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1.
Pan Afr Med J ; 38: 62, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33889228

RESUMO

Introduction: ciprofloxacin is a second-generation fluoroquinolone, which has been used as one of the top three antibacterial agents prescribed in Ethiopia. However, its use has deviated from the recommendation of standard treatment guidelines resulting in a gradual increase in antimicrobial resistance. Therefore, this study aimed to evaluate the annual use of ciprofloxacin in 2016 based on the standard Ethiopian treatment and World Health Organization guidelines, in governmental hospitals, in Eastern Ethiopia from 1st May to 30th June 2018. Methods: a hospital-based retrospective cross-sectional study was conducted to evaluate medical records of patients who had taken ciprofloxacin in 2016. The total sample size (n=522) was proportionally allocated to each hospital based on the respective consumption data. A simple random sampling method was employed to collect the required sample. The collected data were entered into SPSS version 21 and analyzed using descriptive analysis. Results: in this study, 522 medical records were reviewed, with a male to female ratio of 1.03: 1. Ciprofloxacin was indicated in 478 (91.6%) participants whose age was greater than eighteen years. The majority were treated in the medical and emergency outpatient departments (n=477, 91.4%). Urinary tract infections (n=224, 42.9%), acute febrile illnesses (n=68, 13.0%), and typhoid fever (n=54, 10.4%) were the top indications to which ciprofloxacin was prescribed. Non-steroidal anti-inflammatory drugs (NSAIDs) (n=241, 34.7%) and antimicrobials (n=135, 19.6%) were among the most frequently co-indicated agents. Based on the standard Ethiopian treatment guidelines, therapy was appropriate in 30% (n= 159) of patients. The major reason for inappropriate utilization (95%) was the wrong duration of antibiotic use (n=228). Evaluation based on World Health Organization criteria showed that indication, dose, and frequency were in line with the recommendation. Conclusion: ciprofloxacin was primarily indicated for urinary tract infections. The drug was appropriately used in less than one-third of patients, with the wrong duration being the main reason for overall inappropriate utilization. This trend may potentially impose a high risk to the emergence of drug-resistant microorganisms. To this end, further studies addressing the susceptibility pattern of bacterial isolates towards ciprofloxacin should be carried out.


Assuntos
Antibacterianos/administração & dosagem , Ciprofloxacino/administração & dosagem , Prescrição Inadequada/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Adulto , Criança , Estudos Transversais , Farmacorresistência Bacteriana , Etiópia , Feminino , Hospitais , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Infecções Urinárias/tratamento farmacológico , Infecções Urinárias/epidemiologia , Adulto Jovem
2.
J Prim Care Community Health ; 12: 21501327211003687, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33733905

RESUMO

BACKGROUND: The COVID-19 pandemic has changed the delivery of primary care in the NHS. Consultations have largely moved from face-to-face to remote, forcing practitioners to modify the ways in which they deliver care to patients. AIM: In this study, we aim to investigate the appropriateness of antibiotic prescribing in tonsillitis during the COVID-19 pandemic. DESIGN AND SETTING: An observational quantitative analysis in the North Wales primary care setting. METHOD: Retrospective review of computer records across 5 GP centers from March 2020 until the end of October 2020. Data was extracted and analyzed using chi-square or fisher exact rank and Mann-Whitney test. RESULTS: Our results have shown no significant difference in antibiotic prescribing behavior comparing face-to-face and remote consultations. CONCLUSION: Remote consultation is as effective as face-to-face consultation with regards to the assessment of tonsillitis and the appropriateness of antibiotic prescription in primary care.


Assuntos
Antibacterianos/uso terapêutico , Prescrição Inadequada/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Telemedicina , Tonsilite/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Assistência à Saúde , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde , Estudos Retrospectivos , País de Gales , Adulto Jovem
3.
Medicine (Baltimore) ; 100(12): e25015, 2021 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-33761656

RESUMO

ABSTRACT: Older adults are the leading users of medications, where this can be associated with a high number of potentially inappropriate medications (PIMs) and of potentially inappropriate prescribing (PIP) and consequent harm to health. No Brazilian study evaluating potentially inappropriate prescribing in older patients with Alzheimer's disease (AD) was found. This study determined and analyzed the prevalence of PIP and PIM prescribed for older people with AD.A cross-sectional study was carried out at the Specialty Drugs Pharmacy in the city of Sorocaba, São Paulo State, Brazil. The MEDEX system provided the register in older people with AD and data were collected during interviews with patients and/or caregivers between June and September 2017. The PIMs were identified according to the 2019 Beers Criteria. The association between PIMs and independent variables was analyzed by Poisson regression.This study included 234 older patients with AD. The prevalence of PIP prescribed was 66.7% (n = 156). Of the 1073 medications prescribed, 30.5% (n = 327) were inappropriate with most affecting the central nervous system or cardiovascular, particularly quetiapine (12.8%) and acetylsalicylic acid (11.6%), respectively. Around 45.2% of the PIMs should be avoided in older people, especially sertraline (14.2%) and clonazepam (7.4%). After adjusted analysis, the PIMs were associated with the diagnosis of depression (P = 0.010) and the number of comorbidities (P = 0.005).There was a high number of PIMs among older people, a substantial number of which should have been avoided in this population. Health care professionals can apply these findings to improve safety in the use of medications for treating patients with AD.


