Budget impact analysis of medicines: estimated values versus real-world evidence and the implications.

OBJECTIVES: Budget Impact Analyses (BIA) of medicines helps managers in promoting health systems' sustainability when assessing the role and value of new medicines. However, it is not clear whether BIAs typically underestimate or overestimate the impact on real-world budgets. This retroactive analysis seeks to compare estimated values obtained by a BIA and Real-World Evidence (RWE) to guide discussions. METHODS: The estimated values were obtained through a BIA concerning the incorporation of adalimumab for the treatment of Rheumatoid Arthritis into the Brazilian Unified Health System (SUS) carried out retroactively and per international guidelines. RWE data was extracted from SUS computerized systems. We subsequently compared the number of treatments, costs, and Incremental Budget Impact (IBI). RESULTS: - The total number of treatments was underestimated by 10% (6,243) and the total expenditure was overestimated by 463% (US$ 4.7 billion). In five years, the total difference between the estimated values and real IBI reached US$ 1.1 billion. A current expenditure of US$ 1.0 was observed for every US$ 5.60 of estimated expenditure. CONCLUSION: - The higher estimates from the BIA might cause decision makers to be more cautious with the introduction of a new medicine to reduce the opportunity costs for other interventions.

Duration of temporary catheter use for hemodialysis: an observational, prospective evaluation of renal units in Brazil.

BACKGROUND: For chronic hemodialysis, the ideal permanent vascular access is the arteriovenous fistula (AVF). Temporary catheters should be reserved for acute dialysis needs. The AVF is associated with lower infection rates, better clinical results, and a higher quality of life and survival when compared to temporary catheters. In Brazil, the proportion of patients with temporary catheters for more than 3 months from the beginning of therapy is used as an evaluation of the quality of renal units. The aim of this study is to evaluate factors associated with the time between the beginning of hemodialysis with temporary catheters and the placement of the first arteriovenous fistula in Brazil. METHODS: This is an observational, prospective non-concurrent study using national administrative registries of all patients financed by the public health system who began renal replacement therapy (RRT) between 2000 and 2004 in Brazil. Incident patients were eligible who had hemodialysis for the first time. Patients were excluded who: had hemodialysis reportedly started after the date of death (inconsistent database); were younger than 18 years old; had HIV; had no record of the first dialysis unit; and were dialyzed in units with less than twenty patients. To evaluate individual and renal unit factors associated with the event of interest, the frailty model was used (N = 55,589). RESULTS: Among the 23,824 patients (42.9%) who underwent fistula placement in the period of the study, 18.2% maintained the temporary catheter for more than three months until the fistula creation. The analysis identified five statistically significant factors associated with longer time until first fistula: higher age (Hazard-risk - HR 0.99, 95% CI 0.99-1.00); having hypertension and cardiovascular diseases (HR 0.94, 95% CI 0.9-0.98) as the cause of chronic renal disease; residing in capitals cities (HR 0.92, 95% CI 0.9-0.95) and certain regions in Brazil - South (HR 0.83, 95% CI 0.8-0.87), Midwest (HR 0.88, 95% CI 0.83-0.94), Northeast (HR 0.91, 95% CI 0.88-0.94), or North (HR 0.88, 95% CI 0.83-0.94) and the type of renal unit (public or private). CONCLUSION: Monitoring the provision of arteriovenous fistulas in renal units could improve the care given to patients with end stage renal disease.

Strategies to improve the availability of medicines in primary health care in Brazil: findings and implications.

Aim: Access to essential medicines is a key component of managing patients in ambulatory care. In 2008, the State of Minas Gerais, Brazil, created the Pharmacy Network of Minas (Rede Farmácia de Minas [RFM]) program to improve access to medicines, increasing availability and restructuring the infrastructures. The aim was to assess the current situation, comparing municipalities with and without RFM. Materials & methods: Descriptive survey study, data collected from 2014 July to May 2015. Availability was verified by stock levels. Results: The drug availability index was 61.0%, higher in municipalities with RFM. Most physicians considered the pharmaceutical services as good/very good. The main reasons for medicines shortage were 'financial transference problems', 'insufficient financial resources' and 'budget'. Conclusion: Strategies, such as the RFM can promote improvements in medicine availability.

