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1.
Artigo em Inglês | MEDLINE | ID: mdl-34071171

RESUMO

Introduction: We evaluated the effectiveness of an individual, group and community intervention to improve the glycemic control of patients with diabetes mellitus aged 45-75 years with two or three unhealthy life habits. As secondary endpoints, we evaluated the inverventions' effectiveness on adhering to Mediterranean diet, physical activity, sedentary lifestyle, smoking and quality of life. Method: A randomized clinical cluster (health centers) trial with two parallel groups in Spain from January 2016 to December 2019 was used. Patients with diabetes mellitus aged 45-75 years with two unhealthy life habits or more (smoking, not adhering to Mediterranean diet or little physical activity) participated. Centers were randomly assigned. The sample size was estimated to be 420 people for the main outcome variable. Educational intervention was done to improve adherence to Mediterranean diet, physical activity and smoking cessation by individual, group and community interventions for 12 months. Controls received the usual health care. The outcome variables were: HbA1c (main), the Mediterranean diet adherence score (MEDAS), the international diet quality index (DQI-I), the international physical activity questionnaire (IPAQ), sedentary lifestyle, smoking ≥1 cigarette/day and the EuroQuol questionnaire (EVA-EuroQol5D5L). Results: In total, 13 control centers (n = 356) and 12 intervention centers (n = 338) were included with similar baseline conditions. An analysis for intention-to-treat was done by applying multilevel mixed models fitted by basal values and the health center: the HbA1c adjusted mean difference = -0.09 (95% CI: -0.29-0.10), the DQI-I adjusted mean difference = 0.25 (95% CI: -0.32-0.82), the MEDAS adjusted mean difference = 0.45 (95% CI: 0.01-0.89), moderate/high physical activity OR = 1.09 (95% CI: 0.64-1.86), not living a sedentary lifestyle OR = 0.97 (95% CI: 0.55-1.73), no smoking OR = 0.61 (95% CI: 0.54-1.06), EVA adjusted mean difference = -1.26 (95% CI: -4.98-2.45). Conclusions: No statistically significant changes were found for either glycemic control or physical activity, sedentary lifestyle, smoking and quality of life. The multicomponent individual, group and community interventions only showed a statistically significant improvement in adhering to Mediterranean diet. Such innovative interventions need further research to demonstrate their effectiveness in patients with poor glycemic control.


Assuntos
Diabetes Mellitus , Qualidade de Vida , Exercício Físico , Hábitos , Humanos , Atenção Primária à Saúde , Fumar , Espanha/epidemiologia
2.
Artigo em Inglês | MEDLINE | ID: mdl-34080746

RESUMO

We explore, from the perspective of primary care health professionals, the motivations that lead patients to not initiate prescribed treatments, by developing a qualitative study in Spanish primary care. Six focus groups (N = 46) were conducted with general practitioners, nurse practitioners, social workers and community pharmacists and carried out in primary care (PC) of Barcelona Province, from April to July of 2018. The 46 participants were identified by three general practitioners and two pharmacists. In the interviews, the reasons for non-initiation of PC patients' medication were explored. Triangulated content analysis was performed. Patients' perspective, analysed in a previous study, and professionals' perspective agree on most of the factors that affect non-initiation. New factors were categorized into existent categories, confirming, and supplementing the model developed with patients. Health professionals identified some new factors which were not present in the patients' discourse, such as stigma related to the drug, hidden reasons for consultation, the role of nurses in prescription and support, the role of the pharmacy technician, illiteracy and lack of social support. The professionals confirm and expand on the Theoretical Model of Medication Non-Initiation. Primary care professionals should consider the factors described when prescribing a new medication. Knowledge contributed by the model should guide the design of interventions to improve initiation.