Assuntos
Doença de Alzheimer/tratamento farmacológico , Prescrição Inadequada/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Aspirina/efeitos adversos , Aspirina/uso terapêutico , Brasil , Fármacos Cardiovasculares/efeitos adversos , Fármacos Cardiovasculares/uso terapêutico , Fármacos do Sistema Nervoso Central/efeitos adversos , Fármacos do Sistema Nervoso Central/uso terapêutico , Clonazepam/efeitos adversos , Clonazepam/uso terapêutico , Estudos Transversais , Interações Medicamentosas , Feminino , Humanos , Masculino , Polimedicação , Fumarato de Quetiapina/efeitos adversos , Fumarato de Quetiapina/uso terapêutico , Sertralina/efeitos adversos , Sertralina/uso terapêutico
4.
Ars pharm ; 62(1): 75-84, ene.-mar. 2021. tab
Artigo em Espanhol | IBECS | ID: ibc-199702

RESUMO

INTRODUCCIÓN: Identificar las discrepancias existentes entre la medicación prescrita al ingreso en el servicio de traumatología y la medicación habitual de los pacientes, determinar la prevalencia de errores de conciliación y analizar el grado de aceptación de las intervenciones farmacéuticas realizadas para su resolución. MÉTODO: Estudio prospectivo de dos años de duración en un hospital comarcal público de España donde se seleccionaron los pacientes ingresados en traumatología con algún medicación domiciliario prescrito. Tras 24-48 horas del ingreso, el farmacéutico realizó la conciliación de la medicación, comparando la orden médica prescrita al ingreso con el tratamiento domiciliario. Se identificaron las discrepancias comunicándose al médico y se analizó el grado de aceptación de las recomendaciones. RESULTADOS: Se incluyeron 756 pacientes, con un total de 834 episodios de hospitalización; 66,1% mujeres, edad media: 72 ± 12,3 años, media de medicamentos domiciliarios por paciente: 8,1 ± 4,3. Se analizaron 8422 prescripciones, identificándose un 57,5% de discrepancias. La mayoría de las discrepancias no justificadas se debieron a omisión de medicamento (75%) seguido de la modificación de la posología o vía de un medicamento (19,1%). En el 87,4% de los episodios se encontró al menos una discrepancia. Las recomendaciones propuestas por el farmacéutico fueron aceptadas en el 69,9% de los casos. CONCLUSIONES: Existe un alta prevalencia de errores de conciliación al ingreso en el servicio de traumatología. Esta metodología ha permitido la coordinación del farmacéutico con el resto de profesionales implicados en la conciliación de la medicación, con el fin de detectar y resolver las discrepancias de medicación y reducir así los errores


INTRODUCTION: We aim to describe a method that would ensure continuity of patient care as regards drug therapy at admission to the orthopaedic surgery and traumatology department, identify the reconciliation discrepancies, determine the prevalence of reconciliation errors and analyse the acceptance of the pharmacist interventions. METHODS: Prospective observational study was conducted for two years in a regional public hospital in Spain. The study included patients hospitalized in the Orthopaedic Surgery and Traumatology Department with chronic medi¬cation prescribed. At 24-48 hours after hospital admission, the pharmacist compared the pre-admission pharmaco¬logical treatment of patients with the medication received in hospital to identify and reconciliation discrepancies. They were communicated and we analysed the acceptance of the pharmacist interventions. RESULTS: The study included 756 patients, with a total of 834 hospitalization episodes, 66,1% of whom were women, mean age: 72±12,3 years and a mean of 8,1±4,3 drugs. We analysed 8422 prescriptions, 57,5% reconciliation discrep¬ancies. The most frequent unjustified discrepancies were drug omission (75,2%), following by modification of the dose or route of administration (19,1%). There was at least one medication reconciliation discrepancy in 87,4% of hospitalization episodes. Pharmacist recommendations were accepted in 69,9% of cases. CONCLUSIONS: There was a high prevalence of reconciliation errors among patients admitted to the Orthopaedic Surgery and Traumatology Department. This methodology has allowed a workflow to be established that facilitates coordination between the pharmacist and others healthcare providers, to identify and resolve medication discrepancies to reduce medication errors


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Admissão do Paciente/estatística & dados numéricos , Reconciliação de Medicamentos/estatística & dados numéricos , Prescrição Inadequada/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Estudos Prospectivos , Reconciliação de Medicamentos/métodos
5.
Antimicrob Resist Infect Control ; 10(1): 28, 2021 02 03.
Artigo em Inglês | MEDLINE | ID: mdl-33536077

RESUMO

BACKGROUND: The deployment of antimicrobial stewardship (AMS) teams to deal with the COVID-19 pandemic can lead to a loss of developed frameworks, best practices and leadership resulting in adverse impact on antimicrobial prescribing and resistance. We aim to investigate effects of reduction in AMS resources during the COVID-19 pandemic on antimicrobial prescribing. METHODS: One of 5 full-time equivalent AMS pharmacists was deployed to support pandemic work and AMS rounds with infectious disease physicians were reduced from 5 to 2 times a week. A survey in acute inpatients was conducted using the Global Point Prevalence Survey methodology in July 2020 and compared with those in 2015 and 2017-2019. RESULTS: The prevalence of antimicrobial prescribing (55% in 2015 to 49% in 2019 and 47% in 2020, p = 0.02) and antibacterials (54% in 2015 to 45% in 2019 and 42% in 2020, p < 0.01) have been reducing despite the pandemic. Antimicrobial prescribing in infectious disease wards with suspected or confirmed COVID-19 cases was 29% in 2020. Overall, antimicrobial prescribing quality indicators continued to improve (e.g. reasons in notes, 91% in 2015 to 94% in 2019 and 97% in 2020, p < 0.01) or remained stable (compliance to guideline, 71% in 2015 to 62% in 2019 and 73% in 2020, p = 0.08). CONCLUSION: During the COVID-19 pandemic, there was no increase in antimicrobial prescribing and no significant differences in antimicrobial prescribing quality indicators.


