to analyse the uncertainty. RESULTS: The analysis included 1403 patients (IG: n = 688 vs CG: n = 715). The cost analysis showed that the MRF saved 97 € per patient in 6 months. Extrapolating data to 1 year and assuming a fee for service of 22 € per patient-month, the estimated savings were 273 € per patient-year. The cost-benefit ratio revealed that for every 1 € invested in MRF, a benefit of 3.3 € to 6.2 € was obtained. CONCLUSION: The MRF provided health benefits to patients and substantial cost savings to the NHS. Investment in this service would represent an efficient use of healthcare resources.

Evaluation of the implementation process and outcomes of a professional pharmacy service in a community pharmacy setting. A case report.

Pharmacist-led medication review services are recognized as a key to medicines management. This case study describes the implementation process of a medication review with follow-up service in a community pharmacy setting and evaluates its initial outcomes. An implementation-effectiveness hybrid study was undertaken in a community pharmacy setting. The implementation process was divided into four different phases: Exploration and adoption, program installation, initial implementation, and full operation. A core set of implementation outcomes was measured, including penetration, implementation costs, feasibility, fidelity, acceptability, appropriateness and efficiency. The penetration rate of the service was nearly 62.5%, and the implementation costs were 57,359.67€. There was a high retention-participation rate of patients. For every month of service provision, there was a 1.27 increase in the number of patients requesting the service, compared to the number of patients being offered the service. The time spent on service provision was 171.7 min per patient. Average patient satisfaction with the service was 4.82 (SD: 0.39, scale 1-5), and the acceptance rate of care plans by patients and general medical practitioners were 96.99% and 96.46%, respectively. There were 408 negative outcomes associated with the use of medications were identified during the study (3.09 per patient), of which 96.3% were resolved. The average time per patient spent on service provision significantly decreased along the 18 months of service provision. This case report can assist individual pharmacists and professional organizations interested in implementing evidence-based services by offering an example on how to approach the implementation process in a systematic way.

The impact of a medication review with follow-up service on hospital admissions in aged polypharmacy patients.

AIMS: The aims were to assess the impact of a medication review with follow-up (MRF) service provided in community pharmacy to aged polypharmacy patients on the number of medication-related hospital admissions and to estimate the effect on hospital costs. METHODS: This was a sub-analysis of a cluster randomized controlled trials carried out in 178 community pharmacies in Spain. Pharmacies in the intervention group (IG) provided a comprehensive medication review during 6 months. Pharmacists in the comparison group (CG) delivered usual care. For the purposes of this sub-analysis, an expert panel of three internal medicine specialists screened the hospitalizations occurring during the main study, in order to identify medication-related hospitalizations. Inter-rater reliability was measured using Fleiss's kappa. Hospital costs were calculated using diagnosis related groups. RESULTS: One thousand four hundred and three patients were included in the main study and they had 83 hospitalizations. Forty-two hospitalizations (50.6%) were medicine-related, with a substantial level of agreement among the experts (kappa = 0.65, 95% CI 0.52, 0.78, P < 0.01). The number of medication-related hospitalizations was significantly lower in patients receiving MRF (IG 11, GC 31, P = 0.042). The probability of being hospitalized was 3.7 times higher in the CG (odds ratio 3.7, 95% CI 1.2, 11.3, P = 0.021). Costs for a medicine-related hospitalization were €6672. Medication-related hospitalization costs were lower for patients receiving MRF [IG: €94 (SD 917); CG: €301 (SD 2102); 95% CI 35.9, 378.0, P = 0.018]. CONCLUSION: MRF provided by community pharmacists might be an effective strategy to balance the assurance of the benefit from medications and the avoidance of medication-related hospitalizations in aged patients using polypharmacy.

Epigenetic Changes in the Methylation Patterns of KCNQ1 and WT1 after a Weight Loss Intervention Program in Obese Stroke Patients.