3.
Artigo em Inglês | MEDLINE | ID: mdl-33498567

RESUMO

Major depressive disorder (MDD) is one of the most disabling diseases worldwide, generating high use of health services. Previous studies have shown that Mental Health Services (MHS) use is associated with patient and Family Physician (FP) factors. The aim of this study was to investigate MHS use in a naturalistic sample of MDD outpatients and the factors influencing use of services in specialized psychiatric care, to know the natural mental healthcare pathway. Non-randomized clinical trial including newly depressed Primary Care (PC) patients (n = 263) with a 12-month follow-up (from 2013 to 2015). Patient sociodemographic variables were assessed along with clinical variables (mental disorder diagnosis, severity of depression or anxiety, quality of life, disability, beliefs about illness and medication). FP (n = 53) variables were also evaluated. A multilevel logistic regression analysis was performed to assess factors associated with public or private MHS use. Subjects were clustered by FP. Having previously used MHS was associated with the use of MHS. The use of public MHS was associated with worse perception of quality of life. No other sociodemographic, clinical, nor FP variables were associated with the use of MHS. Patient self-perception is a factor that influences the use of services, in addition to having used them before. This is in line with Value-Based Healthcare, which propose to put the focus on the patient, who is the one who must define which health outcomes are relevant to him.


Assuntos
Transtorno Depressivo Maior , Transtornos Mentais , Serviços de Saúde Mental , Transtornos de Ansiedade , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/epidemiologia , Transtorno Depressivo Maior/terapia , Humanos , Masculino , Atenção Primária à Saúde , Qualidade de Vida
4.
Farm. comunitarios (Internet) ; 12(3): 51-57, jul. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-191370

RESUMO

La falta de adherencia es un problema mundial cada vez mayor y es la responsable de que los resultados esperados en salud se alejen de la realidad, aumentando el gasto sanitario. Comprender por qué un paciente no es adherente requiere identificar los factores implicados en su caso concreto y personalizar las estrategias a seguir. Para abordar la no adherencia desde la farmacia comunitaria tenemos el protocolo de la guía ADHe+ de dispensación y uso racional del medicamento, que clasifica a los pacientes no adherentes en tres perfiles (confundido, desconfiado y banalizador), facilitando la tarea de evaluación de sus creencias hacia un medicamento en concreto y en un momento determinado. Siguiendo el protocolo propuesto por la guía, el farmacéutico puede detectar la no adherencia en los medicamentos que el paciente recoge y en los que no e indagar en las causas. Pero el momento actual que estamos viviendo de pandemia por COVID-19 está cambiando el paradigma de la cronicidad. El miedo al contagio, la ralentización de los procesos asistenciales por las nuevas medidas de higiene, la telemedicina, el confinamiento y el desconocimiento de la nueva situación por parte de pacientes y sanitarios puede afectar mucho a la adherencia terapéutica


Non-adherence to treatment is becoming more and more of a global issue and is responsible for the fact that expected health results are getting further away from reality and increasing spending on healthcare. To understand why a patient is not adhering to treatment it is necessary to identify the factors involved in his or her specific case and personalize the strategies to be followed. In order to approach non-adherence to treatment from the community pharmacy perspective, we use the protocol from the ADHe+ guide on the dispensing and rational use of the drug, which classifies non-adhering patients into three profiles (confused, wary and trivializing), facilitating the task of assessing their beliefs with regards to a certain medicine and at a given time. Following the protocol suggested by the guide, pharmacists can detect non-adherence to the medicines the patient collects and does not collect and look into the causes. However, the current times of pandemic that we are experiencing-caused by COVID-19-are changing the pattern of chronicity. Fear of infection, the slowing down of care processes due to the new hygiene measures, telemedicine, quarantine, and the lack of awareness about the new situation by both the patients and healthcare professionals may have a great impact on therapeutic adherence


Assuntos
Humanos , Serviços Comunitários de Farmácia , Cooperação e Adesão ao Tratamento , Infecções por Coronavirus/tratamento farmacológico , Pneumonia Viral/tratamento farmacológico , Betacoronavirus , Pandemias
5.
Artigo em Inglês | MEDLINE | ID: mdl-32408626