Assuntos
Antibacterianos/uso terapêutico , Prescrições de Medicamentos , Antibacterianos/administração & dosagem , Gestão de Antimicrobianos/estatística & dados numéricos , Humanos , Prescrição Inadequada/estatística & dados numéricos , Singapura/epidemiologia , Centros de Atenção Terciária
6.
PLoS One ; 16(1): e0244247, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33411762

RESUMO

In a human immunodeficiency virus (HIV) clinic for children and their families in Eswatini, we sought to understand the use of antibiotics and identify specific areas for improvement. We performed a retrospective patient chart review as part of a quality improvement (QI) initiative to assess antimicrobial use before and after implementation of a standardized antimicrobial guide. For each prescribing period, 100 random patient encounters were selected for review if the indication for antibiotics, duration, and dose were consistent with World Health Organization (WHO) guidelines. Two physicians reviewed each encounter using a structured abstraction tool, with a third resolving discrepancies. Results were analyzed using a chi-square test of proportions and a structured survey was performed to assess perceptions of the guide. After the implementation of an antimicrobial guide, there was a significant decrease in the proportion of clinic visits with an antibiotic prescribed (p < 0.001). Incorrect indication for antimicrobial use decreased from 20.4% in the initial period to 10.31% and 10.2% but did not reach significance (p = .0621) in the subsequent periods after implementation. Incorrect dose/duration decreased from 10.47% in the initial period to 7.37% and 3.1% in the subsequent periods, but this was also was not significant (p = 0.139). All prescribers who completed the survey felt that it positively impacted their prescribing. Our study found that an antimicrobial guide reduced and improved the prescription of antimicrobials, demonstrating practical solutions can have a lasting impact on prescribing in low resource settings.


Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , Antibacterianos/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Família , Infecções por HIV , Adolescente , Adulto , Criança , Essuatíni , Feminino , Humanos , Prescrição Inadequada/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Inquéritos e Questionários , Adulto Jovem
7.
PLoS One ; 16(1): e0244519, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33411824

RESUMO

BACKGROUND: Nurse-led monitoring of patients for signs and symptoms associated with documented 'undesirable effects' of medicines has potential to prevent avoidable harm, and optimise prescribing. INTERVENTION: The Adverse Drug Reaction Profile for polypharmacy (ADRe-p) identifies and documents putative adverse effects of medicines commonly prescribed in primary care. Nurses address some problems, before passing ADRe-p to pharmacists and prescribers for review, in conjunction with prescriptions. OBJECTIVES: We investigated changes in: the number and nature of residents' problems as recorded on ADRe-p; prescription regimens; medicines optimisation: and healthcare costs. We explored aetiologies of problems identified and stakeholders' perspectives. SETTING AND PARTICIPANTS: In three UK care homes, 19 residents completed the study, December 2018 to May 2019. Two service users, three pharmacists, six nurses gave interviews. METHODS: This mixed-method process evaluation integrated data from residents' ADRe-ps and medicines charts, at the study's start and 5-10 weeks later. RESULTS: We recruited three of 27 homes approached and 26 of 45 eligible residents; 19 completed ADRe-p at least twice. Clinical gains were identified for 17/19 residents (mean number of symptoms 3 SD 1.67, range 0-7). Examples included management of: pain (six residents), seizures (three), dyspnoea (one), diarrhoea (laxatives reduced, two), falls (two of five able to stand). One or more medicine was de-prescribed or dose reduced for 12/19 residents. ADRe administration and review cost ~£30 in staff time. ADRe-p helped carers and nurses bring residents' problems to the attention of prescribers. IMPLICATIONS: ADRe-p relieved unnecessary suffering. It supported carers and nurses by providing a tool to engage with pharmacists and prescribers, and was the only observable strategy for multidisciplinary team working around medicines optimisation. ADRe-p improved care by: a) regular systematic checks and problem documentation; b) information transfer from care home staff to prescribers and pharmacists; c) recording changes. REGISTRATION: NLM Identifier NCT03955133; ClinicalTrials.gov.


Assuntos
Estudos Interdisciplinares , Casas de Saúde/estatística & dados numéricos , Polimedicação , Adulto , Idoso , Idoso de 80 Anos ou mais , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Feminino , Humanos , Prescrição Inadequada/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários
8.
BMC Infect Dis ; 21(1): 100, 2021 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-33482749

RESUMO

BACKGROUND: The increasing use of antifungal drugs (AF) in children and the concern for related adverse events and costs has led to the development of specific AF stewardship programmes (AFS). Studies in adult patients have shown improvements in AF prescription and usage after implementation, but paediatric data are scant. The aim of this PROAFUNGI study was to describe the use and appropriateness of AF in a high complexity paediatric centre. METHODS: Observational, prospective, single-centre, modified point-prevalence study (11 surveys, July-October 2018), including paediatric (< 18 years) patients receiving at least one systemic AF. Prescriptions were evaluated by the AFS team. RESULTS: The study included 119 prescriptions in 55 patients (53% males, median age 8.7 years [IQR 2.4-13.8]). The main underlying condition was cancer (45.5% of patients; HSCT in 60% of them); and the first indication for AF was prophylaxis (75 prescriptions, 63.2%). Liposomal amphotericin B was used most commonly (46% prescriptions), mainly as prophylaxis (75%). Among the 219 evaluations, 195 (89%) were considered optimal. The reason for non-optimal prescriptions was mostly lack of indication (14/24), especially in critical patients with ventricular assist devices. The use of AF without paediatric approval accounted for 8/24 inappropriate prescriptions. CONCLUSIONS: A high rate of AF appropriateness was found for the children's hospital as a whole, in relation with a well-established AFS. Nonetheless, the identification of specific areas of improvement should guide future actions of the AFS team, which will focus mainly on prophylaxis in critically ill patients receiving circulatory assistance and the use of non-approved drugs in children.


