Short-term prognosis of polypharmacy in elderly patients treated in emergency departments: results from the EDEN project.

Background: Polypharmacy is a growing phenomenon among elderly individuals. However, there is little information about the frequency of polypharmacy among the elderly population treated in emergency departments (EDs) and its prognostic effect. This study aims to determine the prevalence and short-term prognostic effect of polypharmacy in elderly patients treated in EDs. Methods: A retrospective analysis of the Emergency Department Elderly in Needs (EDEN) project's cohort was performed. This registry included all elderly patients who attended 52 Spanish EDs for any condition. Mild and severe polypharmacy was defined as the use of 5-9 drugs and ⩾10 drugs, respectively. The assessed outcomes were ED revisits, hospital readmissions, and mortality 30 days after discharge. Crude and adjusted logistic regression analyses, including the patient's comorbidities, were performed. Results: A total of 25,557 patients were evaluated [mean age: 78 (IQR: 71-84) years]; 10,534 (41.2%) and 5678 (22.2%) patients presented with mild and severe polypharmacy, respectively. In the adjusted analysis, mild polypharmacy and severe polypharmacy were associated with an increase in ED revisits [odds ratio (OR) 1.13 (95% confidence interval (CI): 1.04-1.23) and 1.38 (95% CI: 1.24-1.51)] and hospital readmissions [OR 1.18 (95% CI: 1.04-1.35) and 1.36 (95% CI: 1.16-1.60)], respectively, compared to non-polypharmacy. Mild and severe polypharmacy were not associated with increased 30-day mortality [OR 1.05 (95% CI: 0.89-2.26) and OR 0.89 (95% CI: 0.72-1.12)], respectively. Conclusion: Polypharmacy was common among the elderly treated in EDs and associated with increased risks of ED revisits and hospital readmissions ⩽30 days but not with an increased risk of 30-day mortality. Patients with polypharmacy had a higher risk of ED revisits and hospital readmissions ⩽30 days after discharge.

Short-term prognosis of polypharmacy in elderly patients treated in emergency departments: results from the EDEN project Management elderly patients with polypharmacy is becoming a major challenge to the emergency services. The progressive aging of the population is producing a progressive increase in the number of patients treated with multiple comorbidities and chronic medications. It's well known that polypharmacy is associated with an increase in hospital admissions and health care system costs. However, the impact of polypharmacy over the risk of new visits to the emergency rooms is not well defined. Understanding the impact of polypharmacy on the frequency of new visits to the emergency room and on patient mortality is the first step to establish prevention measures for new visits, proposing improvements in chronic treatment at discharge. This study aimed to determine the prevalence and effect on short-term prognosis of polypharmacy in elderly patients treated in Emergency departments. The authors used a retrospective multipurpose registry in 52 hospitals in Spain. This study includes 25,557 patients with a mean age of 78 years. On admission, the median number of drugs was 6 (IQR: 3­9), with 10,534 (41.2%) patients taking 5­9 drugs and 5,678 (22.2%) taking ⩾10 drugs. In these patients comorbidities were associated with an increase in the number of drugs. In the patients with severe polypharmacy (⩾10 drugs), diuretics were the most frequently drugs prescribed, followed by antihypertensives and statins. The results obtained indicate that polypharmacy is a frequent phenomenon among the elderly population treated in Emergency departments, being antihypertensives the most frequently used drugs in this population. Those patients who takes ⩾10 drugs have a higher risk of new visits to the emergency room and hospital readmissions in short term period.

Healthcare risk stratification model for emergency departments based on drugs, income and comorbidities: the DICER-score.

BACKGROUND: During the last decade, the progressive increase in age and associated chronic comorbidities and polypharmacy. However, assessments of the risk of emergency department (ED) revisiting published to date often neglect patients' pharmacotherapy plans, thus overseeing the Drug-related problems (DRP) risks associated with the therapy burden. The aim of this study is to develop a predictive model for ED revisit, hospital admission, and mortality based on patient's characteristics and pharmacotherapy. METHODS: Retrospective cohort study including adult patients visited in the ED (triage 1, 2, or 3) of multiple hospitals in Catalonia (Spain) during 2019. The primary endpoint was a composite of ED visits, hospital admission, or mortality 30 days after ED discharge. The study population was randomly split into a model development (60%) and validation (40%) datasets. The model included age, sex, income level, comorbidity burden, measured with the Adjusted Morbidity Groups (GMA), and number of medications. Forty-four medication groups, associated with medication-related health problems, were assessed using ATC codes. To assess the performance of the different variables, logistic regression was used to build multivariate models for ED revisits. The models were created using a "stepwise-forward" approach based on the Bayesian Information Criterion (BIC). Area under the curve of the receiving operating characteristics (AUCROC) curve for the primary endpoint was calculated. RESULTS: 851.649 patients were included; 134.560 (15.8%) revisited the ED within 30 days from discharge, 15.2% were hospitalized and 9.1% died within 30 days from discharge. Four factors (sex, age, GMA, and income level) and 30 ATC groups were identified as risk factors and combined into a final score. The model showed an AUCROC values of 0.720 (95%CI:0.718-0.721) in the development cohort and 0.719 (95%CI.0.717-0.721) in the validation cohort. Three risk categories were generated, with the following scores and estimated risks: low risk: 18.3%; intermediate risk: 40.0%; and high risk: 62.6%. CONCLUSION: The DICER score allows identifying patients at high risk for ED revisit within 30 days based on sociodemographic, clinical, and pharmacotherapeutic characteristics, being a valuable tool to prioritize interventions on discharge.

Pharmacist care in hospital emergency departments: a consensus paper from the Spanish hospital pharmacy and emergency medicine associations. / Atención farmacéutica en los servicios de urgencias: documento de posicionamiento de la Sociedad Española de Farmacia Hospitalaria (SEFH) y la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES).