RESUMO

BACKGROUND: Adherence problems have negative effects on health, but there is little information on the magnitude of non-initiation and single dispensing. OBJECTIVE: The aim of this study was to estimate the prevalence of non-initiation and single dispensation and identify associated predictive factors for the main treatments prescribed in Primary Care (PC) for cardiovascular disease (CVD) and diabetes. METHODS: Cohort study with real-world data. Patients who received a first prescription (2013-2014) for insulins, platelet aggregation inhibitors, angiotensin-converting enzyme inhibitors (ACEI) or statins in Catalan PC were included. The prevalence of non-initiation and single dispensation was calculated. Factors that explained these behaviours were explored. RESULTS: At three months, between 5.7% (ACEI) and 9.1% (antiplatelets) of patients did not initiate their treatment and between 10.6% (statins) and 18.4% (ACEI) filled a single prescription. Body mass index, previous CVD, place of origin and having a substitute prescriber, among others, influenced the risk of non-initiation and single dispensation. CONCLUSIONS: The prevalence of non-initiation and single dispensation of CVD medications and insulin prescribed in PC in is high. Patient and health-system factors, such as place of origin and type of prescriber, should be taken into consideration when prescribing new medications for CVD and diabetes.


Assuntos
Fármacos Cardiovasculares , Doenças Cardiovasculares , Diabetes Mellitus , Hipoglicemiantes , Insulina , Adesão à Medicação , Idoso , Inibidores da Enzima Conversora de Angiotensina , Fármacos Cardiovasculares/uso terapêutico , Doenças Cardiovasculares/tratamento farmacológico , Doenças Cardiovasculares/prevenção & controle , Estudos de Coortes , Diabetes Mellitus/tratamento farmacológico , Feminino , Humanos , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Prevalência
7.
Fam Pract ; 36(1): 3-11, 2019 01 25.
Artigo em Inglês | MEDLINE | ID: mdl-30423158

RESUMO

Objective: The study assessed the predictive factors of diagnostic accuracy and treatment approach (antidepressants versus active monitoring) for depression in primary care. Methods: This is a cross-sectional study that uses information from a naturalistic prospective controlled trial performed in Barcelona (Spain) enrolling newly diagnosed patients with mild to moderate depression by GPs. Treatment approach was based on clinical judgement. Diagnosis was later assessed according to DSM-IV criteria using Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) interview by an external researcher. Patients (sociodemographic, psychiatric diagnosis, severity of depression and anxiety, health-related quality of life, disability, beliefs about medication and illness and comorbidities) and GP factors associated with diagnostic accuracy and treatment approach were assessed using multilevel logistic regression. Variables with missing data were imputed through multiple imputations. Results: Two hundred sixty-three patients were recruited by 53 GPs. Mean age was 51 years (SD = 15). Thirty percent met DSM-IV criteria for major depression. Mean depression symptomatology was moderate-severe. Using multivariate analyses, patients' beliefs about medicines were the only variable associated with the antidepressant approach. Specialization in general medicine and being a resident tutor were associated with a more accurate diagnosis. Conclusions: Clinical depression diagnosis by GPs was not always associated with a formal diagnosis through a SCID-I. GPs' training background was central to an adequate depression diagnosis. Patients' beliefs in medication were the only factor associated with treatment approach. More resources should be allocated to improving the diagnosis of depression.


Assuntos
Antidepressivos/uso terapêutico , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/tratamento farmacológico , Médicos de Atenção Primária/estatística & dados numéricos , Atenção Primária à Saúde/métodos , Adulto , Terapia Cognitivo-Comportamental/métodos , Estudos Transversais , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Médicos de Atenção Primária/educação , Estudos Prospectivos , Qualidade de Vida , Espanha , Inquéritos e Questionários
8.
BMJ Qual Saf ; 27(11): 878-891, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29545326