Medication adherence and persistence of psoriatic arthritis patients treated with biological therapy in a specialty pharmacy in Brazil: a prospective observational study.

BACKGROUND: Pharmaceutical services in Brazil provide access, supply, and rational use of drugs for all population and an effort has been made to improve the quality of these services. Biological drugs are high-cost drugs supplied in Brazil that can inhibit disease progression and improve the quality of life of psoriatic arthritis (PsA) patients. However, some patients did not achieve therapeutic goals. OBJECTIVE: To evaluate the medication adherence and persistence of PsA patients treated with tumor necrosis factor inhibitors (anti-TNF) drugs and their associated factors. METHODS: A prospective observational study was performed at a single-specialty pharmacy in Belo Horizonte, Brazil. Medication adherence, persistence, and clinical outcomes were evaluated at 12 months of follow-up. Medication persistence was historically compared to overall PsA patients treated in Brazil. Associated factors were identified through log-binomial regression. RESULTS: One hundred ninety-seven PsA patients were included in the study, of whom 147 (74.6%) and 142 (72.1%) had medication adherence and persistence, respectively. Patients treated with infliximab presented the highest adherence (90.5%) and persistence rate (95.2%) in comparison to patients treated with other drugs, except for adalimumab versus infliximab for adherence outcome. All clinical measures significantly improved in patients with medication adherence and persistence. Medication persistence was higher for patients attended by specialty pharmacy than other PsA patients in Brazil. The associated factors to higher medication adherence were lower disease activity by BASDAI, being non-white race, and intravenous drug use. The associated factors to higher medication persistence were lower disease activity by Bath Ankylosing Spondylitis Activity Index (BASDAI), intravenous drug use, non-use of corticoids and non-steroidal anti-inflammatory drugs, and comorbidity. CONCLUSIONS: Patients with medication adherence and persistence had significant improvements in clinical measures, functionality, and quality of life. High medication adherence and persistence to biological therapy were observed and associated with lesser disease activity at baseline. Also, medication persistence to PsA patients attended in specialty pharmacy was higher than the overall PsA population in Brazil, which indicates the importance of pharmaceutical services to provide health care and promote the effectiveness and safety of biological therapies.

Health-Related Quality of Life in Psoriatic Arthritis: Findings and Implications.

OBJECTIVES: To assess the quality of life (QOL) and its associated factors in patients with psoriatic arthritis (PsA) who would start treatment with biologic drugs at the Brazilian Unified Health System. METHODS: A cross-sectional study was performed at a single center pharmacy in Belo Horizonte, State of Minas Gerais, Brazil. EQ-5D was used to assess the patients' QOL. The functional status was assessed using the Health Assessment Questionnaire-Disability Index, whereas disease activity was evaluated through the Bath Ankylosing Spondylitis Disease Activity Index and the Clinical Disease Activity Index. Simple and multiple linear regression analyses were performed to assess the factors associated with QOL. RESULTS: A total of 212 patients with PsA were included, of which 185 (87.3%) reported having some pain/discomfort, and 148 (69.8%) presented some level of anxiety/depression. Patients with PsA had a mean QOL score of 0.651 (SD 0.12) with a significant reduction in female patients, concomitant use of nonsteroidal anti-inflammatory drugs, comorbidity, and worse clinical and functional status. Poor QOL was associated with worse functional status by the Health Assessment Questionnaire-Disability Index, disease activity by the Bath Ankylosing Spondylitis Disease Activity Index, and with diagnoses of osteoporosis, hypothyroidism, and depression. CONCLUSION: PsA and its associated comorbidities negatively affect the QOL, evidencing the need for a comprehensive and effective clinical approach.

Access to medicines in the Brazilian Unified Health System's primary health care: assessment of a public policy.