OBJECTIVES: To draft a list of actions and quality indicators for pharmacist care in hospital emergency departments, based on consensus among a panel of experts regarding which actions to prioritize in this setting. MATERIAL AND METHODS: A panel of experts from the Spanish Society of Hospital Pharmacy (SEFH) and the Spanish Society of Emergency Medicine (SEMES) evaluated a preliminary list of potential actions and quality of care indicators. The experts used a questionnaire to assess the proposals on the basis of available evidence. In the first round, each expert individually assessed the importance of each proposed action based on 4 dimensions: evidence base, impact on clinical response and patient safety, ease of implementation, and priority. In the second round the experts attended a virtual meeting to reach consensus on a revised list of proposals; suggestions and comments that had been made anonymously in the first round were included. The group then prioritized each action as basic, intermediate, or advanced. RESULTS: The experts evaluated a total of 26 potential actions and associated quality indicators. No items were eliminated in the analysis of scores and comments from the first round. After the second round, 25 actions survived. Nine were considered basic, 10 intermediate, and 6 advanced. CONCLUSION: The expert panel's list of pharmacist actions and care quality indicators provides a basis for developing a pharmacist care program in Spanish emergency departments on 3 levels of priority. The list can serve as a guide to pharmacists, managers, physicians, and nurses involved in the effort to improve drug therapy in this hospital setting.

OBJETIVO: Desarrollar un conjunto de actividades e indicadores de atención farmacéutica en los servicios de urgencias hospitalarios mediante un consenso colectivo de un panel de expertos que permita priorizar las actividades a realizar por los farmacéuticos en estas unidades. METODO: Un comité formado por miembros de la Sociedad Española de Farmacia Hospitalaria (SEFH) y de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) evaluó una propuesta inicial de actividades e indicadores potenciales, basados en la evidencia científica disponible, en formato de cuestionario. En una primera ronda, cada uno de los expertos del panel clasificó de forma individual la relevancia de cada una de las actividades propuestas en cuatro dimensiones: evidencia científica, impacto en la respuesta clínica y seguridad para el paciente, facilidad de implementación y grado de prioridad. La segunda ronda se realizó mediante una reunión grupal de forma virtual, a partir del cuestionario modificado de acuerdo con las sugerencias planteadas, así como los comentarios vertidos por los participantes del panel de forma anónima. En esta ronda, cada actividad fue clasificada por consenso como básica, intermedia o avanzada en función del grado de prioridad de implantación considerado por el grupo de expertos. RESULTADOS: Se propusieron un total de 26 potenciales actividades a los expertos, con indicadores asociados. Tras el análisis de las puntuaciones y los comentarios realizados en la primera ronda, no se eliminó ninguna de las actividades propuestas. Tras la segunda ronda, se mantuvieron 25 actividades, de las cuales se puntuaron 9 como actividades básicas, 10 actividades como intermedias y 6 actividades como avanzadas. CONCLUSIONES: El desarrollo del conjunto de actividades e indicadores de atención farmacéutica en urgencias, priorizados por grado de relevancia para la unidad, es la base para el desarrollo de esta cartera de servicios en los hospitales españoles, y sirve como guía tanto para farmacéuticos como para gestores, médicos y enfermeros de la unidad a fin de mejorar la farmacoterapia los pacientes atendidos en los servicios de urgencias.

Utilidad de los diagnósticos alertantes CIE-10 para identificar acontecimientos adversos por los medicamentos en los servicios de urgencias / Usefulness of ICD-10 diagnosis triggers to identify adverse drug events in emergency care

Objetivos: Evaluar la utilidad de una herramienta basada en los códigos diagnósticos CIE-10 para identificar a los pacientes que consultan a un servicio de urgencias por acontecimientos adversos por medicamentos (AAM). Métodos: Estudio observacional prospectivo, en el cual se incluyeron los pacientes que acudieron a un servicio de urgencias durante el periodo de mayo-agosto de 2022 con un diagnóstico codificado con alguno de los 27 diagnósticos CIE-10 establecidos como alertantes para el estudio. La confirmación de la presencia de AAM a partir de dichos diagnósticos se realizó analizando los fármacos prescritos previamente al ingreso, a través de un debate entre expertos y mediante una entrevista telefónica con los pacientes. Resultados: Se evaluaron 1.143 pacientes con diagnósticos alertantes, de los cuales 310 (27,1%) correspondieron a pacientes cuya consulta se atribuyó a un AAM. El 58,4% de los AAM se detectaron mediante 3 códigos diagnósticos: K59.0-Estreñimiento (n = 87; 28,1%), I16.9-Crisis hipertensiva (n = 72; 23,2%) e I95.1-Hipotensión ortostática (n = 22; 7,1%). Los códigos diagnósticos con mayor grado de asociación con AAM fueron: E16.2-Hipoglucemia no especificada (73,7%) y E11.65-Diabetes mellitus tipo 2 con hiperglucemia (71,4%), mientras que los diagnósticos D62-Anemia poshemorrágica aguda e I74.3-Embolia y trombosis de arterias de los miembros inferiores no identificaron ningún AAM. Conclusiones: Los códigos CIE-10 asociados a diagnósticos alertantes son una herramienta de utilidad para identificar a los pacientes que consultan los servicios de urgencias por AAM y podrían ser utilizados para abordar las intervenciones de prevención secundaria dirigidas a evitar nuevas consultas al sistema sanitario. (AU)

Objectives: To assess the usefulness of a tool based on ICD-10 diagnostic codes to identify patients who consult an emergency department for adverse drug events (ADE). Methods: Prospective observational study, in which patients discharged from an emergency department during May to August 2022 with a diagnosis coded with one of the 27 ICD-10 diagnoses considered as triggers were included. ADE confirmation was carried out by analyzing drugs prescribed prior to admission, and through a discussion among experts and a phone interview with patients after hospital discharge. Results: 1,143 patients with trigger diagnoses were evaluated, of which 310 (27.1%) corresponded to patients whose emergency visit was attributed to an ADE. A 58.4% of ADE consultations were found with three diagnostic codes: K59.0-Constipation (n = 87; 28.1%), I16.9-Hypertensive Crisis (n = 72; 23.2%) and I95.1-Orthostatic hypotension (n = 22; 7.1%). The diagnoses with the highest degree of association with consultations attributed to ADE were E16.2-Hypoglycemia, unspecified (73.7%) and E11.65-Type 2 diabetes mellitus with hyperglycemia (71.4%), while diagnoses D62-Acute posthemorrhagic anemia and I74.3-Embolism and thrombosis of arteries of the lower limbs were not attributed to any case of ADE. Conclusions: The ICD-10 codes associated with trigger diagnoses are a useful tool to identify patients who consult the emergency services with ADE and could be used to apply secondary prevention programs to avoid new consultations to the health care system. (AU)

[Translated article] Usefulness of ICD-10 diagnostic triggers to identify adverse drug events in emergency care.