RESUMO

OBJECTIVE: Copayment policies aim to reduce the burden of medication expenditure but may affect adherence and generate inequities in access to healthcare. The objective was to evaluate the impact of two copayment measures on initial medication non-adherence (IMNA) in several medication groups and by income level. DESIGN: A population-based study was conducted using real-world evidence. SETTING: Primary care in Catalonia (Spain) where two separate copayment measures (fixed copayment and coinsurance) were introduced between 2011 and 2013. PARTICIPANT: Every patient with a new prescription issued between 2011 and 2014 (3 million patients and 10 million prescriptions). OUTCOMES: IMNA was estimated throughout dispensing and invoicing information. Changes in IMNA prevalence after the introduction of copayment policies (immediate level change and trend changes) were estimated through segmented logistic regression. The regression models were stratified by economic status and medication groups. RESULTS: Before changes to copayment policies, IMNA prevalence remained stable. The introduction of a fixed copayment was followed by a statistically significant increase in IMNA in poor population, low/middle-income pensioners and low-income non-pensioners (OR from 1.047 to 1.370). In high-income populations, there was a large statistically non-significant increase. IMNA decreased in the low-income population after suspension of the fixed copayment and the introduction of a coinsurance policy that granted this population free access to medications (OR=0.676). Penicillins were least affected while analgesics were affected to the greatest extent. IMNA to medications for chronic conditions increased in low/middle-income pensioners. CONCLUSION: Even nominal charge fixed copayment may generate inequities in access to health services. An anticipation effect and expenses associated with IMNA may have generated short-term costs. A reduction in copayment can protect from non-adherence and have positive, long-term effects. Copayment scenarios could have considerable long-term consequences for health and costs due to increased IMNA in medication for chronic physical conditions.


Assuntos
Dedutíveis e Cosseguros/economia , Dedutíveis e Cosseguros/legislação & jurisprudência , Custos de Cuidados de Saúde , Renda/tendências , Adesão à Medicação/estatística & dados numéricos , Atenção Primária à Saúde/economia , Idoso , Estudos de Coortes , Feminino , Política de Saúde/legislação & jurisprudência , Humanos , Masculino , Pessoa de Meia-Idade , Pobreza/economia , Pobreza/estatística & dados numéricos , Atenção Primária à Saúde/métodos , Estudos Retrospectivos , Fatores Socioeconômicos , Espanha
9.
J Affect Disord ; 226: 282-286, 2018 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-29024901

RESUMO

BACKGROUND: Initial medication non-adherence (IMNA) to antidepressants, which are commonly used to treat depression in primary care (PC), is around 6-12%. Although it is well known that post-initial non-adherence to antidepressants increases the cost of depression, the impact of IMNA on cost is unknown. The aim of this study is to assess the impact of IMNA to Selective Serotonin Reuptake Inhibitors (SSRI) on medical visits and sick leave in patients with depression treated in PC in Catalonia (Spain). METHODS: This was a four-year retrospective register-based study (2011-2014). All PC patients of working age who received a new SSRI prescription and had a diagnosis of depression were included (N = 79,642). Treatment initiation, number of visits and days on sick leave were gathered from the database. We assessed the impact of IMNA on costs with ordered logistic regressions. RESULTS: The 3-year incidence of IMNA was 15%. Initially non-adherent patients made a lesser number of GP visits (OR = 0.82; 95% CI = 0.79-0.84) but had more days on sick leave (OR = 1.25; 95% CI = 1.20-1.31). There were no differences in the number of specialist visits (OR = 1.04; 95% CI = 0.99-1.08). LIMITATIONS: Differences between adherent and non-adherent patients could be explained by non-observed variables. GP recognition and documentation of depression might be inaccurate. Costs of unpaid work and use of hospital services were not considered. CONCLUSIONS: Although IMNA decreases the use of medical PC services, it increases the number of days on sick leave. This could also indicate worse health status. These consequences are currently overlooked when considering post-initial medication non-adherence.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Adesão à Medicação/estatística & dados numéricos , Inibidores de Captação de Serotonina/uso terapêutico , Licença Médica/estatística & dados numéricos , Adolescente , Adulto , Antidepressivos/uso terapêutico , Bases de Dados Factuais , Transtorno Depressivo/tratamento farmacológico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde , Estudos Retrospectivos , Espanha
10.
Br J Gen Pract ; 67(662): e614-e622, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28760740