Ischemic stroke patients often show high concentrations of circulating inflammatory markers that are associated with increased risk of recurrence. Epigenetic mechanisms could be involved in obesity, inflammation and stroke. The objective of this research was to investigate, in obese patients suffering a previous stroke, the effects of a nutritional program on anthropometric and biochemical variables, and on the methylation patterns of two stroke-related genes (KCNQ1: potassium channel, voltage gated KQT-like subfamily Q, member 1; and WT1: Wilms tumor 1). Twenty-two ischemic stroke patients were compared with a control group composed of eighteen obese subjects with similar age and body mass index ranges. Both groups followed a 20-week nutritional program based on an energy-restricted balanced diet with high adherence to the Mediterranean dietary pattern. The intervention significantly improved anthropometric and metabolic variables, such as the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) and C-reactive protein concentration, in ischemic stroke patients, and was accompanied by changes in the methylation patterns of both stroke-related genes, which correlated with anthropometric and biochemical variables.

Association between different obesity measures and the risk of stroke in the EPIC Spanish cohort.

INTRODUCTION: There is still a scientific debate on the exact role played by obesity on stroke risk. OBJECTIVE: The aim of the study was to analyze the association between obesity, measured by different indices such as body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR) and a new one called A Body Shape Index (ABSI) and the risk of total and ischemic stroke. SUBJECTS/METHODS: A total of 41,020 subjects (15,490 men and 25,530 women) aged 29-69 years participated in the study. All participants were recruited between 1992 and 1996 and followed up until 2008 to ascertain incident cerebrovascular disease events. Cox proportional hazards models were designed to estimate the relative risk and 95% CI between obesity and cerebrovascular disease incidence. RESULTS: After 13.8 years of follow-up, a total of 674 stroke cases (55.3% in men) were registered (531 ischemic, 79 hemorrhagic, 42 subarachnoid hemorrhage and 22 unspecified). WC fourth quartile (HR 1.95; 95% CI 1.20-3.19) and WHR fourth quartile (HR 1.58; 95% CI 1.12-2.25) were positively associated with total stroke only in men. BMI was not associated with stroke incidence. The new index, ABSI, was significantly associated with total stroke incidence only in men (HR 1.54; 95% CI 1.06-2.23). CONCLUSIONS: Data from the Spanish EPIC cohort study show a strong association of WC and WHR with the relative risk of suffering a stroke only in men, while no associations were found for BMI. It supports the suggestion of other authors of using more than one obesity index in the study of stroke risk prediction.

Obesity and ischemic stroke modulate the methylation levels of KCNQ1 in white blood cells.

Obesity and stroke are multifactorial diseases in which genetic, epigenetic and lifestyle factors are involved. The research aims were, first, the description of genes with differential epigenetic regulation obtained by an 'omics' approach in patients with ischemic stroke and, second, to determine the importance of some regions of these selected genes in biological processes depending on the body mass index. A case-control study using two populations was designed. The first population consisted of 24 volunteers according to stroke/non-stroke and normal weight/obesity conditions. The second population included 60 stroke patients and 55 controls classified by adiposity. DNA from the first population was analyzed with a methylation microarray, showing 80 cytosine-guanine dinucleotides (CpG) sites differentially methylated in stroke and 96 CpGs in obesity, whereas 59 CpGs showed interaction. After validating these data by MassArray Epityper, the promoter region of peptidase M20 domain containing 1 (PM20D1) gene was significantly hypermethylated in stroke patients. One CpG site at Caldesmon 1 (CALD1) gene showed an interaction between stroke and obesity. Two CpGs located in the genes Wilms' tumor 1 (WT1) and potassium voltage-gated channel, KQT-like subfamily, member 1 (KCNQ1) were significantly hypermethylated in obese patients. In the second population, KCNQ1 was also hypermethylated in the obese subjects. Two CpGs of this gene were subsequently validated by methylation-sensitive high-resolution melting. Moreover, KCNQ1 methylation levels were associated with plasma KCNQ1 protein concentrations. In conclusion, obesity induced changes in the KCNQ1 methylation pattern which were also dependent on stroke. Furthermore, the epigenetic marks differentially methylated in the stroke patients were dependent on the previous obese state. These DNA methylation patterns could be used as future potential stroke biomarkers.