OBJECTIVES: To assess the usefulness of a tool based on ICD-10 diagnostic codes to identify patients who consult an emergency department for adverse drug events (ADE). METHODS: Prospective observational study, in which patients discharged from an emergency department during May to August 2022 with a diagnosis coded with one of the 27 ICD-10 diagnoses considered as triggers were included. ADE confirmation was carried out by analyzing drugs prescribed prior to admission, and through a discussion among experts and a phone interview with patients after hospital discharge. RESULTS: 1143 patients with trigger diagnoses were evaluated, of which 310 (27.1%) corresponded to patients whose emergency visit was attributed to an ADE. A 58.4% of ADE consultations were found with three diagnostic codes: K59.0-Constipation (n = 87; 28.1%), I16.9-Hypertensive Crisis (n = 72; 23.2%) and I95.1-Orthostatic hypotension (n = 22; 7.1%). The diagnoses with the highest degree of association with consultations attributed to ADE were E16.2-Hypoglycemia, unspecified (73.7%) and E11.65-Type 2 diabetes mellitus with hyperglycemia (71.4%), while diagnoses D62-Acute posthemorrhagic anemia and I74.3-Embolism and thrombosis of arteries of the lower limbs were not attributed to any case of ADE. CONCLUSIONS: The ICD-10 codes associated with trigger diagnoses are a useful tool to identify patients who consult the emergency services with ADE and could be used to apply secondary prevention programs to avoid new consultations to the health care system.

Drug-Related Problems in Elderly Patients Attended to by Emergency Services.

The progressive aging and comorbidities of the population have led to an increase in the number of patients with polypharmacy attended to in the emergency department. Drug-related problems (DRPs) have become a major cause of admission to these units, as well as a high rate of short-term readmissions. Anticoagulants, antibiotics, antidiabetics, and opioids have been shown to be the most common drugs involved in this issue. Inappropriate polypharmacy has been pointed out as one of the major causes of these emergency visits. Different ways of conducting chronic medication reviews at discharge, primary care coordination, and phone contact with patients at discharge have been shown to reduce new hospitalizations and new emergency room visits due to DRPs, and they are key elements for improving the quality of care provided by emergency services.

Validation protocol of the LESS-CHRON deprescription tool in multimorbidity patients. LESS-CHRON-VALIDATION Project.

OBJECTIVE: Deprescribing is considered one of the main strategies available for  preparing an individualized therapeutic plan in patients with multiple pathologies or complex chronic conditions. However, despite the practice has been in place for some years, there is a need for studies that support the achievement of satisfactory health outcomes, as well as tools that help implement deprescribing in routine clinical practice. The  bjective of this project is to analyze the impact of reducing polypharmacy,  through the LESS-CHRON deprescribing tool, on a population  of elderly polymedicated patients with multiple conditions. METHOD: This will be a quasi-experimental, pre-and-post intervention multicenter cohort study. The variables to be analyzed will be  divided into two large groups: those related to pharmacology and those related to health outcomes. They will be collected at baseline, at 3 and at 6-12  months. A first screening phase will be carried out to recruit candidate patients  and obtain information about the identified deprescribing  opportunities. The second phase will constitute the intervention phase, where  the LESS-CHRON tool will be applied and the actual deprescribing of the drugs  will be carried out. DISCUSSION: LESS-CHRON has been proclaimed as a suitable deprescribing tool in clinical practice. Validation of LESS-CHRON will seek to show the results that can be achieved following the deprescribing of drugs,  in addition to demonstrating that the tool can reliably be used by clinicians in  their routine practice. On the other hand, the results of this project may  provide information leading to improving or adapting the tool itself, giving rise  to a second generation of more efficient version.

OBJETIVO: La desprescripción se considera una de las principales estrategias disponibles para el abordaje del plan terapéutico individualizado en  pacientes pluripatológicos o crónicos complejos. Sin embargo, a pesar de ser una práctica ya instaurada desde hace algunos años, se reclama la necesidad de estudios que avalen la obtención de buenos resultados en salud, además de herramientas que ayuden a su desarrollo en la práctica clínica habitual. El objetivo de este proyecto es analizar el impacto en  la disminución de la farmacoterapia mediante la desprescripción de fármacos, aplicando la herramienta LESS-CHRON, en una población de  pacientes de edad avanzada, polimedicada y con múltiples patologías.Método: Estudio cuasiexperimental, pre-post, multicéntrico. Las variables a analizar se dividirán en dos grandes grupos: referidas a la esfera  farmacológica y referidas a resultados en salud. Se recogerán en el momento  basal, a los 3 y a los 6-12 meses. Se realizará una primera fase de screening  para localizar a los pacientes candidatos, que permitirá obtener la información relativa a las oportunidades de desprescripción identificadas. La  segunda constituirá la fase de intervención, en la que se aplicará la  herramienta LESS-CHRON y se llevará a cabo la desprescripción real de los  fármacos.Discusión: LESS­CHRON se ha proclamado como una herramienta adecuada para llevar a cabo la desprescripción de fármacos en la práctica clínica. La validación de la herramienta LESS-CHRON tratará de poner  de manifiesto los resultados que se logran tras efectuar la desprescripción,  además de demostrar su fiabilidad como herramienta, de modo que los clínicos puedan usarla como parte de su actividad asistencial con total  confianza. Por otro lado, los resultados de este proyecto podrán arrojar  información para la mejora o adaptación de la propia herramienta, dando lugar  a una segunda generación o futuras versiones mejoradas y más  eficientes.

Anticholinergic burden and revisit risk in frail patients with pharmacological sleepiness.

