Longitudinalidad en atención primaria y polifarmacia. Una revisión sistemática / Longitudinality in Primary Care and Polypharmacy. A Systematic Review

El objetivo de este trabajo es recopilar, evaluar e interpretar las evidencias disponibles sobre la relación existente entre el grado de longitudinalidad en atención primaria (AP) y la prevalencia de polifarmacia y sus problemas asociados. Siguiendo la declaración PRISMA realizamos una revisión sistemática de la literatura en las bases de datos PubMed y Scopus. El cribado por títulos y resúmenes, y la revisión de referencias realizados de forma independiente por 2 autores detectó 16 trabajos de potencial interés. Tras la revisión independiente de todos los originales, 4 fueron descartados por no satisfacer los criterios de inclusión. Los 12 trabajos seleccionados, 9 estudios de cohortes retrospectivos y 3 estudios transversales, estudiaban la relación de la longitudinalidad en AP, medida con diversos índices cuantitativos, con la prevalencia de polifarmacia y otros problemas terapéuticos asociados, como las prescripciones inadecuadas, las duplicidades o las interacciones medicamentosas. Todos mostraban una relación significativa, frecuentemente fuerte (RR>2 o<0,5), entre los indicadores de longitudinalidad y las diversas variables dependientes. Aunque nuestro conocimiento podría mejorar mediante estudios prospectivos que evaluaran directamente la longitudinalidad y su repercusión en los problemas por exceso de medicación, con las evidencias existentes, se puede afirmar que la protección y la promoción de la longitudinalidad en la AP es un elemento clave para el control de la polifarmacia y los problemas asociados (AU)

The aim of this work was to collect, evaluate and interpret the available evidence on the relationship between continuity in primary care (i.e., longitudinality), and the prevalence of polypharmacy and its associated problems. Following the PRISMA reporting statement, we carried out a systematic review of the literature searching PubMed and Scopus databases. The screening of titles and summaries and the review of references carried out independently by two authors detected 16 works of potential interest, of which 4 were discarded after the independent review of all the originals because they did not meet inclusion criteria. The 12 papers selected studied the relationship between Longitudinality, measured with various quantitative indices, and the rate of polypharmacy or various associated problems, such as duplicate drugs, inadequate prescriptions or drug interactions. They all showed a significant relationship, often strong (RR>2 or<0.5), between longitudinality indicators and the various dependent variables. Although our knowledge could be improved by prospective studies that more directly evaluate longitudinality and its impact on problems due to excess medication, with the existing evidence, we can affirm that the protection and promotion of continuity in primary care can be a key element for the control of polypharmacy and associated problems (AU)

[Longitudinality in Primary Care and Polypharmacy. A Systematic Review]. / Longitudinalidad en atención primaria y polifarmacia. Una revisión sistemática.

The aim of this work was to collect, evaluate and interpret the available evidence on the relationship between continuity in primary care (i.e., longitudinality), and the prevalence of polypharmacy and its associated problems. Following the PRISMA reporting statement, we carried out a systematic review of the literature searching PubMed and Scopus databases. The screening of titles and summaries and the review of references carried out independently by two authors detected 16 works of potential interest, of which 4 were discarded after the independent review of all the originals because they did not meet inclusion criteria. The 12 papers selected studied the relationship between Longitudinality, measured with various quantitative indices, and the rate of polypharmacy or various associated problems, such as duplicate drugs, inadequate prescriptions or drug interactions. They all showed a significant relationship, often strong (RR>2 or<0.5), between longitudinality indicators and the various dependent variables. Although our knowledge could be improved by prospective studies that more directly evaluate longitudinality and its impact on problems due to excess medication, with the existing evidence, we can affirm that the protection and promotion of continuity in primary care can be a key element for the control of polypharmacy and associated problems.

Criterios de medicación potencialmente inapropiada para el anciano: una propuesta cubana / Medication approaches potentially inappropriate for the elderly: a Cuban proposal

Introducción: El impacto de la prescripción inapropiada de fármacos en el anciano ha llevado al desarrollo de métodos para su reducción en varias partes del mundo. Objetivo: Diseñar y validar los criterios de medicación potencialmente inapropiada en el anciano, adaptados al entorno sociosanitario de Cuba. Métodos: Se realizó una investigación cualitativa, en la cual los criterios fueron validados por medio de la metodología Delphi, por un comité de expertos (especialistas en medicina geriátrica y clínica de diferentes zonas geográficas del país), y se les calculó la consistencia interna mediante el coeficiente alfa de Cronbach. Resultados: Los criterios quedaron estructurados en tres listas: 1) medicación potencialmente inapropiada, medicamento indicado no prescripto, cuando no existe contraindicación para su uso; 2) medicación potencialmente inapropiada independiente del diagnóstico o la condición clínica; 3) medicación potencialmente inapropiada dependiente del diagnóstico o la condición clínica. Conclusiones: Se demostró la validez del contenido y la adecuada consistencia interna de los criterios diseñados para la identificación de medicación potencialmente inapropiada en el anciano.

