Avoiding concomitant prescription of drugs with a potential for interaction: mission impossible?

OBJECTIVE: The increased prevalence of multi-drug therapy increases the risk of drug interactions. We conducted a study with the aim of evaluating the prevalence of prescribing potentially interacting drug combinations, their severity, mechanism, and in particular, their clinical relevance, in medical inpatients at two Croatian university hospitals. METHODS: A cross-sectional study was conducted that included all medical inpatients receiving >= 2 drugs. Data were analyzed for 200 predefined drug-drug combinations compiled from the Micromedex data-base and literature. Two rating scales were used, one indicating the severity of a potential drug-drug interaction (pDDI) (minor, moderate, major), and the other assessing its clinical relevance (1: contraindicated; 2: avoidable; 3: consider risk-benefit ratio; 4: hardly avoidable). RESULTS: The prescribing patterns were similar between evaluated hospitals. The prevalence of pDDIs was 46%. The mean number of drugs prescribed per patient was 6.2 (± 95% CI 5.9 - 6.5). Out of 200 predefined pDDIs, 96 were found in our study population with mean 2.8 pDDIs per patient (± 95% CI 2.4 - 3.1). Out of 478 single identified pDDIs, most were of moderate and major severity (56% and 33%, respectively). However, only 9% out of them were considered completely avoidable, 57% were considered hardly avoidable, and for 35% the consideration of risk-benefit ratio was recommended. Most pDDIs were classified as pharmacodynamic by mechanism of interaction (45%). Age and number of prescribed drugs were significant risk factors for prescription of potentially interacting drug combinations (OR 1.01 (± 95% CI 1.001 - 1.03) and OR 1.46 (± 95% CI 1.33 - 1.59), respectively). CONCLUSIONS: Despite the high prevalence of pDDIs, only 1 in 10 was considered avoidable.

Inadequate use of preventive strategies in patients receiving NSAIDs.

OBJECTIVE: Little is known about the factors that influence the decision to use NSAIDs in combination with gastroprotective drugs. The aims of this observational study were to evaluate the extent to which NSAID users are prescribed concomitant gastroprotective drug regimens ('preventive strategies'), and to determine how patient risk factors for NSAID-associated gastrointestinal toxicity and physician prescribing preferences influenced the decision to prescribe a gastroprotective drug in combination with an NSAID. DESIGN AND PATIENTS: The study was conducted on 29 June 2004 and comprised 109 eligible adult patients hospitalised at the Clinical Hospital Center, Zagreb. Use of NSAIDs and gastroprotective drugs, risk factors for NSAID-associated gastrointestinal toxicity, and physician prescribing preferences were monitored throughout the study. RESULTS: Sixty-six percent of patients receiving proton pump inhibitors or histamine H(2)-receptor antagonists with NSAIDs had no risk factors for gastrointestinal toxicity. Furthermore, 29% of patients who used NSAIDs had risk factors for gastrointestinal toxicity but were not receiving gastroprotective drugs. Even though patients at risk of NSAID-associated gastrointestinal complications had higher odds of receiving preventive strategies (odds ratio 1.25), the absolute rate of utilisation of these therapies in at-risk populations was unacceptably low (69%). However, the strongest independent correlation for gastroprotective drug use was the prescribing physician, with an odds ratio of 6.40. CONCLUSION: This study demonstrates that an individual physician's prescribing style largely determines the odds of receiving preventive strategies with NSAID treatment and is more important than the patient's risk factors for gastrointestinal toxicity.

Privatization in the health care system of Croatia: effects on general practice accessibility.

This paper analyzes some effects of the privatization process in primary health care in Croatia, and in particular evaluates actions taken by providers to improve their accessibility for patients. The sample was stratified by regional density of practices and the status of practices in relation to privatization. Three groups of general practices were included in the study and were assessed twice (in 1997/1998 and 1999/2000): (1) 106 privatized before the beginning of the study; (2) 96 privatized during the study period and (3) 65 that were not yet privatized. The research was performed by structured interview with general practitioners as informants. The indicators analyzed were: possibilities of obtaining first and follow-up visit appointments, honouring scheduled appointments, scheduling visits by telephone, visiting the practitioner after hours and obtaining telephone advice after working hours. Number of registered patients in the practice and perception of patients' waiting times were also assessed. Privatized practices performed better in improving the accessibility of their services for patients: they increasingly offered the possibility for first and follow-up appointments at precise times, scheduled visits by telephone and provided telephone advice outside working hours. They showed greater intention to honour made appointments in order to lower their patients' waiting times. The study indicates that, in the initial stage of privatization, practitioners tend to extend accessibility by structural improvements that are not time consuming. It seems that providers adjust the level of offered accessibility benefits according to the intensity of market competitiveness. Further research is needed to precisely delineate the range of structural adjustments that could be expected by privatization and to verify the effect of observed changes on the quality of care and health outcomes.

Estimation of physical activity by different questionnaires in overweight subjects and patients with Type 2 diabetes mellitus: relationship with anthropometric and metabolic variables.

AIM: This study assessed the level of physical activity in overweight and obese subjects, and overweight and obese patients with Type 2 diabetes mellitus (T2DM). It also compared their physical activity level with that of the general population and investigated benefits of physical activity on anthropometric and metabolic parameters and blood pressure in the studied groups of patients using Baecke's questionnaire and the Lipid Research Clinics Physical Activity (LRC PA) questionnaire. The two questionnaires were also compared in the evaluation of benefits. METHODS: Physical activity level and other parameters (body weight, body height, body mass index, waist-to-hip ratio, systolic and diastolic blood pressure, lipoprotein and creatinine concentrations in the blood, concentration of fasting glucose and HbA1c in the blood, albuminuria-to-creatinuria ratio) of 136 subjects and their relationships were investigated during their out-patient visits. RESULTS: No difference in physical activity level was found among the four groups of investigated patients. The comparison between the level of physical activity in the investigated patients and the general population obtained by Baecke's questionnaire revealed a lower sports index in all groups of investigated men and obese women with diabetes mellitus. Our results confirm the benefit of physical activity on a high number of investigated parameters in the studied patients. The Baecke's questionnaire was found to estimate the effects of physical activity on metabolic and anthropometric parameters, as well as blood pressure, better than the LRC PA questionnaire, especially the two-point scoring system. CONCLUSIONS: LRC PA and especially Baecke's questionnaires are valuable aids in the estimation of physical activity level and its benefits in overweight and obese patients and patients with T2DM.