Defining a Standard Set of Patient-Reported Outcomes for Patients With Advanced Ovarian Cancer.

Purpose: Advanced ovarian cancer (AOC) and its treatment cause several symptoms and impact on patients' health-related quality of life (HRQoL). We aim to reach a consensus on the most relevant patient-reported outcome (PROs), the corresponding measures (PROMs), and measurement frequency during AOC patients' follow-up from patients' and healthcare professionals' (HCP) perspective. Methods: The project comprised five steps: 1) a literature review, 2) a focus group with patients, 3) a nominal group with HCP, 4) two round-Delphi consultations with patients and HCP, and 5) a final meeting with HCP. Delphi questionnaire was elaborated based on literature review, focus group (n=5 patients), and nominal group (n=16 HCP). The relevance of each PRO and the appropriateness (A) and feasibility (F) of the proposed PROM were assessed (Likert scale 1=strongly agree; 9=strongly disagree). The consensus was reached when at least 75% of the panelists rated it as 'relevant', 'appropriate', or 'feasible' (score 7-9). Results: A total of 56 HCP [51.8% Hospital Pharmacy; 41.1% Oncology; 3.6% Nursing; and 3.6% Psycho-oncology; mean time in specialty 12.5 (8.0) years] and 10 AOC patients [mean time diagnosis 5.4 (3.0) years] participated in the 1st round. All PROs achieved consensus regarding their relevance, except dry skin (58.0%). Agreement was reached for PRO-CTCAE to be used to assess fatigue (A:84.9%; F:75.8%), neuropathy (A:92.4%; F:77.3%), diarrhea (A:87.9%; F:88.7%), constipation (A:86.4%; F:75.8%), nausea (A:89.4%; F:75.8%), insomnia (A:81.8%; F:88.7%), abdominal bloating (A:82.2%; F:82.2%) and sexuality (A:78.8%; F:88.6%); EQ-5D to determine patients' HRQoL (A:87.9%; F:80.3%), pain (A:87.9%; F:75.8%) and mood (A:77.7%; F:85.5%); to assess treatment adherence the Morisky-Green (A:90.9%; F:84.9%) and the dispensing register (A:80.3%; F:80.3%) were chosen. It was agreed to note in the medical record whether the patient's treatment preferences had been considered during decision-making (A:78.8%; F:78.8%) and to use a 5-point Likert scale to assess treatment satisfaction (A:86.4%; F:86.4%). Panelists agreed (A:92.4%; F: 77.3%) to collect these PROs (1) at the time of diagnosis/relapse; (2) one month after starting treatment/change therapeutic strategy; (3) every three months during the 1st-year of treatment; and later (4) every six months until treatment completion/change. Conclusions: The consensus reached represents the first step towards including the patient's perspective in AOC follow-up. The standardized collection of PROs in clinical practice may contribute to optimizing the follow-up of these patients and thus improving the quality of care.

Deprescribing of non-antiretroviral therapy in HIV-infected patients.

PURPOSE: In recent decades, the life expectancy of HIV-infected patients has increased considerably, to the extent that the disease can now be considered chronic. In this context of progressive aging, HIV-infected persons have a greater prevalence of comorbid conditions. Consequently, they usually take more non-antiretroviral drugs, and their drug therapy are more complex. This supposes a greater risk of drug interactions, of hospitalization, falls, and death. In the last years, deprescribing has gained attention as a means to rationalize medication use. METHODS: Review of the different therapeutic approach that includes optimization of polypharmacy and control and reduction of potentially inappropriate prescription. RESULTS: There are several protocols for systematizing the deprescribing process. The most widely used tool is the Medication Regimen Complexity Index, an index validated in HIV-infected persons. Anticholinergic medications are the agents that have been most associated with major adverse effects so, various scales have been employed to measure it. Other tools should be employed to detect and prevent the use of potentially inappropriate drugs. Prioritization of candidates should be based, among others, on drugs that should always be avoided and drugs with no justified indication. CONCLUSIONS: The deprescribing process shared by professionals and patients definitively would improve management of treatment in this population. Because polypharmacy in HIV-infected patients show that a considerable percentage of patients could be candidates for deprescribing, we must understand the importance of deprescribing and that HIV-infected persons should be a priority group. This process would be highly feasible and effective in HIV-infected persons.