In 2008, the Programa Rede Farmácia de Minas (RFM, literally translated: 'Minas Gerais Pharmacy Network' program) was created as a strategy to expand access to medicines. Aim: Measure access to medicines in public pharmacies through comparison between municipalities that joined or not the RFM. Materials & methods: Cross-sectional, evaluative study, gathering information from a representative sample of the municipalities in Minas Gerais between July 2014 and May 2015. The Poisson regression results were obtained by calculating the prevalence ratios. Results: Adequate access to medicines in Minas Gerais was 69.9%, being 75.8% in municipalities with and 69.2% without the RFM. The municipalities with the RFM showed statistically higher percentages in the Availability, Adequacy/Accommodation, and Acceptability dimensions. Conclusion: RFM appears an efficient strategy for promoting access to medicines.

[Patient's understanding of information on antiretroviral therapy: an application of the latent trait model]. / Compreensão da terapia anti-retroviral: uma aplicação de modelo de traço latente.

The aim of this study was to develop a score to determine the level of understanding regarding information on antiretroviral therapy (ART) among patients initiating treatment. This was a cross-sectional analysis based on interviews with HIV patients in outpatient public referral centers (Belo Horizonte, Minas Gerais State, Brazil). The score for patients' understanding of their medicines was obtained using a latent trait model, estimated by the Item Response Theory, based on the concordance between each patient answer and the written prescription. Hierarchical linear regression was used to assess patients' global understanding of ART, considering each class of drugs (level 1) and the individual (level 2). Among 406 patients, 37.9% failed to reach a minimum level of understanding of their treatment. The item with the highest level of difficulty was "precaution in use". The item "dosage" showed the most varied understanding of ART. A high proportion of patients displayed minimal understanding of ART, indicating a high potential risk for non-adherence to therapy. It is thus necessary to identify factors associated with insufficient understanding of ART.

Hipoglicemiantes Orais Para Diabetes Mellitus Tipo 2: Comparação de Preços no Brasil e em Outros Sistemas Universais de Saúde.

OBJECTIVES: To estimate the average price of oral hypoglycemic agents provided by the Brazilian health system (SUS) and to compare them to other public health systems. METHODS: Cross-sectional study about drug prices purchased by Belo Horizonte (municipal level), Minas Gerais (state level) and federal institutions in January and February of 2014. Average prices were calculated by defined daily dosage (DDD) and were compared to the management levels and the program "Aqui Tem Farmácia Popular" (ATFP). For international comparison, reimbursement values from Spain, Portugal, the United Kingdom and Canada (Province of Quebec) were used. RESULTS: Belo Horizonte had higher average prices than Minas Gerais. In general, essential oral hypoglycemic agents purchased by the SUS had lower prices than ATFP. For example, glibenclamide 5 mg was 1.023% more expensive. Metformin purchased by ATFP was more expensive than by SUS. Eight drugs purchased by SUS had average values above the respective Brazilian price ceiling. As an international comparison, SUS had lower average prices for glibenclamide and metformin. In ATFP, metformin was more expensive than in other countries, while glibenclamide was cheaper than Portugal only. CONCLUSION: The municipal management level had higher average prices than state level. Oral hypoglycemic agents purchased by SUS are predominantly cheaper than ATFP. Average prices paid by SUS are lower, while the prices paid by ATFP are higher than the reimbursed amounts from other countries.

Self-reported adverse reactions among patients initiating antiretroviral therapy in Brazil.

A cross-sectional analysis was carried out to describe adverse reactions to antiretroviral therapy (ART) reported by HIV-infected patients initiating treatment at two public health AIDS referral centers in Belo Horizonte, Brazil, 2001-2003 and to verify their association with selected variables. Adverse reactions were obtained through interview at the first follow-up visit (first month) after the antiretroviral prescription. Socio-demographic and behavioral variables related to ART were obtained from baseline and follow-up interviews and clinical variables from medical charts. Patients with four or more reactions were compared to those with less than four. Odds ratio with 95% confidence interval were estimated using logistic regression model for both univariate and multivariate analyses. At least one adverse reaction was reported by 92.2% of the participants while 56.2% reported four or more different reactions. Antiretroviral regimens including indinavir/ritonavir, irregular use of antiretrovirals and switch in regimens were independently associated with four or more adverse reactions (OR=7.92, 5.73 and 2.03, respectively). The initial period of ARV treatment is crucial and patients' perception of adverse reactions should be carefully taken into account. Strategies for monitoring and management of adverse reactions including the choice of regimens and the prevention of irregular ART should be developed in AIDS/HIV referral centers in Brazil to promote better adherence to antiretroviral therapy.

