Colaboración farmacéutico-médico en la elaboración de protocolos consensuados para el tratamiento de síntomas menores: programa 'INDICA+PRO' / Collaborative care protocols for the management of minor ailments agreed between pharmacists and medical practitioners: INDICA+PRO Study

Introducción: la colaboración entre médicos y farmacéuticos es necesaria en el manejo de los síntomas menores, ya que el paciente acude a ambos profesionales sanitarios para su tratamiento. El objetivo del estudio fue elaborar protocolos de trabajo consensuados entre farmacéuticos comunitarios y médicos de atención primaria para el Servicio de Indicación Farmacéutica (SIF). Material y método: se utilizaron dos metodologías: revisión bibliográfica y grupo de expertos para el consenso. Estos protocolos se actualizaron y diseñaron a partir de un documento previo de 2008. En el grupo de expertos se incluyeron cuatro farmacéuticos comunitarios de SEFAC (2), MICOF (2) y cuatro médicos de atención primaria de semFYC (2) y SEMERGEN (2). Resultados: se consensuaron protocolos de trabajo para 31 síntomas menores distribuidos en cinco grupos: respiratorios, dolor moderado, digestivos, dermatológicos y otros. Se añadieron cinco síntomas nuevos al documento de partida. Respecto a la estructura de cada síntoma se consideró: concepto, causas más frecuentes, criterios de derivación al médico (edad, síntomas de alarma, duración de los síntomas, otros problemas de salud y/o medicamentos y situaciones especiales), recomendaciones para la prevención y tratamiento (no farmacológico y farmacológico). Conclusión: el documento desarrollado mediante colaboración entre profesionales de la medicina y la farmacia es una herramienta que contribuye a la mejora de la actuación del farmacéutico en el manejo de los síntomas menores desde la farmacia comunitaria, con énfasis en la definición de indicadores que señalan la necesidad de derivar el paciente al médico de atención primaria

Background: To increase the collaboration between community pharmacists and medical practitioners working in primary care it is critical to have collaborative protocols in place. Minor ailments could be a good example where this collaboration would benefit patient care as patients are seeking treatment in both settings. These collaborative protocols would assist in diminishing the variability of treatments in both settings. The aim of the study was to develop care protocols for minor ailments agreed between medical practitioners and pharmacists Methods: Two different methodologies were used to arrive at a consensus for the proto-cols: literature review and expert group. Some of the clinical protocols were updated from a previous document created in 2008. Expert group was composed of four community pharma-cists (SEFAC, MICOF) and four medical practitioners (SemFyC y Semergen). Results: Thirty-one protocols for minor ailments were agreed and allocated to five groups (five new minor ailments protocols were added: respiratory tract-related conditions, gastrointestinal disturbance, pain, dermatological problems and others.Protocols were structured following: definition, more frequent causes, referral criteria (pa-tient’s age, red flags, symptom’s duration, patient’s health problems and treatments and physiological situations), recommendations for management (prevention, non-pharmacological and pharmacological treatment) and references used. Conclusions: Clinical protocols agreed between health professionals of medicine and phar-macy are a tool that contribute to better management of minor ailments in community pharmacy

Correction: Lipid profile, cardiovascular disease and mortality in a Mediterranean high-risk population: The ESCARVAL-RISK study.

[This corrects the article DOI: 10.1371/journal.pone.0186196.].

Lipid profile, cardiovascular disease and mortality in a Mediterranean high-risk population: The ESCARVAL-RISK study.