Assuntos
Antifúngicos/uso terapêutico , Gestão de Antimicrobianos , Hospitais Pediátricos/normas , Centros de Atenção Terciária/normas , Adolescente , Criança , Pré-Escolar , Prescrições de Medicamentos/normas , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Prescrição Inadequada/estatística & dados numéricos , Masculino , Prevalência , Estudos Prospectivos , Inquéritos e Questionários
9.
Dis Colon Rectum ; 64(1): 103-111, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33306536

RESUMO

BACKGROUND: Closer scrutiny of prescription patterns following surgery could contribute to the national effort to combat the opioid epidemic. OBJECTIVE: This study aimed to define opioid consumption patterns following anorectal operations for development of an institutional prescribing guideline. DESIGN: This was a retrospective cohort study. SETTING: The study was conducted at a single tertiary care center. PATIENTS: Patients undergoing outpatient anorectal surgery between July 2018 and January 2019 were included. MAIN OUTCOME MEASURES: The study measured prescription and consumption quantities measured as equianalgesic oxycodone 5-mg pills. RESULTS: There were 174 operations categorized into 4 operation categories: 72 hemorrhoid excisions, 55 fistulas-in-ano operations, 8 anal condyloma fulgurations, and 39 miscellaneous operations (14 sphincterotomies, 16 anal biopsies/skin tag excisions, and 9 transanal rectal lesion excisions). Prescription quantity was varied (range, 3-80 equianalgesic oxycodone 5-mg pills). Overall, 39% of patients consumed no pills, 18% consumed all, and 5% required refills. Of total pills prescribed, 63% of were unconsumed. Consumption was significantly different by operation category (average 13.6 equianalgesic oxycodone 5-mg pills after hemorrhoidectomies, 6.3 after fistula-in-ano operations, 5.8 after condyloma fulguration, and 2.9 after miscellaneous operations; p < 0.001). Home opioid requirements would be met for 80% of patients using the following guideline: 27 equianalgesic oxycodone 5-mg pills after hemorrhoidectomies, 13 after fistula-in-ano operations, 20 after anal condyloma fulguration, and 4 after miscellaneous operations. Guideline adoption would result in a 41% reduction in excess pills per prescription. LIMITATIONS: The study was limited by its retrospective, single-center design and because opioid consumption was self-reported. CONCLUSIONS: Opioid prescribing patterns and consumption are widely variable after anorectal operations and appear to be highly dependent on the operation category. It is noteworthy that 63% of opioids prescribed after anorectal operations were unused by the patient and may pose a significant public health risk. Based on the usage patterns observed in this study, prospective studies should be performed to optimize opioid prescribing. See Video Abstract at http://links.lww.com/DCR/B374. PATRONES DE CONSUMO DE OPIOIDES DESPUÉS DE OPERACIONES ANORRECTALES: DESARROLLO DE UNA GUÍA PARA PRESCRIPCIÓN INSTITUCIONAL: Una revisión enfocada de los patrones de prescripción después de la cirugía podría contribuir al esfuerzo nacional para combatir la epidemia de opioides.Este estudio tuvo como objetivo definir los patrones de consumo de opioides después de las operaciones anorrectales para el desarrollo de una guía para prescripción institucional.Estudio de cohorte retrospectivo.El estudio se realizó en un solo centro de atención de tercer nivel.pacientes de cirugía anorrectal ambulatoria entre julio de 2018 y enero de 2019.El estudio valoro el numero de recetas medicas y consumo de píldoras equianalgésicas de oxicodona de 5 mg.174 operaciones se clasificaron en cuatro categorías: 72 extirpaciones de hemorroides, 55 operaciones de fistula anal, 8 fulguraciones de condilomas anales y 39 operaciones misceláneas (14 esfinterotomías, 16 biopsias anales / extirpaciones de lesiones de piel y 9 escisiones de lesiones rectales por vía transanal). La cantidad de medicamentos recetados fue variada (rango: 3-80 pastillas de oxicodona equianalgésica de 5 mg). En general, el 39% de los pacientes no consumió píldoras, el 18% consumió todo y el 5% requirió equianalgesica adicional. Del total de píldoras recetadas, el 63% no se consumió. El consumo fue significativamente diferente según la categoría de la operación (promedio de 13,6 píldoras de oxicodona equianalgésica de 5 mg después de las hemorroidectomías, 6,3 después de las operaciones de fístula en el ano, 5,8 después de la fulguración del condiloma y 2,9 después de las operaciones misceláneas, p <0,001). Los requisitos de opioides en el hogar se cumplirían para el 80% de los pacientes con las siguientes pautas: 27 píldoras de oxicodona equianalgésicas de 5 mg después de las hemorroidectomías, 13 después de las operaciones de fístula anal, 20 después de la fulguración del condiloma anal y 4 después de operaciones misceláneas. La adopción de la guía daría como resultado una reducción del 41% en el exceso de píldoras por receta.El estudio estuvo limitado por su diseño retrospectivo de un solo centro y el consumo de opioides fue autoinformado.Los patrones de prescripción de opioides y el consumo son variables después de las operaciones anorrectales y parecen ser altamente dependientes de la categoría de la operación. En particular, el 63% de los opioides recetados después de las operaciones anorrectales no fueron utilizados por el paciente y pueden representar un riesgo significativo para la salud pública. Según los patrones de uso observados en este estudio, se deben realizar estudios prospectivos para optimizar la prescripción de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B374.


Assuntos
Analgésicos Opioides/uso terapêutico , Colo/cirurgia , Uso de Medicamentos/estatística & dados numéricos , Prescrição Inadequada/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Reto/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Eletivos , Feminino , Seguimentos , Humanos , Prescrição Inadequada/prevenção & controle , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Estudos Retrospectivos , Autorrelato
10.
Ann Pharmacother ; 55(1): 44-51, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32578446