Consumer Willingness to Pay for Dengue Vaccine (CYD-TDV, Dengvaxia®) in Brazil; Implications for Future Pricing Considerations.

Introduction and Objective: Dengue virus is a serious global health problem with an estimated 3.97 billion people at risk for infection worldwide. In December 2015, the first vaccine (CYD-TDV) for dengue prevention was approved in Brazil, developed by Sanofi Pasteur. However, given that the vaccine will potentially be paid via the public health system, information is need regarding consumers' willingness to pay for the dengue vaccine in the country as well as discussions related to the possible inclusion of this vaccine into the public health system. This was the objective of this research. Methods: We conducted a cross-sectional study with residents of Greater Belo Horizonte, Minas Gerais, about their willingness to pay for the CYD-TDV vaccine. Results: 507 individuals were interviewed. These were mostly female (62.4%) had completed high school (62.17%), were working (74.4%), had private health insurance (64.5%) and did not have dengue (67.4%). The maximum median value of consumers' willingness to pay for CYD-TDV vaccine is US$33.61 (120.00BRL) for the complete schedule and US$11.20 (40.00BRL) per dose. At the price determined by the Brazil's regulatory chamber of pharmaceutical products market for the commercialization of Dengvaxia® for three doses, only 17% of the population expressed willingness to pay for this vaccine. Conclusion: Brazil is currently one of the largest markets for dengue vaccine and the price established is a key issue. We believe the manufacturer should asses the possibility of lower prices to reach a larger audience among the Brazilian population.

Opioid Use and Risk of Nonvertebral Fractures in Adults With Rheumatoid Arthritis: A Nested Case-Control Study Using Administrative Databases.

OBJECTIVE: To assess the risk of nonvertebral fractures in patients with rheumatoid arthritis (RA) who were exposed to opioids. METHODS: A population-based, nested case-control study was conducted using health services administrative databases (Quebec, Canada) from 1997 to 2012. Among RA patients, cases of nonvertebral fractures from 2007 to 2012 were identified using a validated algorithm. The date of the first fracture was the index date for the case and his/her matched control. Controls were selected using incidence density sampling and were matched 5:1 to cases for age, sex, and date of RA diagnosis. Opioid exposure was classified as current use, recent past use, remote past use, and nonuse. Conditional logistic regression was used to assess the association of nonvertebral fractures with opioid exposure, adjusting for comorbidity, indicators of RA severity, drugs influencing fracture risk, and health care utilization. RESULTS: In total, 1,723 cases and 8,046 controls were identified. Among these patients, 2,595 (722 cases and 1,873 controls) had been exposed to opioids. Current use (versus nonuse) increased the risk of nonvertebral fracture. Cumulative current use of opioids according to the quartile distribution was also associated with the risk of nonvertebral fracture: for continuous use for 1-20 days before the index date, odds ratio (OR) 11.49 (95% confidence interval [95% CI] 8.81-14.99); for 21-155 days, OR 1.75 (95% CI 1.31-2.33); for 156-355 days, OR 1.54 (95% CI 1.17-2.04); and for ≥356 days, OR 1.73 (95% CI 1.31-2.30). No association between the risk of nonvertebral fractures and recent past use or remote past use of opioids was observed. CONCLUSION: Among RA patients, the risk of nonvertebral fracture is increased in those treated with opioids.

Clinical Effectiveness and Safety of Analog Glargine in Type 1 Diabetes: A Systematic Review and Meta-Analysis.