Antifungal stewardship in a tertiary hospital / Asesoramiento en la prescripción de antifúngicos en un hospital terciario

Background. The inappropriate use of antifungals is an important health problem related to increasing adverse effects, unnecessary cost and promotion of resistant and emerging fungal infections. Despite its relevance, many health institutions assign few resources to improve prescribing practices. Aims. To evaluate the efficiency of an antifungal stewardship programme (ASP) centered on restricted antifungal agents. Methods. The main activity during the eight-month study was to perform a programmed review of restricted antifungals (lipid formulations of amphotericin B, echinocandins and voriconazole) prescribed in hospitalized patients. In the case of amendable antifungal treatment, a recommendation was included in the electronic medical record. Results. A total of 280 antifungal prescriptions for 262 patients were revised during the study period. The indications were prophylactic in 85 cases (30.4%), pre-emptive in 10 cases (3.5%), empiric in 122 cases (43.6%), and directed in 63 cases (22.5%). A total of 70 prescriptions (25%) in 61 patients were considered to be amendable. In most of these cases, treatment could have been reduced considering the patient's clinical improvement and microbiological results. The most common advice was antifungals change (70%), antifungal withdrawal (21%), removal of one antifungal drug in cases of combined therapy (7%), and switching to oral route (1%). Proposed recommendations were addressed in 28 cases (40%). There was no significant difference in adherence with respect to the type of recommendation (p = 0.554). There was a 42% lower use of antifungals during the period of the study compared to that observed during a similar previous period. Mortality among patients who were treated according to the recommendations of the ASP was 17% and in whom treatment was not modified it was 30% (p = 0.393). Conclusions. ASPs centered on hospitalized patients may be an efficient strategy to ameliorate antifungal use in hospitals (AU)

Antecedentes. El uso inadecuado de los antifúngicos es un problema de salud relevante que puede incrementar los efectos adversos y generar costes innecesarios, además de favorecer la aparición de resistencias y de infecciones micóticas emergentes. A pesar de su importancia, muchas instituciones sanitarias destinan escasos recursos para mejorar las prácticas de prescripción. Objetivos. Evaluar la eficiencia de un programa de asesoramiento sobre antifúngicos basado en la prescripción de agentes antifúngicos restringidos. Métodos. La principal actividad durante el estudio de ocho meses de duración fue la realización de una revisión programada de antifúngicos restringidos, prescritos en los pacientes hospitalizados (formulaciones lipídicas de anfotericina B, equinocandinas y voriconazol). En el caso del tratamiento antifúngico modificable, se procedió a anotar una recomendación en la historia clínica electrónica. Resultados. Se revisó un total de 280 prescripciones de antifúngicos en 262 pacientes durante el período de estudio. Las indicaciones fueron de tipo profiláctico en 85 casos (30,4%), anticipado en 10 (3,5%), empírico en 122 (43,6%) y dirigido en 63 (22,5%). Se consideraron modificables un total de 70 prescripciones (25%) en 61 pacientes. En la mayoría de estos casos, el tratamiento podía reducirse teniendo en cuenta la mejoría clínica y los resultados microbiológicos del paciente. La indicación más frecuentemente realizada fue el cambio de antifúngico (70%), seguido por la retirada de dicho fármaco (21%), la eliminación de uno de los fármacos antifúngicos en casos de tratamiento combinado (7%) y, finalmente, la sustitución del tratamiento por la administración oral (1%). Las recomendaciones propuestas se aceptaron en 28 casos (40%). No se produjo una diferencia significativa en la adherencia con respecto al tipo de recomendación (p = 0,554). Durante el período de estudio se evidenció un descenso en el uso de antifúngicos del 42%, en comparación con el uso observado en un período previo similar. La mortalidad de los pacientes que fueron tratados de acuerdo con las recomendaciones fue del 17%, y del 30% en aquellos en los que no se modificó el tratamiento (p = 0,393). Conclusiones. El programa de asesoramiento sobre los antifúngicos prescritos en pacientes hospitalizados puede resultar una estrategia eficaz para mejorar el uso de estos fármacos (AU)

Antifungal stewardship in a tertiary hospital.