RESUMO

BACKGROUND: Inappropriate albumin use in clinical practice remains problematic. Health-systems face continued challenges in promoting cost-appropriate use. OBJECTIVE: To evaluate the clinical and economic impact of a clinical pharmacist-led intervention strategy targeting inappropriate albumin use in general ward patients. METHODS: A retrospective cohort study evaluated all adult (≥18 years) general ward patients administered ≥1 dose of albumin at a university medical center over a 2-year period. The intervention consisted of a clinical pharmacist-led strategy intervening on all albumin orders not in accordance with institutional guidelines. The primary end point was to compare inappropriate albumin utilization before and after implementation. Secondary end points compared the rates of inappropriate albumin use adjusted for hospital admission and patient-days as well as associated costs by appropriateness between study periods. RESULTS: A total of 4420 patients were screened, with 1971 (44.6%) patients meeting inclusion criteria. The clinical pharmacist strategy significantly reduced inappropriate albumin (grams) utilization by 86.0% (P < 0.001). A 7-fold reduction of inappropriate albumin administered adjusted for the number of patient admissions was found from the preimplementation period following clinical pharmacist intervention strategy implementation (415.3 ± 83.2 vs 57.5 ± 34.2 g per 100 general ward hospital admissions, respectively; P < 0.001). Also, the adjusted inappropriate albumin rate was reduced from 62.2 ± 12.3 to 8.6 ± 5.2 g per 100 patient-days in the preimplementation and postimplementation periods, respectively (P < 0.001). Annual cost savings were $421 455 overall, with $341 930 resulting from mitigation of inappropriate use. CONCLUSION AND RELEVANCE: Clinical pharmacist-led interventions significantly reduced inappropriate albumin use and costs in hospitalized patients.


Assuntos
Albuminas/economia , Uso de Medicamentos/economia , Prescrição Inadequada/economia , Serviço de Farmácia Hospitalar/normas , Adulto , Albuminas/uso terapêutico , Redução de Custos , Custos de Medicamentos , Uso de Medicamentos/estatística & dados numéricos , Feminino , Hospitalização/economia , Hospitais de Ensino/economia , Hospitais de Ensino/organização & administração , Humanos , Prescrição Inadequada/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Farmacêuticos/normas , Serviço de Farmácia Hospitalar/estatística & dados numéricos , Estudos Retrospectivos
11.
Gac. sanit. (Barc., Ed. impr.) ; 34(6): 539-545, nov.-dic. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-200244

RESUMO

OBJETIVO: Averiguar si una intervención mediante carta dirigida a usuarios de benzodiacepinas consigue disminuir su consumo. MÉTODO: Estudio antes-después sin grupo control realizado en atención primaria en mayo de 2016. A 1.582 pacientes que tomaban una única dosis diaria de una benzodiacepina como hipnótico durante más de 3 meses se les envió una carta personalizada de su médico de familia con información sobre los efectos desfavorables de dicho consumo y la recomendación para retirarlo, con una pauta de descenso escalonada (Benzocarta). Se evaluó el porcentaje de pacientes que cesaron el consumo de benzodiacepinas, el porcentaje que las disminuyeron y la diferencia en la dosis total dispensada (miligramos equivalentes de diazepam dispensados en 3 meses) entre el periodo preintervención y postintervención (a los 6 y 12 meses). RESULTADOS: Se obtuvieron datos de dispensaciones de 1.561 pacientes (media de edad: 69,3 años; 74% mujeres). Al año de la intervención, el 22,0% (intervalo de confianza del 95% [IC95%]:19,9-24,0) habían abandonado el consumo de benzodiacepinas y el 18,8% (IC95%:16,9-20,8) lo habían disminuido. Se observó una reducción estadísticamente significativa de la dosis total dispensada (media de la diferencia: 89mg; IC95%: 72,2-105,7). CONCLUSIÓN: La Benzocarta se asocia a una disminución relevante en el consumo de hipnóticos. Es una intervención sencilla y factible que puede aplicarse en poblaciones amplias, e incluso de forma repetida en el tiempo. Se requieren estudios controlados para confirmar su eficacia


OBJECTIVE: To determine whether a letter-based intervention to patients taking benzodiazepines reduces their consumption. METHOD: A before-after study without control group performed in primary care in May 2016. 1582 patients who took a single daily dose of benzodiazepines as hypnotic for more than 3 months were sent a personalized letter from their family doctor. The letter contained information about the risks of long-term benzodiazepine consumption and the recommendation to discontinue them with a gradual drop protocol (Benzoletter). The percentage of patients who stopped or decreased the use of benzodiazepines, and the difference in the total dose dispensed (mg equivalents of diazepam dispensed in three months) between the pre- and post-intervention period (at 6 and 12 months) were evaluated. RESULTS: Dispensing data from 1561 patients were collected (average age: 69.3 years; 74% women). Twelve months after the intervention, 22.0% (95% confidence interval [95%CI]: 19.9-24.0) discontinued benzodiazepine consumption and 18.8% (95%CI: 16.9-20.8) reduced their consumption. A statistically significant reduction was observed in the total dose dispensed (mean difference: 89mg; 95%CI: 72.2-105.7). CONCLUSION: The Benzoletter is associated with a significant decrease in the consumption of hypnotics. It is a simple and feasible intervention that allows acting on large populations, and it could even be periodically repeated. Controlled studies are required to confirm its effectiveness


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Benzodiazepinas/uso terapêutico , Distúrbios do Início e da Manutenção do Sono/tratamento farmacológico , Prescrição Inadequada/estatística & dados numéricos , Desprescrições , Conduta do Tratamento Medicamentoso/organização & administração , Benzodiazepinas/efeitos adversos , Atenção Primária à Saúde/métodos , Estudos Controlados Antes e Depois , Correspondência como Assunto , Suspensão de Tratamento/estatística & dados numéricos
12.
BMC Geriatr ; 20(1): 341, 2020 09 11.
Artigo em Inglês | MEDLINE | ID: mdl-32912192