OBJECTIVE: Drug-induced sleepiness is a frequent cause of emergency department (ED) visits for frail patients. The aim of this study was to assess the impact of anticholinergic burden on 90-day revisitation risk for frail patients who visit the ED due to drug-induced sleepiness. METHODS: This was a retrospective study in which patients treated at a fragility care area of an ED who sought consultation for drug-associated sleepiness from June 2020 to June 2021 were included. To evaluate the 90-day revisitation risk factors, a multivariate analysis was performed, including those factors with a p<0.200 from a previous univariate model. A Cox regression model was performed to assess the impact of a high burden on the time until 90-day ED revisitation. RESULTS: One hundred and forty-eight patients were included (mean age 80.7±12.3 years). The median number of drugs that patients were currently on at emergency admission was eight (range 2-19), while at hospital discharge it was nine (range 2-20), with the median number of central nervous system (CNS) depressant drugs on admission being three (range 1-6). Thirty-five (23.6%) patients revisited the ED 90 days after discharge for sleepiness or agitation. In the multivariate model, a significant association was observed between a high anticholinergic burden during treatment at discharge (OR 3.74, 95% CI 1.36 to 9.71), chronic kidney disease (OR 2.87, 95% CI 1.19 to 6.81), and the risk of 90-day revisitation. Patients with high anticholinergic burden had a shorter time to revisit than those with medium or low anticholinergic burden (HR 1.96, 95% CI 1.05 to 3.99). CONCLUSIONS: Patients with pharmacological sleepiness and a high anticholinergic burden in their chronic treatment carry a greater risk of revisitation to EDs, and should be considered candidates for specific interventions after visiting these units.

Protocolo de validación de la herramientade desprescripción LESS-CHRON en pacientespluripatológicos. Proyecto LESS-CHRON-VALIDATION / Validation protocol of the LESS-CHRON deprescription tool in multimorbidity patients. LESS-CHRON-VALIDATION Project

Objetivo: La desprescripción se considera una de las principales estrategias disponibles para el abordaje del plan terapéutico individualizado enpacientes pluripatológicos o crónicos complejos. Sin embargo, a pesar deser una práctica ya instaurada desde hace algunos años, se reclama lanecesidad de estudios que avalen la obtención de buenos resultados ensalud, además de herramientas que ayuden a su desarrollo en la prácticaclínica habitual. El objetivo de este proyecto es analizar el impacto en ladisminución de la farmacoterapia mediante la desprescripción de fármacos,aplicando la herramienta LESS-CHRON, en una población de pacientes deedad avanzada, polimedicada y con múltiples patologías.Método: Estudio cuasiexperimental, pre-post, multicéntrico. Las variables aanalizar se dividirán en dos grandes grupos: referidas a la esfera farmacológica y referidas a resultados en salud. Se recogerán en el momento basal,a los 3 y a los 6-12 meses. Se realizará una primera fase de screening paralocalizar a los pacientes candidatos, que permitirá obtener la informaciónrelativa a las oportunidades de desprescripción identificadas. La segundaconstituirá la fase de intervención, en la que se aplicará la herramientaLESS-CHRON y se llevará a cabo la desprescripción real de los fármacos.(AU)

Objective: Deprescribing is considered one of the main strategies available for preparing an individualized therapeutic plan in patients withmultiple pathologies or complex chronic conditions. However, despite thepractice has been in place for some years, there is a need for studies thatsupport the achievement of satisfactory health outcomes, as well as toolsthat help implement deprescribing in routine clinical practice. The objective of this project is to analyze the impact of reducing polypharmacy,through the LESS-CHRON deprescribing tool, on a population of elderlypolymedicated patients with multiple conditions.Method: This will be a quasi-experimental, pre-and-post interventionmulticenter cohort study. The variables to be analyzed will be dividedinto two large groups: those related to pharmacology and those related to health outcomes. They will be collected at baseline, at 3 and at6-12 months. A first screening phase will be carried out to recruit candidate patients and obtain information about the identified deprescribingopportunities. The second phase will constitute the intervention phase,where the LESS-CHRON tool will be applied and the actual deprescribingof the drugs will be carried out. (AU)

Cost-effectiveness analysis of implementing a secondary prevention programme in those patients who visited an emergency department for drug-related problems.

OBJECTIVE: To evaluate the cost-effectiveness of a secondary prevention programme in patients admitted to the emergency department due to drug-related problems (DRPs). METHODS: A decision model compared costs and outcomes of patients with DRPs admitted to the emergency department. Model variables and costs, along with their distributions, were obtained from the trial results and literature. The study was performed from the perspective of the National Health System including only direct costs. KEY FINDINGS: The implementation of a secondary prevention programme for DRPs reduces costs associated with emergency department revisits, with an annual net benefit of €87 639. Considering a mortality rate attributable to readmission of 4.7%, the cost per life-years gained (LYG) with the implementation of this programme was €2205. In the short term, the reduction in the number of revisits following the programme implementation was the variable that most affected the model, with the benefit threshold value corresponding to a relative reduction of 12.4% of the number of revisits of patients with DRPs to obtain benefits. CONCLUSIONS: Implementing a secondary prevention programme is cost-effective for patients with DRPs admitted to the emergency department. Implementation costs will be exceeded by reducing revisits to the emergency department.

Cefepime Dosing Requirements in Elderly Patients Attended in the Emergency Rooms.

OBJECTIVE: This study aimed to assess the probability of reaching an adequate pharmacokinetic/pharmacodynamic (pK/pD) index for different cefepime dosages in frail patients with bacteremia treated in the emergency room. METHODS: Simulation study based on Gram-negative bacterial strains that cause bacteremia. The probability of reaching a time above the minimum inhibitory concentration (MIC) at 50% and 100% dosing intervals (fT > 50 and fT > 80% MIC) was assessed for two different renal clearance intervals. RESULTS: One hundred twenty nine strains were collected, the predominant species being Escherichia coli (n = 83 [64.3%]). In patients with a ClCr of 30 mL/min, an fT > 50% MIC was reached in more than 90% of the simulations. However, a dose of at least 1 g every 12 h must be administered to reach an fT > 80% MIC. In patients with a ClCr of 30-60 mL/min, the probability of reaching an fT > 50% MIC was higher than 90% with doses of 1 g every 8 h or more, but this value was not reached in > 90% simulations for any of the doses tested in this study. CONCLUSIONS: Standard cefepime dosing can reach an adequate PK/PD index in frail patients. Nevertheless, a high dose or extended infusion is necessary to reach an fT > 80% MIC in patients with a ClCr > 60 mL/min.