INTRODUCTION: The use of insulin analogs for the treatment of type 1 diabetes mellitus (T1DM) is widespread; however, the therapeutic benefits still require further evaluation given their higher costs. The objective of this study was to evaluate the effectiveness and safety of analog insulin glargine compared to recombinant DNA (rDNA) insulin in patients with T1DM in observational studies, building on previous reviews of randomized controlled trials comparing neutral protamine Hagedorn insulin and insulin glargine. METHODS: A systematic review with a meta-analysis was performed. The review included cohort studies and registries available on PubMed, LILACS, and the Cochrane Central Register of Controlled Trials (CENTRAL), as well as manual and gray literature searches. The meta-analysis was conducted in Review Manager 5.3 software. The primary outcomes were glycated hemoglobin (Hb1Ac), weight gain, and hypoglycemia. Methodological quality was assessed using the Newcastle-Ottawa scale. RESULTS: Out of 796 publications, 11 studies were finally included. The meta-analysis favored insulin glargine in HbA1c outcomes (adult patients) and hypoglycemic episodes (P < 0.05), but without reaching glycemic control (Hb1Ac to approximately 7%). The methodological quality of the studies was moderate, noting that 45% of studies were funded by pharmaceutical companies. CONCLUSION: Given the high heterogeneity of the studies, the discrete value presented by the estimated effect on effectiveness and safety, potential conflicts of interest of the studies, and the appreciable higher cost of insulin glargine, there is still no support for recommending first-line therapy with analogs. The role of analogs in the treatment of T1DM could be better determined by further observational studies of good methodological quality to assess their long-term effectiveness and safety, as well as their cost-effectiveness.

Budget impact analysis of medicines: updated systematic review and implications.

This evaluation determines whether published studies to date meet the key characteristics identified for budget impact analyses (BIA) for medicines, accomplished through a systematic review and assessment against identified key characteristics. Studies from 2001-2015 on 'budget impact analysis' with 'drug' interventions were assessed, selected based on their titles/abstracts and full texts, and their characteristics checked according to key criteria. Out of 1,984 studies, 92 were subsequently identified for review. Of these, 95% were published in Europe and the USA. 2012 saw the largest number of publications (16%) with a decline thereafter. 48% met up to 7 out of the 9 key characteristics. Only 22% stated no conflict of interest. The results indicate low adherence to the key characteristics that should be considered for BIAs and strong conflict of interest. This is an issue since BIAs can be of fundamental importance in managing the entry of new medicines including reimbursement decisions.

Medication Persistence of Disease-Modifying Antirheumatic Drugs and Anti-Tumor Necrosis Factor Agents in a Cohort of Patients With Rheumatoid Arthritis in Brazil.

OBJECTIVE: To assess the use and persistence of anti-tumor necrosis factor (anti-TNF) versus disease-modifying antirheumatic drug (DMARD) therapies in patients with rheumatoid arthritis (RA) in Brazil. METHODS: This was a new-user cohort study of RA patients from 2003 to 2010, using administrative data. Individuals were classified as being persistent using a drug at the first year and the first 2 years after cohort entry, if they did not discontinue that drug during that period. Cox regression was used to identify potential determinants of discontinuation of therapy in each medication group. RESULTS: Among 76,351 patients, 14,313 were using anti-TNF (+/- DMARD) therapy. At the end of the first year of followup, 48.2% continued using anti-TNF (+/- DMARD) therapy compared to 42.6% who persisted with DMARDs only. At the end of the second year, 23.1% of anti-TNF (+/- DMARD) users and 19.3% of DMARD-only users continued with therapy. Infliximab users had the lowest persistence rates. Multivariate Cox regression analysis showed that among anti-TNF (+/- DMARD) users, higher discontinuation rates were observed in female patients, in patients with lower income (only at the first 2 years of followup), in nonresidents of the region with the highest Human Development Index (HDI) rates, in those with a higher comorbidity score, and in those enrolled in the 2003-2006 period. Among DMARD-only users, younger patients, patients with lower income, nonresidents in regions with high HDI, those with a higher comorbidity score, and those enrolled in the 2003-2006 period were also more likely to discontinue therapy. CONCLUSION: Brazilian patients with RA showed low rates of medication persistence for DMARDs and anti-TNF agents, particularly at the first 2 years of followup. Future work could determine what other factors might contribute to drug persistence in RA.

Non-adherence among patients initiating antiretroviral therapy: a challenge for health professionals in Brazil.