INTRODUCTION: The potential impact of targeting different components of an adverse lipid profile in populations with multiple cardiovascular risk factors is not completely clear. This study aims to assess the association between different components of the standard lipid profile with all-cause mortality and hospitalization due to cardiovascular events in a high-risk population. METHODS: This prospective registry included high risk adults over 30 years old free of cardiovascular disease (2008-2012). Diagnosis of hypertension, dyslipidemia or diabetes mellitus was inclusion criterion. Lipid biomarkers were evaluated. Primary endpoints were all-cause mortality and hospital admission due to coronary heart disease or stroke. We estimated adjusted rate ratios (aRR), absolute risk differences and population attributable risk associated with adverse lipid profiles. RESULTS: 51,462 subjects were included with a mean age of 62.6 years (47.6% men). During an average follow-up of 3.2 years, 919 deaths, 1666 hospitalizations for coronary heart disease and 1510 hospitalizations for stroke were recorded. The parameters that showed an increased rate for total mortality, coronary heart disease and stroke hospitalization were, respectively, low HDL-Cholesterol: aRR 1.25, 1.29 and 1.23; high Total/HDL-Cholesterol: aRR 1.22, 1.38 and 1.25; and high Triglycerides/HDL-Cholesterol: aRR 1.21, 1.30, 1.09. The parameters that showed highest population attributable risk (%) were, respectively, low HDL-Cholesterol: 7.70, 11.42, 8.40; high Total/HDL-Cholesterol: 6.55, 12.47, 8.73; and high Triglycerides/HDL-Cholesterol: 8.94, 15.09, 6.92. CONCLUSIONS: In a population with cardiovascular risk factors, HDL-cholesterol, Total/HDL-cholesterol and triglycerides/HDL-cholesterol ratios were associated with a higher population attributable risk for cardiovascular disease compared to other common biomarkers.

Abordaje de la hipertensión arterial en el paciente anciano / Approach to hypertension in the older population

La hipertensión arterial es una de las primeras causas de consulta en atención primaria y su prevalencia aumenta con la edad, afectando a un 68% de las personas mayores de 60 años. Se dispone de datos que indican que la prevalencia de hipertensos ≥ 65 años se ha incrementado desde un 48% en 2002 a un 58% en 2010. La presión arterial elevada se relaciona con 1 de cada 2 muertes cardiovasculares en españoles ≥ 50 años de edad y causa el 13,5% de las muertes prematuras en el mundo, en hipertensos y en sujetos con presión arterial normal-alta. A pesar de disponer de pocos ensayos clínicos en población anciana y, sobre todo, muy anciana, hay evidencias de que el control de la presión arterial sistólica y diastólica reduce la morbimortalidad cardiovascular en los hipertensos de mayor edad, por lo que las actualizaciones de las diferentes guías de práctica clínica siguen manteniendo entre sus objetivos, con algunas matizaciones, el adecuado control de la presión arterial en este grupo poblacional. En este trabajo se revisan las nuevas evidencias aparecidas en relación con el abordaje de la hipertensión arterial en el paciente anciano y que han condicionado modificaciones en las guías de práctica clínica de las diferentes sociedades científicas (AU)

Hypertension is one of the most frequent causes for seeking primary care attention and its prevalence increases with age, affecting 68% of people older than 60 years. Data indicate that the prevalence of hypertense individuals older than 65 years has increased from 48% in 2002 to 58% in 2010. High blood pressure is related to 1 out of every 2 deaths from cardiovascular causes in the Spanish population ≥ 50 years and causes 13.5% of premature deaths worldwide, both in persons with hypertension and in those with high-normal blood pressure. Although few clinical trials have been performed in the older population, especially in the very old, there is evidence that diastolic and systolic blood pressure control reduces cardiovascular morbidity and mortality in older hypertense individuals. Consequently, the updates of the various clinical practice guidelines continue to include among their objectives-with some nuances-good blood pressure control in this population group. The present article reviews new evidence on the approach to hypertension in the elderly, which has modified some of the recommendations made in the clinical practice guidelines of several scientific societies (AU)

Is the physician's behavior in dyslipidemia diagnosis in accordance with guidelines? Cross-sectional ESCARVAL study.