Introduction: The impact of inappropriate prescription of medication in the elderly has led to the development of methods for its reduction in several parts of the world. Objective: To design and validate the medication approaches potentially inappropriate in the elderly, adapted to the socio-sanitary environment of Cuba. Methods: A qualitative investigation was carried out, in which the approaches were validated by means of the Delphi methodology, by an experts committee (specialists in geriatrics medicine and clinic from different geographical areas of the country), and the internal consistency was calculated by means of the alpha coefficient of Cronbach. Results: The approaches were structured in three lists: 1) potentially inappropriate medication, advised medication non prescribed, when contraindication doesn't exist for its use; 2) medication potentially inappropriate, independent from the diagnosis or clinical condition; 3) potentially inappropriate medication, depending on the diagnosis or clinical condition. Conclusions: The validity of the content and the appropriate internal consistency of the designed approaches for the medication identification potentially inappropriate in the elderly were demonstrated.

Uso de medicamentos potencialmente inapropriados em idosos institucionalizados: prevalência e fatores associados / Use of potentially inappropriate medications in institutionalized elderly: prevalence and associated factors

Resumo Este trabalho teve como objetivo verificar a prevalência do uso de medicamento potencialmente inapropriado (MPI) para idosos residentes em Instituições de Longa Permanência para Idosos (ILPI), assim como os tipos de medicamentos e seus fatores associados. Trata-se de estudo transversal realizado em 10 ILPI da cidade do Natal, entre outubro e dezembro de 2013. Os medicamentos inapropriados foram classificados de acordo com os Critérios de Beers da American Geriatric Society 2015. Foram analisadas variáveis sociodemográficas, relacionadas à ILPI e às condições de saúde. Para as análises univariada e multivariada entre a variável principal (uso de MPI) e as demais foi utilizada a regressão de Poisson. A amostra foi composta por 321 idosos e, destes, 304 utilizavam medicamentos. A prevalência de uso de MPI foi de 54,6% (IC 95%: 48,9-60,2) e no modelo final esteve associada à polifarmácia e à demência. As classes terapêuticas de MPI mais identificadas foram antipsicóticos e benzodiazepínicos. O estudo revelou alta prevalência de MPI entre os idosos das ILPI, configurando a necessidade de adoção de indicadores do uso destes medicamentos e a implantação de estratégias que tornem a farmacoterapia mais segura e adequada aos idosos.

Abstract This study aimed to verify the prevalence of the use of Potentially Inappropriate Medications (PIM) for elderly living in Long-Term Care Institutions for the Elderly (LTCIE), as well as the types of medications and their associated factors. This is a cross-sectional study carried out in 10 LTCIEs in the city of Natal in the period October-December 2013. Potentially inappropriate medications were classified according to the 2015 American Geriatric Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults - 2015. Sociodemographic, LTCIE-related and health-related variables were considered. Univariate and multivariate analyses were performed between the primary variable (PIM use) and the independent variables using Poisson regression. The sample consisted of 321 older people, of whom 304 used medications. The prevalence of PIM use was 54.6% (95% CI: 48.9-60.2) and was associated with polypharmacy and dementia in the final model. The most common PIMs were antipsychotics and benzodiazepines. The study revealed a high prevalence of PIM use among the elderly of the LTCIEs, evidencing the need to adopt indicators on the use of these drugs and the implementation of strategies that make drug therapy safer and more adequate for older adults.

Spanish list of potentially inappropriate drugs in the elderly (ES-PIA project).