BACKGROUND: The inappropriate use of antifungals is an important health problem related to increasing adverse effects, unnecessary cost and promotion of resistant and emerging fungal infections. Despite its relevance, many health institutions assign few resources to improve prescribing practices. AIMS: To evaluate the efficiency of an antifungal stewardship programme (ASP) centered on restricted antifungal agents. METHODS: The main activity during the eight-month study was to perform a programmed review of restricted antifungals (lipid formulations of amphotericin B, echinocandins and voriconazole) prescribed in hospitalized patients. In the case of amendable antifungal treatment, a recommendation was included in the electronic medical record. RESULTS: A total of 280 antifungal prescriptions for 262 patients were revised during the study period. The indications were prophylactic in 85 cases (30.4%), pre-emptive in 10 cases (3.5%), empiric in 122 cases (43.6%), and directed in 63 cases (22.5%). A total of 70 prescriptions (25%) in 61 patients were considered to be amendable. In most of these cases, treatment could have been reduced considering the patient's clinical improvement and microbiological results. The most common advice was antifungals change (70%), antifungal withdrawal (21%), removal of one antifungal drug in cases of combined therapy (7%), and switching to oral route (1%). Proposed recommendations were addressed in 28 cases (40%). There was no significant difference in adherence with respect to the type of recommendation (p=0.554). There was a 42% lower use of antifungals during the period of the study compared to that observed during a similar previous period. Mortality among patients who were treated according to the recommendations of the ASP was 17% and in whom treatment was not modified it was 30% (p=0.393). CONCLUSIONS: ASPs centered on hospitalized patients may be an efficient strategy to ameliorate antifungal use in hospitals.

Correction: Antimicrobial stewardship in patients recently transferred to a ward from the ICU / Asesoramiento antibiótico en pacientes tras estancia en cuidados intensivos

This paper is a corrigendum to the previously published paper: "Antimicrobial stewardship in patients recently transferred to a ward from the ICU" [Rev Esp Quimioter. 2014 Mar;27(1):46-50.] This corrigendum was prepared in order to correct some erroneous comments included in the discussion section. First, it should be pointed out that there could have been several suitable options for treating many infections and that, therefore, the word "nadequate" was not the most appropriate in this situation. In addition, some comments about the interpretation of microbiological results made by ICU physicians have been removed from the first article because this variable was not included in the study. Finally, another change made to the discussion was to clarify the ICU physicians’ alleged low level of compliance with advice given by infectious disease specialists. This has been suggested in previous studies it cannot be substantiated when analyzing the results of the study. Purpose. Inappropriate use of antibiotics is an important health problem that is related to increasing bacterial resistance. Despite its relevance, many health institutions assign very limited resources to improving prescribing practices. An antimicrobial stewardship programme (APS) centred on patients discharged from the ICU could efficiently undertake this task. Methods. During this six month study the main activity was performing a programmed review of antimicrobial prescriptions in patients transferred to the ward from the ICU. In the case of amendable antimicrobial treatment, a recommendation was included in the medical record. Results. A total of 437 antimicrobial prescriptions for 286 patients were revised during a six month period and a total of 271 prescriptions (62%) in 183 patients were considered to be amendable. In most of these cases, treatment could have been reduced taking into consideration each patient’s clinical improvement and their location in a hospital area with a lower risk of infection due to resistant bacteria. The most common advice was antimicrobial withdrawal (64%), antimicrobial change (20%) and switching to oral route (12%). Proposed recommendations were addressed in 212 cases (78%). There was no significant difference in adherence with respect to the type of recommendation (p=0.417). There was a 5% lower use of antibiotics during the year the study was conducted compared to the previous one. Conclusions. ASPs centred on patients discharged from the ICU may be an efficient strategy to ameliorate antimicrobial use in hospitals