Development of an Emergency Revisit Score for Patients With Drug-Related Problems.

Background: Drug-related problems (DRPs) are a frequent reason for emergency departments (EDs) visits. However, data about the risk factors associated with EDs revisits are limited. Objective: To develop and validate a predictive model indicating the risk factors associated with EDs revisit within 30 days of the first visit. Methods: A retrospective cohort study was conducted involving patients who attended an ED for DRPs related to cardiovascular drugs. A 30-day prediction model was created in a derivation cohort by logistic regression. An integer score proportional to the regression coefficient was assigned to the variables with P < .100 in the multivariate analysis. Results: 581 patients (mean age: 80.0 [12.6] years) were included, 133 (22.9%) revisited the ED within 30 days from discharge. Six factors (chronic kidney disease, chronic heart failure, visit to an ED in the preceding 3 months, high anticholinergic burden, DRPs associated with heparin, and safety-related DRPs) were identified as risk factors and combined into a final score, termed the DREAMER score. The model reached an area under the receiver operating curve values of 0.72 (95% confidence interval [CI] = 0.67-0.77) in the referral cohort and 0.71 (95% CI = 0.65-0.74) in the validation cohort (P = .273). Three risk categories were generated, with the following scores and estimated risks: low risk (0-8 points): 11.6%; intermediate risk (9-14 points): 21.3%; and high risk (>14 points): 41.2%. Conclusion and Relevance: The DREAMER score identifies patients at high risk for ED revisit within 30 days from the first visit for a DRPs, being a useful tool to prioritize interventions on discharge.

The Impact of Pharmaceutical Care in Multidisciplinary Teams on Health Outcomes: Systematic Review and Meta-Analysis.

OBJECTIVES: Pharmacists' care has an essential role in multidisciplinary teams in charge of chronic patients. However, data available on the clinical outcomes of these activities appear inconclusive. This study aimed to systematically investigate the effect of multidisciplinary teams that include coordinated pharmaceutical care on clinical outcomes. DESIGN: Systematic review and meta-analysis. Relevant studies identified from MEDLINE, Cochrane, Web of Science, Scopus and CINAHL databases were analyzed. The search included randomized clinical trials published in 2000-2018. Included studies were all published studies in English that compared the effectiveness of multidisciplinary teams including pharmacist care to usual care. Meta-analysis was carried out using a random effects model, and subgroup analysis was conducted to determine the sources of heterogeneity. SETTING AND PARTICIPANTS: 29 studies involving 4186 adult patients were included. MEASURES: Follow-up time varied from 30 to 180 days. The most common primary endpoint was the frequency of hospitalizations or readmissions, followed by variation in clinical parameter variables related to quality of prescription, treatment adherence and costs. RESULTS: Twelve (41.3%) of the included studies scored low risk of bias according to the AMSTAR-2 scale, the remaining 17 (58.7%) being classified as intermediate risk. The intervention of a multidisciplinary team reduced the probability of readmission by 32% [odds ratio (OR) 0.74, 95% confidence interval (CI) 0.62-0.89]. Six of the 29 (20.7%) studies included met the inclusion criteria of the meta-analysis on quality-of-life outcomes. The intervention of the multidisciplinary team represented a significant increase in patients' quality of life (OR 0.58, 95% CI 0.47-0.69). Analysis of heterogeneity showed a significant difference between the studies. No evidence of publication bias was identified. CONCLUSIONS AND IMPLICATIONS: Multidisciplinary programs that include pharmaceutical care reduce the risk of visiting hospitals and improve patients' quality of life. This review supports the importance of the pharmacists as part of multidisciplinary teams.

The usefulness of measuring the anion gap in diagnosing metformin-associated lactic acidosis: a case series.

BACKGROUND: Metformin-associated lactic acidosis (MALA) is a widely documented adverse event of metformin. Despite being considered one of the main causes of metabolic acidosis, the association between an anion gap and MALA diagnosis is still uncertain. CASE PRESENTATION: Cases involving six Caucasian patients with suspected MALA who were admitted to the emergency department were analysed. All these patients presented with pH values < 7.35, lactate levels > 2 mmol/L, and estimated glomerular filtration < 30 mL/min. Metformin plasma concentrations were > 2.5 mg/L in all the patients. The highest metformin concentrations were not found in the patients with the highest lactate levels. The anion gap values ranged from 12.3 to 39.3, with only two patients exhibiting values > 14. CONCLUSIONS: In patients with MALA, there is a significant variability in the anion gap values, which is not related to the level of metformin accumulation, and therefore, it is doubtful whether measuring anion gaps is useful as an approach for MALA diagnosis.

Anticholinergic burden in patients treated for constipation in an emergency department. / Carga anticolinérgica en pacientes atendidos por estreñimiento en un servicio de ugencias.

OBJECTIVES: To evaluate the anticholinergic burden on discharge of patients treated for constipation in an emergency department (ED) and to assess the effect on emergency revisiting within 30 days. MATERIAL AND METHODS: Observational retrospective cohort study. We collected cases with a discharge diagnosis of constipation after ED treatment between September 2018 and June 2019 and recorded information on all drugs taken and the anticholinergic burden of treatment. A revisit to the ED within 30 days was the primary outcome. RESULTS: We included 104 patients. A high anticholinergic burden of treatment was identified in 47 (56.6%), an intermediate burden in 30 (36.1%), and a low burden in 6 (7.2%). Twenty-nine (27.9%) patients revisited the ED within 30 days of discharge. An intermediate anticholinergic burden (23 patients [31.1%] vs 4 [13.3%]; P = .061) and high burden (19 [40.4%] vs 8 [14.1%]; P = .002] was associated with revisiting within 30 days in the univariate analysis. On multivariate analysis, a high anticholinergic burden was independently associated with a higher rate of revisiting than a low burden: adjusted odds ratio (aOR), 4.21; 95% CI, 1.07-16.5; P = .039. An intermediate load was not associated with more revisits, however: aOR, 1.27; 95% CI, 0.25-6.41; P = .776. Prescription of long-term treatment with laxatives on discharge did not reduce revisiting withing 30-days in the group with a high anticholinergic load (OR, 0.86; 95% CI, 0.48-3.27; P = .526), but it did have an effect in patients an intermediate burden (OR, 0.13; 95% CI, 0.02-0.99; P = .049). CONCLUSION: The prescription of drugs leading to a high anticholinergic burden was a factor associated with ED revisits within 30 days in patients treated for constipation.