PURPOSE: In the last decades, different criteria have been developed for detecting inappropriate prescription in older patients. In Spain, translations and adaptations of international lists are available but it would be necessary a national list which could cope with the peculiarities of our health system, existing pharmaceutical market, and prescription habits. We propose in this project the creation of a Spanish potentially inappropriate drugs list which could be applicable in our clinical scenario. METHODS: We use a Delphi method involving 25 experts from different backgrounds (Clinical Pharmacology, Geriatrics, Rational Use of Drugs and Pharmacy, Primary Care and Pharmacoepidemiology, and Pharmacovigilance) that were asked to participate in two-round questionnaires. For analysis, current recommendations of Worth and Pigni were applied, and every statement was classified into one of three groups: strong, moderate, or low agreement. Statements with strong agreement were accepted to be part of the inadequate prescription list. Moderate agreement statements were selected to enter the second questionnaire, and statements with low agreement were further analyzed to determine if it was due to heterogeneity or due to dispersion in the answers. RESULTS: The first questionnaire consisted of 160 proposed sentences, of which 106 reached a high agreement, 32 a moderate agreement, and 22 a low agreement. All sentences proposed in the second questionnaire reached a strong agreement. The total accepted sentences were 138. CONCLUSIONS: We offer a list of inadequate prescription in older patients adapted to the Spanish pharmacopeia and according to the prescription habits in our environment.

Evaluación de una estrategia de mejora sobre la incidencia de errores en la prescripción de medicamentos en una unidad de cuidados intensivos pediátricos / Evaluation of an improvement strategy on the incidence of medication prescribing errors in a pediatric intensive care unit

Los errores en la prescripción médica (EPM) son una de las causas más frecuentes de eventos adversos. Las unidades de cuidados intensivos constituyen un ámbito de alto riesgo para su aparición. Objetivos. Describir la incidencia y los tipos de EPM en nuestra Unidad de Cuidados Intensivos Pediátricos. Evaluar si la implementación de una estrategia de mejora sobre los EPM modifica su incidencia a inmediato y largo plazo. Población y métodos. Estudio tipo antes y después, no controlado, prospectivo. Universo y muestra. Todas las prescripciones médicas de los pacientes internados en la Unidad de Cuidados Intensivos Pediátricos del Hospital General de Niños Pedro de Elizalde, en los períodos julio-diciembre de 2013 y julio-agosto de 2014. Resultados. En la etapa preintervención, la tasa de EPM fue de 13,9%; el EPM más frecuente fue la falta de hora de modificación de un determinado medicamento, seguido por la omisión de dosis o medicamento. La medicación implicada con mayor frecuencia en los EPM fue el grupo de sedoanalgesia continua. Luego de la aplicación de un programa de mejora sobre EPM, la incidencia disminuyó a 6,3 errores por 100 prescripciones. El tipo de EPM en el cual se evidenció mayor reducción fue la falta de hora de modificación. A excepción del ítem plan de hidratación parenteral y electrolitos, todos los demás grupos de drogas analizados presentaron una marcada reducción. La tasa de EPM, luego de transcurrido un año del diagnóstico de situación, fue del 5,8%; mantuvo valores similares a la etapa de posintervención inmediata. Conclusión. La gestión de un programa de mejora sobre los EPM permitió un descenso en su incidencia.

Medical prescribing errors (MPEs) are one of the most common causes of adverse events. Intensive care units are a high-risk setting for their occurrence. Objectives. To describe the incidence and types of MPEs in our Pediatric Intensive Care Unit. To assess whether the implementation of an improvement strategy on MPEs affects their incidence in the short- and long-term. Population and Methods. Prospective, uncontrolled, before-after study. Universe and sample. All medical prescriptions for patients hospitalized in the Pediatric Intensive Care Unit of the Hospital General de Niños Pedro de Elizalde from July-December, 2013 and from July-August, 2014. Results. In the pre-intervention period, MPEs rate was 13.9%, the most common being the absence of the time a given medication was modified, followed by missing a dose or medication. The medication most frequently involved in MPEs was the sedation and continuous analgesia group. After the implementation of an improvement program on MPEs, the incidence decreased to 6.3 errors every 100 prescriptions. The MPE type which showed the greatest reduction was the absence of the time of modification. Except for parenteral hydration and electrolyte supplementation, the rest of the analyzed medication groups showed a marked reduction. One year after having reviewed the situation, the MPE rate was 5.8%, and values remained similar to those of the immediate postintervention period. Conclusion. Managing an improvement program on MPEs resulted in a decrease in its incidence.