RESUMO

BACKGROUND: Antibiotic overprescribing for suspected urinary tract infection (UTI) in nursing homes (NHs) is common. Typical clinical scenarios in which antibiotics are inappropriately prescribed include response to nonspecific signs and symptoms and/or a positive urine test in the absence of symptoms referable to the urinary tract. These and other scenarios for inappropriate antibiotic prescribing were addressed in a recent international Delphi study which resulted in the development of a decision tool for the empiric treatment of UTI in frail older adults. The aim of the current study is to implement this decision tool, by integrating it into the electronic health record (EHR) and providing education on its content and use, and to evaluate its effect on appropriate antibiotic prescribing. An additional aim is to evaluate the quality of the intervention and the implementation process. METHODS: A cluster Randomized Controlled Trial (cRCT) is conducted in sixteen NHs and aims to include 897 residents diagnosed with suspected UTI. NHs in the intervention group use the EHR-integrated decision tool, and receive education for physicians and nursing staff; in the control group care as usual is provided. Data is collected through case report forms within the EHR at the day of diagnosis and at 3, 7, and 21 days thereafter. The primary outcome is appropriate antibiotic prescribing for suspected UTI at the day of diagnosis. Secondary outcomes include the course of symptoms, alternative diagnoses, treatment changes, complications, hospitalization, and mortality. Data on total antibiotic prescribing are additionally collected in the participating NHs 12 months before and during the study. Finally, the process evaluation combines cRCT data with questionnaires and qualitative interviews with NH professionals. DISCUSSION: This is the first cRCT to evaluate the recently developed, international decision tool for empiric treatment of suspected UTI in NH residents. Study findings will elucidate the effect of the intervention on appropriate antibiotic prescribing for suspected UTI, and provide insight into the applicability of the decision tool in NHs in general and in specific subgroups of NH residents. With this study we aim to contribute to antibiotic stewardship efforts in long-term care. TRIAL REGISTRATION: The ANNA study was registered at the Netherlands Trial Register on 26 February 2019, with identification number NTR NL7555 .


Assuntos
Antibacterianos/uso terapêutico , Gestão de Antimicrobianos/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos , Prescrição Inadequada/estatística & dados numéricos , Casas de Saúde/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto , Infecções Urinárias/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Protocolos Clínicos , Feminino , Humanos , Assistência de Longa Duração/métodos , Masculino , Países Baixos/epidemiologia , Padrões de Prática Médica , Infecções Urinárias/diagnóstico
13.
West J Emerg Med ; 21(5): 1283-1286, 2020 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-32970587

RESUMO

While current research efforts focus primarily on identifying patient level interventions that mitigate the direct impact of COVID-19, it is important to consider the collateral effects of COVID-19 on antimicrobial resistance. Early reports suggest high rates of antibiotic utilization in COVID-19 patients despite their lack of direct activity against viral pathogens. The ongoing pandemic is exacerbating known barriers to optimal antibiotic stewardship in the ED, representing an additional direct threat to patient safety and public health. There is an urgent need for research analyzing overall and COVID-19 specific antibiotic prescribing trends in the ED. Optimizing ED stewardship during COVID-19 will likely require a combination of traditional stewardship approaches (e.g. academic detailing, provider education, care pathways) and effective implementation of host response biomarkers and rapid COVID-19 diagnostics. Antibiotic stewardship interventions with demonstrated efficacy in mitigating the impact of COVID-19 on ED prescribing should be widely disseminated and inform the ongoing pandemic response.


Assuntos
Antibacterianos/uso terapêutico , Gestão de Antimicrobianos/métodos , Betacoronavirus , Infecções por Coronavirus/tratamento farmacológico , Serviço Hospitalar de Emergência , Prescrição Inadequada/prevenção & controle , Pneumonia Viral/tratamento farmacológico , Padrões de Prática Médica , Gestão de Antimicrobianos/organização & administração , Gestão de Antimicrobianos/estatística & dados numéricos , Betacoronavirus/isolamento & purificação , Técnicas de Laboratório Clínico , Infecções por Coronavirus/diagnóstico , Diagnóstico Diferencial , Serviço Hospitalar de Emergência/organização & administração , Humanos , Prescrição Inadequada/estatística & dados numéricos , Pandemias , Pneumonia Viral/diagnóstico , Padrões de Prática Médica/estatística & dados numéricos
14.
Proc Natl Acad Sci U S A ; 117(39): 24039-24046, 2020 09 29.
Artigo em Inglês | MEDLINE | ID: mdl-32958646

RESUMO

Many mental health disorders first manifest in adolescence, and early treatment may affect the course of the disease. Using a large national database of insurance claims, this study focuses on variations in the type of care that adolescent patients receive when they are treated for an initial episode of mental illness. We found large variations in the probability that children receive follow-up care and in the type of follow-up care received across zip codes. We also found large variations in the probability that children receive drug treatments that raise a red flag when viewed through the lens of treatment guidelines: Overall, in the first 3 mo after their initial claim for mental illness, 44.85% of children who receive drug treatment receive benzodiazepines, tricyclic antidepressants, or a drug that is not Food and Drug Administration-approved for their age. On average, these children are 12 y old. While the supply of mental health professionals impacts treatment choices, little of the overall variation is explained by supply-side variables, and at least half of the variation in treatment outcomes occurs within zip codes. These results suggest that other factors, such as physician practice style, may play an important role in the types of treatment that children receive.


Assuntos
Assistência ao Convalescente/estatística & dados numéricos , Fidelidade a Diretrizes/estatística & dados numéricos , Prescrição Inadequada/estatística & dados numéricos , Transtornos Mentais/terapia , Psicotrópicos/uso terapêutico , Adolescente , Criança , Feminino , Disparidades em Assistência à Saúde , Humanos , Masculino , Psicologia do Adolescente
15.
Cien Saude Colet ; 25(9): 3413-3419, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32876249

RESUMO

When Covid-19 emerged in December last year, there was no vaccine nor was there specific effective treatment for this fast-spreading and life-threatening viral respiratory infection. Clinical trials were planned and are in progress to investigate whether drugs used for influenza, HIV and other viruses, and also anthelmintics (ivermectin, nitazoxanide, niclosamide), and antimalarials (chloroquine, hydroxychloroquine) showing antiviral activity in in vitro assays, are effective and safe for Covid-19. So far there is no convincing evidence that these antiviral and antiparasitic drugs are of any benefit for Covid-19. Notwithsanding the absence of evidence of clinical efficacy, these drugs are widely used outside of clinical trials (off label) for prophylaxis and treatment of this viral infection. The rationale behind the prescription of macrolide antibiotics (azithromycin) for Covid-19 is obscure as well. The widespread prescription and use of drugs of unproven efficacy and safety for Covid-19 is at odds with the rational use of medicines, a cornerstone principle of pharmacotherapy advanced by WHO in 1985. This irrational use of drugs is cause for concern because some of them are associated with serious heart disorders and deaths.