OBJECTIVE: To assess the incidence, magnitude and factors associated with the first episode of non-adherence for 12 months after the first antiretroviral prescription. DESIGN: A prospective study of HIV-infected patients receiving their first antiretroviral prescription in public referral centers, Belo Horizonte, Brazil. Baseline assessment occurred at the moment of the first prescription and follow-up visits at the first, fourth and seventh month, from May 2001 to May 2003. METHODS: Non-adherence was self-reported and defined as the intake of less than 95% of the prescribed doses for 3 days before the follow-up interviews. Cumulative and person-time incidence were estimated and Cox's proportional model was used to assess the relative hazard (RH) of non-adherence with 95% confidence interval for both univariate and multivariate analysis. RESULTS: Among 306 patients, the cumulative incidence of non-adherence was 36.9% (incidence rate 0.21/100 person-days). Multivariate analysis (P < 0.05) showed that unemployment (RH = 2.17), alcohol use (RH = 2.27), self-report of three or more adverse reactions (RH = 1.64), number of pills per day (RH = 2.04), switch in antiretroviral regimen (RH = 2.72), and a longer time between the HIV test result and the first antiretroviral prescription (RH = 2.27) were associated with an increased risk of non-adherence, whereas the use of more than one health service indicated a negative association (RH = 0.54). CONCLUSION: The current analysis has pointed out the importance of clinical and health service characteristics as potential indicators of non-adherence after initiating therapy. Early assessment and intervention strategies should be priorities in these AIDS public referral centres. Feasible and reliable indicators for the routine monitoring of adherence should be incorporated in clinical practice.

[HIV patients' understanding of information on antiretroviral therapy]. / Compreensão de informações relativas ao tratamento anti-retroviral entre indivíduos infectados pelo HIV.

To assess the understanding of information related to antiretroviral therapy among HIV-infected patients enrolled in public AIDS services (Belo Horizonte, Minas Gerais State, Brazil), a cross-sectional analysis was carried out, based on interviews with patients after initial provision of antiretroviral drugs. The study evaluated the information on antiretroviral therapy provided by healthcare professionals and the patients' level of understanding in relation to prescription information. This level was classified as insufficient if there was disagreement of more than 30.0% between the information reported by the patient and the written prescription. Divergence between prescriptions and information reported by 358 interviewed patients was observed. The level of understanding regarding the prescribed antiretroviral was obtained, and 26.3% of patients displayed insufficient understanding. The results show an important proportion of patients with misunderstanding of information regarding antiretroviral therapy, mainly those with limited schooling and low income. It is necessary to bolster strategies to increase quality of recommendations provided to these patients. Improving the multidisciplinary team approach to patient care should help reverse the observed situation.

Analysis of medical prescriptions dispensed at health centers in Belo Horizonte, Minas Gerais, Brazil.

This article focuses on medical prescriptions dispensed at health centers under the Municipal Health Department in Belo Horizonte, Minas Gerais State, Brazil. The study analyzed 4,607 prescriptions from March to April 1999, grouped according to origin (internal or external). The analysis focused on information written on medical prescriptions. The main findings were: (a) an average of 2.4 drugs per prescription in both groups; (b) prescriptions filled out with 4 or more drugs accounted for 18.0% of internal and 17.6% of external prescriptions; (c) 84.3% of internal and 85.5% of external prescriptions provided no instructions for use of medication; (d) information on dosage regimen varied from 51.2% to 97.6% for internal and 57.9% to 96.5% for external prescriptions; (e) generic names were specified for 51.9% and 28.4% of all drugs on internal and external prescriptions, respectively; (f) prescriptions containing standard drugs from the Municipal Health Department accounted for 88.7% of internal and 76.4% of external prescriptions. Data analysis shows the need for continuing education of physicians and adoption of other methods to improve quality of prescriptions and promote rational use of drugs.

[The interruption of outpatient clinical care of HIV-infected patients]. / Interrupção do acompanhamento clínico ambulatorial de pacientes infectados pelo HIV.