Evaluación de una estrategia de mejora sobre la incidencia de errores en la prescripción de medicamentos en una unidad de cuidados intensivos pediátricos / Evaluation of an improvement strategy on the incidence of medication prescribing errors in a pediatric intensive care unit

Los errores en la prescripción médica (EPM) son una de las causas más frecuentes de eventos adversos. Las unidades de cuidados intensivos constituyen un ámbito de alto riesgo para su aparición. Objetivos. Describir la incidencia y los tipos de EPM en nuestra Unidad de Cuidados Intensivos Pediátricos. Evaluar si la implementación de una estrategia de mejora sobre los EPM modifica su incidencia a inmediato y largo plazo. Población y métodos. Estudio tipo antes y después, no controlado, prospectivo. Universo y muestra. Todas las prescripciones médicas de los pacientes internados en la Unidad de Cuidados Intensivos Pediátricos del Hospital General de Niños Pedro de Elizalde, en los períodos julio-diciembre de 2013 y julio-agosto de 2014. Resultados. En la etapa preintervención, la tasa de EPM fue de 13,9%; el EPM más frecuente fue la falta de hora de modificación de un determinado medicamento, seguido por la omisión de dosis o medicamento. La medicación implicada con mayor frecuencia en los EPM fue el grupo de sedoanalgesia continua. Luego de la aplicación de un programa de mejora sobre EPM, la incidencia disminuyó a 6,3 errores por 100 prescripciones. El tipo de EPM en el cual se evidenció mayor reducción fue la falta de hora de modificación. A excepción del ítem plan de hidratación parenteral y electrolitos, todos los demás grupos de drogas analizados presentaron una marcada reducción. La tasa de EPM, luego de transcurrido un año del diagnóstico de situación, fue del 5,8%; mantuvo valores similares a la etapa de posintervención inmediata. Conclusión. La gestión de un programa de mejora sobre los EPM permitió un descenso en su incidencia.(AU)

Medical prescribing errors (MPEs) are one of the most common causes of adverse events. Intensive care units are a high-risk setting for their occurrence. Objectives. To describe the incidence and types of MPEs in our Pediatric Intensive Care Unit. To assess whether the implementation of an improvement strategy on MPEs affects their incidence in the short- and long-term. Population and Methods. Prospective, uncontrolled, before-after study. Universe and sample. All medical prescriptions for patients hospitalized in the Pediatric Intensive Care Unit of the Hospital General de Niños Pedro de Elizalde from July-December, 2013 and from July-August, 2014. Results. In the pre-intervention period, MPEs rate was 13.9%, the most common being the absence of the time a given medication was modified, followed by missing a dose or medication. The medication most frequently involved in MPEs was the sedation and continuous analgesia group. After the implementation of an improvement program on MPEs, the incidence decreased to 6.3 errors every 100 prescriptions. The MPE type which showed the greatest reduction was the absence of the time of modification. Except for parenteral hydration and electrolyte supplementation, the rest of the analyzed medication groups showed a marked reduction. One year after having reviewed the situation, the MPE rate was 5.8%, and values remained similar to those of the immediate postintervention period. Conclusion. Managing an improvement program on MPEs resulted in a decrease in its incidence.(AU)

[Prescription appropriateness: Indication of citicoline in Primary Care]. / Adecuación prescripción-indicación de citicolina en atención primaria.

INTRODUCTION: The economic situation has made it necessary to optimize resources by adjusting the pharmaceutical expenditure. Citicoline was (2011) the 10th drug by rank of billed amount. Its approved indications are stroke (acute and sub-acute) and head injury, but not cognitive decline associated with age, the presumed indication for most of its use. OBJECTIVES: To assess the conditions of use of citicoline in the Health Area of Tenerife, in order to detect deviations from the indications of use as stipulated in the prescribing information sheet and the pattern of prescription, with emphasis on the analysis of its use in dementia where currently it has no indication or evidence to support it. METHOD: Cross-sectional study of prescription-indication. A 680 patient sample, segmented by reference hospital (error±5%; CI: 0.95%; P=0.5) was taken from the 4036 patients with a prescription of citicoline billed during august-october 2011 (obtained from the prescription database program, Farmacanarias). RESULTS: We found that 123 patients (18.1%) had an appropriate indication. By including the prescription regimen, 28 patients (4.1%) had adequate indication and dose levels, and in only 2 patients (0.2%) an appropriate indication, dosage and duration were found. CONCLUSIONS: "The correct prescription-indication" of citicoline is inappropiate in almost all patients studied. Impact actions are needed in order to optimize prescription, improve patient safety by reducing potential interactions, and the occurrence of adverse effects, and improve efficiency by promoting savings.