Assuntos
Infecções por Coronavirus/tratamento farmacológico , Uso Off-Label , Pneumonia Viral/tratamento farmacológico , Antivirais/administração & dosagem , Antivirais/efeitos adversos , Infecções por Coronavirus/virologia , Humanos , Prescrição Inadequada/estatística & dados numéricos , Pandemias , Pneumonia Viral/virologia , Padrões de Prática Médica/normas
16.
J. negat. no posit. results ; 5(9): 998-1009, sept. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-199377

RESUMO

Los pacientes de la tercera edad conforman el grupo etario más medicado de la sociedad, principalmente por el incremento de la prevalencia de enfermedades crónicas, por lo tanto tienen una mayor probabilidad a presentar interacciones medicamentosas debido a otros factores dependientes del estado de su organismo, presentan tres características principales que lo diferencian de otros grupos de edad: polipatología, polifarmacia y cambios fisiológicos relacionados con el envejecimiento que alteran la farmacocinética y farmacodinamia de los medicamentos


The patients of the third age make up the most medicated age group in society, mainly due to the increase in the prevalence of chronic diseases, therefore they are more likely to present drug interactions due to other factors dependent on the state of their organism, they present three main characteristics that differentiate it from other age groups: polypathology, polypharmacy and physiological changes related to aging that alter the pharmacokinetics and pharmacodynamics of medications


Assuntos
Humanos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Interações Medicamentosas , Contraindicações de Medicamentos , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Polimedicação , Saúde do Idoso , Prescrição Inadequada/estatística & dados numéricos , Fatores de Risco , Inquéritos Epidemiológicos/estatística & dados numéricos , Múltiplas Afecções Crônicas/tratamento farmacológico
17.
PLoS One ; 15(8): e0238064, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32841285

RESUMO

BACKGROUND: Inappropriate prescribing in the elderly is a critical issue in primary care, causing a higher risk of Adverse Drug Reactions (ADRs) and resulting in major patient safety concerns. At international level, many tools have been developed to identify Potentially Inappropriate Medications (PIMs). OBJECTIVE: The aim of this study was the application of Beers, Screening Tool of Older People's Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) and Improving Prescribing in the Elderly Tool (IPET) criteria as key tool to improve the quality of prescribing. METHODS: A retrospective study was conducted using the aforementioned criteria. Two different cohorts of elderly patients were enrolled between January 2015 and December 2016, 1800 at admission and 1466 at hospital stay. The index of each criterion divided by politherapy were correlated with comorbidities (Pearson correlation). A comparison was made between admission and hospital stay through a Student's t test of the average of the index. RESULTS: The Proton Pump Inhibitors (PPIs) were the most prescribed PIMs according Beers criteria in both patient cohorts (56%). The most detected drug-drug and drug-disease interactions at admission and at hospital stay were 3 or more drugs active on the Central Nervous System (CNS) as they can predispose to fall-risk. The most detected PIMs with STOPP criteria at admission were PPIs administered for more than 8 weeks. Inhaled ß2-agonists or antimuscarinics were the most prescribed Potential Prescription Omissions (PPOs) according to START criteria. Nonsteroidal Anti-inflammatory Drugs (NSAIDs) in patients with high blood pressure were the most detected PIMs according to IPET criteria during hospital stay. A significant correlation between the comorbidities and the all index at hospital stay, while at admission there was no significant correlation for Beers and IPET index. CONCLUSION: The prescriptive criteria were a useful tool for assessing the quality of prescriptions in the geriatric population and identifying their critical issues.


Assuntos
Prescrições de Medicamentos/normas , Medicina Baseada em Evidências , Geriatria , Admissão do Paciente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Prescrição Inadequada/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Padrões de Referência
18.
N Z Med J ; 133(1519): 62-69, 2020 07 31.
Artigo em Inglês | MEDLINE | ID: mdl-32777796

RESUMO

AIM: To assess whether trimethoprim remains an appropriate empiric treatment for uncomplicated cystitis in women 15-55 years old. METHODS: General practitioners in Auckland, Nelson-Marlborough, Otago and Southland were invited to participate in this audit of current practice. Participating general practitioners were asked to submit urine to the laboratory for microscopy and culture from any woman aged 15-55 years presenting with uncomplicated cystitis. Urine samples submitted as part of the audit were identified by a "copy to" code. Data on laboratory results were extracted from the laboratory information system. RESULTS: Data were collected from June 2016 to August 2018. Four hundred and eighty-one samples were submitted, of which 340 (70.7%) met the inclusion criteria of the audit. A urinary pathogen was identified in 181 (53.2%) specimens, of which 148 (81.8%) were E. coli, 13 (7.2%) other coliforms and 20 (11.0%) Staphylococcus saprophyticus. Of the E. coli isolates, 109 of 148 (73.6%, 95% CI 66.6-80.7) were susceptible to trimethoprim, 144 of 144 (100%, 95% CI 100-100) to nitrofurantoin and 143 of 148 (96.6%, 95% CI 93.7-99.5) to cefalexin. Of the urinary pathogens, 139 of 185 (75.1%, 95% CI 68.9-81.4) were susceptible to trimethoprim, 164 of 177 tested (92.7%, 95% CI 88.8-96.5) to nitrofurantoin and 166 of 178 tested (93.3%, 95% CI 89.6-96.9) to cefalexin. Overall, a uropathogen resistant to trimethoprim was detected in 13.5%, to nitrofurantoin in 3.8%, and to cefalexin in 3.5% of samples tested. CONCLUSION: Similar rates of resistance to trimethoprim were seen in women 15-55 years old presenting with cystitis compared with unselected samples submitted from the general community. Given the high rates of resistance, trimethoprim is no longer appropriate as an empiric treatment option for cystitis in this group. Nitrofurantoin or cefalexin are appropriate alternative empiric treatment options. Given the current recommendation that a urine sample should not be submitted to the laboratory from women with uncomplicated cystitis, ongoing audits will be required to ensure that empiric treatment recommendations remain appropriate.