OBJECTIVE: To determine factors associated with the interruption of outpatient care of HIV-positive patients. METHODS: Non-concurrent prospective study carried out in a public AIDS referral center in Belo Horizonte, Brazil. Medical records were reviewed in order to assess factors associated with the interruption of clinical care of HIV patients admitted between 1993 and 1995. Patients should have attended at least one follow-up visit within a period of 7 months. Statistical analysis was carried out using Chi-square and relative hazard (RH) with 95% confidence interval (CI) estimated by Cox Regression Model. RESULTS: Cumulative incidence of interruption was 54% among 517 patients included in the study (mean follow-up=24.6 months; 26.5/100 person-years). Multivariate analysis indicated that those individuals who had fewer (<2) CD4+ T lymphocyte cell counts (RH=1.94; 95% CI=1.32-2.84) did not have viral load measured (RH=14.94; IC 95%=5.44-41.04), attended <7 medical follow-up visits (RH =2.80; IC 95%=1.89-4.14), did not change clinical category (RH =1.40; IC 95% =1.00-1.93) and did not undergo any anti-retroviral therapy (RH =1.43; IC 95% =1.06-1.93) had independently an increased risk of interrupting clinical care. CONCLUSIONS: The rate of clinical interruption in this center is high. The results suggest that interruption may be a function of better clinical outcome, i.e. the service may give priority to those patients with more severe clinical condition, and interruption of clinical care may be a marker for future antiretroviral compliance.

Evaluation of drug-drug interaction screening software combined with pharmacist intervention.

BACKGROUND: Drug-drug interactions (DDI) in hospitalized patients are highly prevalent and an important source of adverse drug reactions. DI computerized screening system can prevent the occurrence of some of these events. OBJECTIVE: To evaluate the impact of drug-drug interaction (DDI) screening software combined with active intervention in preventing drug interactions. SETTING: The study was conducted at General Hospital of Vitória da Conquista (HGVC), Brazil. METHOD: A quasi-experimental study was used to evaluate the impact of IM-Pharma, a locally developed drug-drug interaction screening system, coupled with pharmacist intervention on adverse drug events in the hospital setting. MAIN OUTCOME MEASURE: The proportion of patients co-prescribed two interacting drugs were measured in two phases, prior the implementation of IM-Pharma and during the intervention period. DDI rates per 100 patient days were calculated before and after implementation. Risk ratios were estimated by Poisson regression models. RESULTS: A total of 6,834 instances of drug-drug interactions were identified; there was an average of 3.3 DDIs per patient in phase one and 2.5 in phase two, a reduction of 24 % (P = 0.03). There was a 71 % reduction in high-severity drug-drug interaction (P < 0.01). The risk for all DDIs decreased 50 % after the implementation of IM-Pharma (P < 0.01), and for those with high-severity, the reduction was 81 % (P < 0.01). CONCLUSION: The performance of IM-Pharma combined with pharmacist intervention was positive with an expressive reduction in the risk of DDIs.

Drug utilization and polypharmacy among the elderly: a survey in Rio de Janeiro City, Brazil.

OBJECTIVES: To describe drug utilization by Brazilian retirees with an emphasis on inappropriate use. METHODS: Cross-sectional study with a simple random sample of 800 retirees of the Brazilian Institute of Social Security, 60 years of age and older, residing in Rio de Janeiro City, through face-to-face interviews. RESULTS: Medication use in the 15 days before the study was reported by 85% of the sample, with a mean of 3.7 products per person (standard deviation=2.9). About half the sample used one to four medications and a third used five or more. The highest number of drugs used per patient was 24. More women than men used multiple medications. There is a tendency toward positive association (P<0.001) between drug use and variables relating to disease and health care. This trend continues in the analysis by gender. Men who reported five or more diseases were five times more likely to use multiple drugs than men with up to two (zero, one, or two) diseases (prevalence ratio 5.21, 95% confidence interval=2.48-10.90). Women who reported five or more diseases were nearly four times more likely to use multiple drugs than women with up to two diseases (prevalence ratio 3.67, 95% confidence interval=2.24-6.02). Of the active substances used by the sample, 10% were considered inappropriate. CONCLUSIONS: To improve drug therapy for the elderly, health practitioners can take measures to reduce unwarranted use of medication and to optimize the benefits from important drugs. Further studies should be conducted to adjust lists of medications inappropriate for the elderly to the situation in developing countries.