OBJETIVO: Evaluar la frecuencia e impacto de la carga anticolinérgica del tratamiento en la reconsulta a los 30 días en los pacientes atendidos por estreñimiento en un servicio de urgencias (SU). METODO: Estudio observacional de cohortes retrospectivo. Se incluyeron por oportunidad pacientes que fueron dados de alta con diagnóstico de estreñimiento desde un SU entre septiembre 2018 y junio 2019. Se recogieron los fármacos y su carga anticolinérgica. La variable de resultado fue la reconsulta por cualquier causa a los 30 días. RESULTADOS: Se incluyeron 104 pacientes, 47 (56,6%) se clasificaron como tratamiento con alta carga colinérgica, 30 (36,1%) intermedia y 6 (7,2%) baja. Veintinueve (27,9%) pacientes sufrieron una reconsulta a urgencias en los primeros 30 días tras el alta. Los pacientes con fármacos con una carga anticolinérgica alta tuvieron una mayor frecuencia de reconsultas a 30 días [19/47 (40,4%) vs 8/57 (14,1%); p = 0,002]. Tras el análisis multivarible, en comparación con aquellos con tratamiento con baja carga anticolinérgica, el tener una alta carga (ORa = 4,21; IC 95% 1,07-16,5; p = 0,039), pero no intermedia (ORa = 1,27; IC 95% 0,25-6,41; p = 0,776), se asoció de forma independiente con una mayor reconsulta a los 30 días. La prescripción de laxantes crónicos al alta no redujo la reconsulta a 30 días en el grupo con alta carga anticolinérgica (OR = 0,86; IC 95% 0,48-3,27; p = 0,526), pero sí en aquellos con carga intermedia (OR = 0,13; IC 95% 0,02-0,99; p = 0,049). CONCLUSIONES: La prescripción de fármacos con alta carga anticolinérgica fue un factor asociado con reconsulta a los 30 días en los pacientes atendidos por estreñimiento en urgencias.

Carga anticolinérgica en pacientes atendidos por estreñimiento en un servicio de ugencias / Anticholinergic burden in patients treated for constipation in an emergency department

OBJETIVO: Evaluar la frecuencia e impacto de la carga anticolinérgica del tratamiento en la reconsulta a los 30 días en los pacientes atendidos por estreñimiento en un servicio de urgencias (SU). MÉTODO: Estudio observacional de cohortes retrospectivo. Se incluyeron por oportunidad pacientes que fueron dados de alta con diagnóstico de estreñimiento desde un SU entre septiembre 2018 y junio 2019. Se recogieron los fármacos y su carga anticolinérgica. La variable de resultado fue la reconsulta por cualquier causa a los 30 días. RESULTADOS: Se incluyeron 104 pacientes, 47 (56,6%) se clasificaron como tratamiento con alta carga colinérgica, 30 (36,1%) intermedia y 6 (7,2%) baja. Veintinueve (27,9%) pacientes sufrieron una reconsulta a urgencias en los primeros 30 días tras el alta. Los pacientes con fármacos con una carga anticolinérgica alta tuvieron una mayor frecuencia de reconsultas a 30 días [19/47 (40,4%) vs 8/57 (14,1%); p = 0,002]. Tras el análisis multivarible, en comparación con aquellos con tratamiento con baja carga anticolinérgica, el tener una alta carga (ORa = 4,21; IC 95% 1,07-16,5; p = 0,039), pero no intermedia (ORa = 1,27; IC 95% 0,25-6,41; p = 0,776), se asoció de forma independiente con una mayor reconsulta a los 30 días. La prescripción de laxantes crónicos al alta no redujo la reconsulta a 30 días en el grupo con alta carga anticolinérgica (OR = 0,86; IC 95% 0,48-3,27; p = 0,526), pero sí en aquellos con carga intermedia (OR = 0,13; IC 95% 0,02-0,99; p = 0,049). CONCLUSIONES: La prescripción de fármacos con alta carga anticolinérgica fue un factor asociado con reconsulta a los 30 días en los pacientes atendidos por estreñimiento en urgencias

OBJECTIVES: To evaluate the anticholinergic burden on discharge of patients treated for constipation in an emergency department (ED) and to assess the effect on emergency revisiting within 30 days. METHODS: Observational retrospective cohort study. We collected cases with a discharge diagnosis of constipation after ED treatment between September 2018 and June 2019 and recorded information on all drugs taken and the anticholinergic burden of treatment. A revisit to the ED within 30 days was the primary outcome. RESULTS: We included 104 patients. A high anticholinergic burden of treatment was identified in 47 (56.6%), an intermediate burden in 30 (36.1%), and a low burden in 6 (7.2%). Twenty-nine (27.9%) patients revisited the ED within 30 days of discharge. An intermediate anticholinergic burden (23 patients [31.1%] vs 4 [13.3%]; P = .061) and high burden (19 [40.4%] vs 8 [14.1%]; P = .002] was associated with revisiting within 30 days in the univariate analysis. On multivariate analysis, a high anticholinergic burden was independently associated with a higher rate of revisiting than a low burden: adjusted odds ratio (aOR), 4.21; 95% CI, 1.07-16.5; P = .039. An intermediate load was not associated with more revisits, however: aOR, 1.27; 95% CI, 0.25-6.41; P = .776. Prescription of long-term treatment with laxatives on discharge did not reduce revisiting withing 30-days in the group with a high anticholinergic load (OR, 0.86; 95% CI, 0.48-3.27; P = .526), but it did have an effect in patients an intermediate burden (OR, 0.13; 95% CI, 0.02-0.99; P = .049). CONCLUSION: The prescription of drugs leading to a high anticholinergic burden was a factor associated with ED revisits within 30 days in patients treated for constipation

Factors associated with inappropriate intravenous antibiotic prescription in patients discharged from the emergency department.