Assuntos
Antibacterianos/uso terapêutico , Cistite , Farmacorresistência Bacteriana/efeitos dos fármacos , Prescrição Inadequada/estatística & dados numéricos , Trimetoprima/uso terapêutico , Adolescente , Adulto , Antibacterianos/farmacologia , Cistite/tratamento farmacológico , Cistite/microbiologia , Escherichia coli , Infecções por Escherichia coli/tratamento farmacológico , Infecções por Escherichia coli/microbiologia , Feminino , Clínicos Gerais , Humanos , Auditoria Médica , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Nova Zelândia , Trimetoprima/farmacologia , Adulto Jovem
19.
Clin Interv Aging ; 15: 865-876, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32606626

RESUMO

Purpose: Most older people with cognitive impairment usually have multiple comorbidities. In the last decade, the guidelines for the management of chronic diseases have been changed, leading to changes in the patterns of medication prescribing and in the prevalence of drug-related problems (DRPs). The main objectives were to explore the changes in medication use and in the prevalence of polypharmacy (PP), the use of potentially inappropriate medications (PIMs) and drug-drug interactions (DDIs) among older hospitalized adults with cognitive impairment in a 5-year period. Patients and Methods: Older hospitalized patients with cognitive impairment diagnosed by cognitive performance scale (CPS) score of 2 or more at tertiary hospital in Brisbane, Australia in 2009 and 2015 to 2016 were enrolled. Prescribed medication use, and exposures to PP, PIM and/or DDI were evaluated at two time points. The associated factors with patients exposed to >1 criteria of PP, PIM or DDI were analyzed by using logistic regression analyses. Results: The median number of prescribed medications was not significantly different between the two periods. The number of medications use as dermatological agents and analgesics substantially increased over 5 years. In contrast, there was a decrease in prescription of drugs for acid-related disorders, drugs used in diabetes, and mineral supplements. Most of the participants were exposed to at least one of PP, PIM or DDI. In multivariate regression analysis, the presence of diabetes diagnosis was a risk factor associated with increased exposure to >1 criteria of PP, PIM or DDI. Conclusion: The patterns of many prescribed medications use have altered in a 5-year period. The present study confirms that the majority of older adults with cognitive impairment admitted in an acute care setting are prone to PP, PIM and DDI. Comprehensive medication reviews should be undertaken in clinical care of older patients with cognitive impairment.


Assuntos
Disfunção Cognitiva/epidemiologia , Prescrição Inadequada/estatística & dados numéricos , Polimedicação , Lista de Medicamentos Potencialmente Inapropriados/estatística & dados numéricos , Medicamentos sob Prescrição/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Instituições de Assistência Ambulatorial , Austrália , Doença Crônica/tratamento farmacológico , Disfunção Cognitiva/tratamento farmacológico , Comorbidade , Estudos Transversais , Interações Medicamentosas , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Estudos Longitudinais , Masculino , Medicamentos sob Prescrição/efeitos adversos , Prevalência , Fatores de Risco
20.
Pediatrics ; 146(2)2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32616629

RESUMO

OBJECTIVES: To compare the frequency of opioid and corticosteroid prescriptions dispensed for children with pneumonia or sinusitis visits on the basis of location of care. METHODS: We evaluated 2016 South Carolina Medicaid claims data for 5 to 18 years olds with pneumonia or sinusitis. Visits were associated with 1 of 3 locations: the emergency department (ED), urgent care, or the ambulatory setting. RESULTS: Inclusion criteria were met by 31 838 children. Pneumonia visits were more often linked to an opioid prescription in the ED (34 of 542 [6.3%]) than in ambulatory settings (24 of 1590 [1.5%]; P ≤ .0001) and were more frequently linked to a steroid prescription in the ED (106 of 542 [19.6%]) than in ambulatory settings (196 of 1590 [12.3%]; P ≤ .0001). Sinusitis visits were more often linked to an opioid prescription in the ED (202 of 2705 [7.5%]) than in ambulatory settings (568 of 26 866 [2.1%]; P ≤ .0001) and were more frequently linked to a steroid prescription in the ED (510 of 2705 [18.9%]) than in ambulatory settings (1922 of 26 866 [7.2%]; P ≤ .0001). In logistic regression for children with pneumonia, the ED setting was associated with increased odds of receiving an opioid (adjusted odds ratio [aOR] 4.69) or steroid (aOR 1.67). Similarly, patients with sinusitis were more likely to be prescribed opioids (aOR 4.02) or steroids (aOR 3.05) in the ED than in ambulatory sites. CONCLUSIONS: School-aged children received opioid and steroid prescriptions for pneumonia or sinusitis at a higher frequency in the ED versus the ambulatory setting.


Assuntos
Corticosteroides/uso terapêutico , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Analgésicos Opioides/uso terapêutico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Prescrição Inadequada/estatística & dados numéricos , Ambulatório Hospitalar/estatística & dados numéricos , Pneumonia/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Sinusite/tratamento farmacológico , Adolescente , Assistência Ambulatorial , Criança , Pré-Escolar , Serviços Médicos de Emergência , Feminino , Fidelidade a Diretrizes , Humanos , Modelos Logísticos , Masculino , Medicaid , Guias de Prática Clínica como Assunto , South Carolina , Estados Unidos
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