BACKGROUND: Clinical inertia has been defined as mistakes by the physician in starting or intensifying treatment when indicated. Inertia, therefore, can affect other stages in the healthcare process, like diagnosis. The diagnosis of dyslipidemia requires ≥2 high lipid values, but inappropriate behavior in the diagnosis of dyslipidemia has only previously been analyzed using just total cholesterol (TC). OBJECTIVES: To determine clinical inertia in the dyslipidemia diagnosis using both TC and high-density lipoprotein cholesterol (HDL-c) and its associated factors. DESIGN: Cross-sectional. SETTING: All health center visits in the second half of 2010 in the Valencian Community (Spain). PATIENTS: 11,386 nondyslipidemic individuals aged ≥20 years with ≥2 lipid determinations. MEASUREMENT VARIABLES: Gender, atrial fibrillation, hypertension, diabetes, cardiovascular disease, age, and ESCARVAL training course. Lipid groups: normal (TC<5.17 mmol/L and normal HDL-c [≥1.03 mmol/L in men and ≥1.29 mmol/L in women], TC inertia (TC≥5.17 mmol/L and normal HDL-c), HDL-c inertia (TC<5.17 mmol/L and low HDL-c), and combined inertia (TC≥5.17 mmol/L and low HDL-c). RESULTS: TC inertia: 38.0% (95% CI: 37.2-38.9%); HDL-c inertia: 17.7% (95% CI: 17.0-18.4%); and combined inertia: 9.6% (95% CI: 9.1-10.2%). The profile associated with TC inertia was: female, no cardiovascular risk factors, no cardiovascular disease, middle or advanced age; for HDL-c inertia: female, cardiovascular risk factors and cardiovascular disease; and for combined inertia: female, hypertension and middle age. LIMITATIONS: Cross-sectional study, under-reporting, no analysis of some cardiovascular risk factors or other lipid parameters. CONCLUSIONS: A more proactive attitude should be adopted, focusing on the full diagnosis of dyslipidemia in clinical practice. Special emphasis should be placed on patients with low HDL-c levels and an increased cardiovascular risk.

Blood pressure control and management of very elderly patients with hypertension in primary care settings in Spain.

This study aimed to determine the clinical profile, blood pressure (BP) control rates, therapeutic management and physicians' therapeutic behavior regarding very elderly hypertensive patients. A total of 1540 hypertensive patients 80 years old on antihypertensive therapy and receiving care in primary care settings in Spain were included in this cross-sectional study. The mean patient age was 83.4±3.1 years, 61.9% of patients were women and 49.3% of patients had cardiovascular disease. Of the patients, 27.7% were on monotherapy and 72.3% were on combined therapy (47.4% on two antihypertensive agents and 24.9% on three or more antihypertensive agents). A total of 40.8% (95% confidence interval (CI): 38.4-43.3%) of patients achieved BP goals (<140/90 mm Hg; <130/80 in patients with diabetes, chronic renal disease or cardiovascular disease). Patients with uncontrolled BP were more likely to have metabolic syndrome, diabetes, obesity, a history of cardiovascular disease, ischemic heart disease, renal disease and stroke and were more frequently smokers. Physicians modified the antihypertensive regimens for 27.4% (95% CI: 23.9-30.8%) of the patients with uncontrolled BP, and the addition of another antihypertensive agent was the most frequent modification. With regard to the physicians' perception of patients' BP control, the BPs of 44.1% of the patients with uncontrolled BP were considered well controlled by the physicians.

Blood pressure control and physicians' therapeutic behavior in a very elderly Spanish hypertensive population.

This study sought to assess blood pressure (BP) control rates by determining the factors associated with poor BP control, therapeutic management and physicians' therapeutic behavior among elderly Spanish hypertensive patients in a primary care setting. This cross-sectional multicenter study included hypertensive patients at least 80 years of age in primary care settings throughout Spain who were on pharmacologic treatment. BP was considered well controlled at <140/90 mm Hg (<130/80 in patients with diabetes, chronic renal disease or cardiovascular disease). A total of 923 patients were included (83.3+/-3.5 years; 62.9% women). Almost two-thirds (64.0%) of the patients were taking a combined therapy (68.7%; 2 drugs) and approximately one-third (35.6%; 95% CI 32.6-38.7) of the patients attained BP goals. Physicians modified the antihypertensive treatment in 26.1% (95% CI 22.3-29.9) of patients with uncontrolled BP, which most frequently involved the addition of another drug (47.6%). Predictive factors for no BP control and no therapeutic modification in patients with uncontrolled BP included diabetes (OR 2.8 (95% CI 2.0-3.9); P<0.0001) and mistaken physician perceptions about BP control (OR 108.1 (95% CI 40.5-288.6); P<0.0001), respectively. Only three out of 10 hypertensive patients 80 years or older in Spain achieved the BP goals. Physicians only modified the treatment in one out of four patients with uncontrolled BP. Diabetes was associated with a threefold increase in the likelihood of uncontrolled BP, and the mistaken physician perceptions about BP control were associated with a 100-fold rise in the probability of not modifying antihypertensive therapy.