WHAT IS KNOWN AND OBJECTIVE: Since 2011, a collaborative territorial network for urgent care has been deployed in Hospital de la Santa Creu i Sant Pau area, which allows direct and early transfer of patients with frailty from the hospital emergency department (ED) to other healthcare settings according to the destination's adequacy. This study aimed to identify factors associated with inappropriate intravenous antibiotic treatment prescribed on referral of patients with frailty based on microbiological culture and analyse the effect of inappropriate prescription on ED reconsultations for any cause 30 days after hospital discharge. METHODS: This observational, retrospective study was performed at a tertiary hospital between March 2018 and February 2019 and included 264 patients. A multivariate analysis, including variables with a P-value <.2 in the previous univariate analysis, was conducted. The variables included in the analysis were age, sex, patient comorbidities (COPD, diabetes and chronic kidney disease), antibiotic treatment in the last 30 days and patient referral (nursing home or family home). RESULTS AND DISCUSSION: Multidrug-resistant bacteria were isolated from 85 patients (51.5% of the isolates). In total, 159 patients received carbapenem, of whom 87 (54.7%) had non-drug-resistant bacteria. The antibiotic was considered inappropriate in 33 patients (12.5%) according to an antibiogram. Only 71 (26.8%) patients had a definitive culture on discharge. Moreover, 73 (28.3%) patients were readmitted after 30 days. Patients with an inappropriate antibiotic treatment had more reconsultations within 30 days than those with adequate treatment (59.3% vs 24.5%; P < .001). In a multivariate analysis, an inappropriate prescription was significantly associated with a higher number of reconsultations at 30 days (OR, 3.22 [1.37-7.57]). WHAT IS NEW AND CONCLUSION: In patients discharged from the ED with intravenous antibiotics, the empirical prescription of an inappropriate drug according to the final culture is a frequent problem and is related to a higher number of reconsultations. This highlights the need to implement early communication strategies with outpatient units to optimize antibiotic therapy once microbiological results are known.

Intervention effectiveness by pharmacists integrated within an interdisciplinary health team on chronic complex patients.

BACKGROUND: Nowadays, it is difficult to establish a specific method of intervention by the pharmacist and its clinical repercussions. Our aim was to identify interventions by pharmacists integrated within an interdisciplinary team for chronic complex patients (CCPs) and determine which of them produce the best results. METHODS: A systematic review (SR) was performed based on PICO(d) question (2008-18): (Population): CCPs; (Intervention): carried out by health system pharmacists in collaboration with an interdisciplinary team; (Comparator): any; (Outcome): clinical and health resources usage outcomes; (Design): meta-analysis, SR and randomized clinical trials. RESULTS: Nine articles were included: one SR and eight randomized clinical trials. The interventions consisted mainly in putting in order the pharmacotherapy and the review of the medication adequacy, medication reconciliation in transition of care and educational intervention for health professionals. Only one showed significant improvements in mortality (27.9% vs. 38.5%; HR = 1.49; P = 0.026), two in health-related quality of life [according to EQ-5D (European Quality of Life-5 Dimensions) and EQ-VAS (European Quality of Life-Visual Analog Scale) tests] and four in other health-related results (subjective self-assessment scales, falls or episodes of delirium and negative health outcomes associated with medication). Significant differences between groups were found in hospital stay and frequency of visits to the emergency department. No better results were observed in hospitalization rate. Otherwise, one study measured cost utility and found a cost of €45 987 per quality-adjusted life year gained due to the intervention. CONCLUSIONS: It was not possible to determine with certainty which interventions produce the best results in CCPs. The clinical heterogeneity of the studies and the short follow-up of most studies probably contributed to this uncertainty.

Prestación farmacéutica especializada en centros sociosanitarios en España / Pharmaceutical services in nursing homes in Spain

Objetivo: Describir la situación actual de la prestación farmacéutica especializada en centros sociosanitarios en España desde una perspectiva asistencial reflejando la actividad, la atención y los servicios prestados. Método: Estudio observacional, transversal, multicéntrico realizado entre febrero y junio de 2018 mediante encuesta dirigida a todos los servicios de farmacia hospitalaria de España. Una vez valorada la versión inicial por 12 evaluadores cuya labor asistencial estaba relacionada con centros sociosanitarios, se diseñó un formulario electrónico que constó de 10 dimensiones y 66 preguntas, y se realizó un pilotaje por seis farmacéuticos de centros sociosanitarios. Los resultados se analizaron de forma descriptiva. Resultados: La tasa de respuesta global fue del 29,7% (113 de 380). El 46,0% (n = 52) atendían centros sociosanitarios (9 como servicios de farmacia de centros sociosanitarios) cuyas características concretaron un perfil de servicio de farmacia de hospital, titularidad pública, consolidado en esta actividad, con gran variabilidad en número de centros y pacientes atendidos por servicio, y con dedicación parcial del farmacéutico. En el 51,3%, las comisiones de farmacia y terapéutica tenían representación de profesionales de los centros sociosanitarios, y el 38,5% de los servicios de farmacia participó en selección de productos sanitarios. El 67,4% realizó una gestión integral del tratamiento. El 34,6% disponía de prescripción electrónica asistida, el 88,5% realizó una validación farmacéutica de la prescripción previa a la dispensación que, en el 71,2% fue en dosis unitaria individualizada. El 42,3% llevó a cabo una revisión integral del tratamiento de nivel 3 y el 25,0% participó en la valoración nutricional interdisciplinar. El 34,6% participó activamente en la valoración geriátrica integral o de casos clínicos en los equipos interdisciplinares y el 46,2% disponía de programas para el uso seguro de los medicamentos. Conclusiones: La atención farmacéutica especializada en los centros sociosanitarios es una realidad, aunque presenta diferencias importantes en aspectos esenciales para la calidad de la asistencia prestada. Es necesario profundizar en el modelo asistencial a desarrollar y en una mayor implicación de los servicios de farmacia para lograr una atención integrada y centrada en la persona