RESUMO

BACKGROUND: Initial medication non-adherence is highly prevalent in primary care but no previous studies have evaluated its impact on the use of healthcare services and/or days on sick leave. AIM: To estimate the impact of initial medication non-adherence on the use of healthcare services, days of sick leave, and costs overall and in specific medication groups. DESIGN AND SETTING: A 3-year longitudinal register-based study of all primary care patients (a cohort of 1.7 million) who were prescribed a new medication in Catalonia (Spain) in 2012. METHOD: Thirteen of the most prescribed and/or costly medication subgroups were considered. All medication and medication subgroups (chronic, analgesics, and penicillin) were analysed. The number of healthcare services used and days on sick leave were considered. Multilevel multivariate linear regression was used. Three levels were included: patient, GP, and primary care centre. RESULTS: Initially adherent patients made more use of medicines and some healthcare services than non-adherent and partially adherent patients. They had lower productivity losses, producing a net economic return, especially when drugs for acute diseases (such as penicillins) were considered. Initial medication non-adherence resulted in a higher economic burden to the system in the short term. CONCLUSION: Initial medication non-adherence seems to have a short-term impact on productivity losses and costs. The clinical consequences and long-term economic consequences of initial medication non-adherence need to be assessed. Interventions to promote initial medication adherence in primary care may reduce costs and improve health outcomes.


Assuntos
Sobremedicalização , Adesão à Medicação/estatística & dados numéricos , Conduta do Tratamento Medicamentoso , Licença Médica , Adulto , Feminino , Humanos , Masculino , Sobremedicalização/economia , Sobremedicalização/prevenção & controle , Conduta do Tratamento Medicamentoso/economia , Conduta do Tratamento Medicamentoso/normas , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/estatística & dados numéricos , Melhoria de Qualidade , Licença Médica/economia , Licença Médica/estatística & dados numéricos , Espanha
11.
Br J Clin Pharmacol ; 83(6): 1328-1340, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28229476

RESUMO

AIMS: Adherence to medicines is vital in treating diseases. Initial medication non-adherence (IMNA) - defined as not obtaining a medication the first time it is prescribed - has been poorly explored. Previous studies show IMNA rates between 6 and 28% in primary care (PC). The aims of this study were to determine prevalence and predictive factors of IMNA in the most prescribed and expensive pharmacotherapeutic groups in the Catalan health system. METHODS: This is a retrospective, register-based cohort study which linked the Catalan PC System (Spain) prescription and invoicing databases. Medication was considered non-initiated when it was not collected from the pharmacy by the end of the month following the one in which it was prescribed. IMNA prevalence was calculated using July 2013-June 2014 prescription data. Predictive factors related to patients, general practitioners and PC centres were identified through multilevel logistic regression analyses. Missing data were attributed using simple imputation. RESULTS: Some 1.6 million patients with 2.9 million prescriptions were included in the study sample. Total IMNA prevalence was 17.6% of prescriptions. The highest IMNA rate was observed in anilides (22.6%) and the lowest in angiotensin-converting-enzyme (ACE) inhibitors (7.4%). Predictors of IMNA are younger age, American nationality, having a pain-related or mental disorder and being treated by a substitute/resident general practitioner in a resident-training centre. CONCLUSIONS: The rate of IMNA is high when all medications are taken into account. Attempts to strengthen trust in resident general practitioners and improve motivation to initiate a needed medication in the general young and older immigrant population should be addressed in Catalan PC.


Assuntos
Adesão à Medicação/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Prescrições de Medicamentos , Feminino , Previsões , Clínicos Gerais , Humanos , Masculino , Transtornos Mentais/complicações , Transtornos Mentais/epidemiologia , Pessoa de Meia-Idade , Dor/complicações , Dor/epidemiologia , Prevalência , Sistema de Registros , Estudos Retrospectivos , Fatores Socioeconômicos , Espanha/epidemiologia , Resultado do Tratamento
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