Objective: To describe the current situation regarding the specialized pharmaceutical service provision in nursing homes in Spain, from a healthcare perspective reflecting activity, care and services provided. Method: Observational, cross-sectional, multicenter study conducted between February-June 2018 through a survey aimed at all Hospital Pharmacy Units in Spain. Once the initial version was assessed by twelve evaluators whose healthcare assistance work were related to nursing homes, an electronic form was designed, consisting on 10 dimensions and 66 questions. A piloting was carried out by six nursing homes pharmacists. The results were analyzed descriptively. Results: The overall response rate was 29.7% (113 out of 380). Out of all studied hospital pharmacy units, 46.0% (n = 52) served nursing homes (9 as Nursing Homes Pharmacy Department) whose characteristics defined a profile of pharmacy unit at hospital, public ownership, consolidation in this activity, with great variability in the number of centers and patients to be attended by service, and with the pharmacist's partial dedication. In 51.3% of cases, nursing homes professionals were represented at pharmacy and therapeutic committees, while 38.5% were from pharmacy services who participated in the selection of medical devices. Also, 67.4% performed an integral management of the therapy. The study has also shown that 34.6% counted on assisted electronic prescription, while 88.5% performed a pharmaceutical validation of the prescription prior to dispensing, which in 71.2% of cases consisted of individualized unit doses. It was found that 42.3% performed a third-level treatment comprehensive review, and 25.0% participated in the interdisciplinary nutritional assessment. It also showed that 34.6% actively participated in either comprehensive geriatric assessment, or clinical cases in interdisciplinary teams, and 46.2% counted on programs for the safe use of medicines. Conclusions: The specialized pharmaceutical care at nursing homes is a reality, although it presents important differences in essential aspects for the quality of the assistance provided. It is necessary to go in-depth on the care model to be developed, as well as having a greater involvement of pharmacy services to achieve a comprehensive and person-centered care

Pharmaceutical services in nursing homes in Spain.

OBJECTIVE: To describe the current situation regarding the specialized pharmaceutical service provision in nursing homes in Spain,  from a healthcare perspective reflecting activity, care and services  provided. METHOD: Observational, cross-sectional, multicenter study conducted between February-June 2018 through a survey aimed at all  Hospital Pharmacy Units in Spain. Once the initial version was assessed  by twelve evaluators whose healthcare assistance work were related to  nursing homes, an electronic form was designed, consisting on 10  dimensions and 66 questions. A piloting was carried out by six nursing  homes pharmacists. The results were analyzed descriptively. Results: The overall response rate was 29.7% (113 out of 380). Out of  all studied hospital pharmacy units, 46.0% (n = 52) served nursing  homes (9 as Nursing Homes Pharmacy Department) whose  characteristics defined a profile of pharmacy unit at hospital, public  ownership, consolidation in this activity, with great variability in the  number of centers and patients to be attended by service, and with the  pharmacist's partial dedication. In 51.3% of cases, nursing homes  professionals were represented at pharmacy and therapeutic  committees, while 38.5% were from pharmacy services who  participated in the selection of medical devices. Also, 67.4% performed  an integral management of the therapy. The study has also shown that  34.6% counted on assisted electronic prescription, while 88.5%  performed a pharmaceutical validation of the prescription prior to  dispensing, which in 71.2% of cases consisted of individualized unit  doses. It was found that 42.3% performed a third-level treatment  comprehensive review, and 25.0% participated in the interdisciplinary  nutritional assessment. It also showed that 34.6% actively participated  in either comprehensive geriatric assessment, or clinical cases in  interdisciplinary teams, and 46.2% counted on programs for the safe  use of medicines. CONCLUSIONS: The specialized pharmaceutical care at nursing homes is a reality, although it presents important differences in essential  aspects for the quality of the assistance provided. It is necessary to go  in-depth on the care model to be developed, as well as having a greater  involvement of pharmacy services to achieve a comprehensive and  person-centered care.

Objetivo: Describir la situación actual de la prestación farmacéutica  especializada en centros sociosanitarios en España desde una  perspectiva asistencial reflejando la actividad, la atención y los servicios  prestados.Método: Estudio observacional, transversal, multicéntrico realizado  entre febrero y junio de 2018 mediante encuesta dirigida a todos los  servicios de farmacia hospitalaria de España. Una vez valorada la  versión inicial por 12 evaluadores cuya labor asistencial estaba  relacionada con centros sociosanitarios, se diseñó un formulario  electrónico que constó de 10 dimensiones y 66 preguntas, y se realizó  un pilotaje por seis farmacéuticos de centros sociosanitarios. Los  resultados se analizaron de forma descriptiva.Resultados: La tasa de respuesta global fue del 29,7% (113 de 380). El 46,0% (n = 52) atendían centros sociosanitarios (9 como  servicios de farmacia de centros sociosanitarios) cuyas características  concretaron un perfil de servicio de farmacia de hospital, titularidad  pública, consolidado en esta actividad, con gran variabilidad en número  de centros y pacientes atendidos por servicio, y con dedicación parcial  del farmacéutico. En el 51,3%, las comisiones de farmacia y terapéutica  tenían representación de profesionales de los centros  sociosanitarios, y el 38,5% de los servicios de farmacia participó en  selección de productos sanitarios. El 67,4% realizó una gestión integral  del tratamiento. El 34,6% disponía de prescripción electrónica asistida,  el 88,5% realizó una validación farmacéutica de la prescripción previa a  la dispensación que, en el 71,2% fue en dosis unitaria individualizada. El  42,3% llevó a cabo una revisión integral del tratamiento de nivel 3 y  el 25,0% participó en la valoración nutricional interdisciplinar. El 34,6%  participó activamente en la valoración geriátrica integral o de casos  clínicos en los equipos interdisciplinares y el 46,2% disponía de  programas para el uso seguro de los medicamentos.Conclusiones: La atención farmacéutica especializada en los centros sociosanitarios es una realidad, aunque presenta diferencias importantes en aspectos esenciales para la calidad de la asistencia prestada. Es necesario profundizar en el modelo asistencial a desarrollar y en una mayor implicación de los servicios de farmacia para lograr una atención integrada y centrada en la persona.