Este artículo es una corrección del artículo previamente publicado: "Antimicrobial stewardship in patients recently transferred to a ward from the ICU" [Rev Esp Quimioter. 2014 Mar;27(1):46-50.] Esta corrección ha sido elaborada para subsanar algunos comentarios erróneos incluidos en la discusión. Primero, hay que señalar que podría haber habido varias opciones adecuadas para el tratamiento de muchas infecciones y que, por tanto, la palabra "inadecuada" no era el más apropiada en esta situación. Además, algunos comentarios sobre la interpretación de los resultados microbiológicos realizados por médicos de la UCI se han eliminado del primer artículo porque esta variable no se incluyó en el estudio. Por último, otro cambio realizado en la discusión fue aclarar que los médicos de la UCI alegaron bajo nivel de cumplimiento con las recomendaciones dadas por los especialistas en enfermedades infecciosas. Esto ha sido sugerido en estudios previos y no puede ser demostrado en el análisis de los resultados de este estudio Objetivos. El uso inapropiado de antimicrobianos es un problema de salud relevante que se relaciona con aumento de la resistencia bacteriana y con el gasto farmacéutico innecesario. A pesar de su relevancia, un número elevado de instituciones sanitarias destinan escasos recursos para mejorar la prescripción antimicrobiana. Un programa de asesoramiento sobre el uso de antimicrobianos centrado en los pacientes dados de alta una unidad de cuidados intensivos (UCI) podría constituir una herramienta eficiente para mejorar este problema. Métodos. Durante este estudio de seis meses de duración se realizó una intervención consistente en una revisión programada, por expertos en enfermedades infecciosas, de las prescripciones antimicrobiana en pacientes trasladados a una sala de hospitalización desde UCI. En el caso de prescripción modificable se realizaba una recomendación en la historia electrónica. Resultados. Se revisaron de 437 prescripciones de antimicrobianos en 286 pacientes. En total, 271 prescripciones (62%) en 183 pacientes se consideraban modificables. En la mayoría de estos casos, el tratamiento podría ser ajustado a la baja teniendo en cuenta la mejoría clínica del paciente y su actual ubicación en un área hospitalaria con menos riesgo de infección por bacterias resistentes. El consejo más común fue retirada a los antimicrobianos (64%), el cambio a los antimicrobianos (20%) y la administración por vía oral (12%). Las recomendaciones propuestas fueron aceptadas en 212 casos (78 %). No hubo diferencia significativa en la adherencia a la recomendación por parte del clínico responsable ni con el tipo de recomendación (p = 0,417). Durante el año en que realizó el estudio se redujo la prescripción antibiótica en un 5% en comparación con el año anterior. Conclusiones. La revisión del tratamiento antimicrobiano en pacientes dados de alta de UCI puede ser una estrategia eficiente para mejorar el uso de estos fármacos (AU)

Antimicrobial stewardship in patients recently transferred to a ward from the ICU / Asesoramiento antibiótico en pacientes tras estancia en cuidados intensivos

Purpose. Inappropriate use of antibiotics is an important health problem that is related to increasing bacterial resistance. Despite its relevance, many health institutions assign very limited resources to improving prescribing practices. An antimicrobial stewardship programme (APS) centred on patients discharged from the ICU could efficiently undertake this task. Methods. During this six month study the main activity was performing a programmed review of antimicrobial prescriptions in patients transferred to the ward from the ICU. In the case of inadequate antimicrobial treatment, a recommendation was included in the medical record. Results. A total of 437 antimicrobial prescriptions for 286 patients were revised during a six month period. In all, 271 prescriptions (62%) were considered inappropriate in 183 patients. The most common reasons for inappropriateness were treating unconfirmed infection (43%), inadequate antimicrobial coverage (34%) and intravenous administration when the oral route was feasible (11%). Proposed recommendations were addressed in 212 cases (78%). There was no significant difference in adherence with respect to the type of recommendation (p=0.417). There was a 5% lower use of antibiotics during the year the study was conducted compared to the previous one. Conclusions. ASPs centred on patients discharged from the ICU may be an efficient strategy to ameliorate antimicrobial use in hospitals (AU)

Objetivos. El uso inapropiado de antimicrobianos es un problema de salud relevante que se relaciona con aumento de la resistencia bacteriana y con el gasto farmacéutico innecesario. A pesar de su relevancia, un número elevado de instituciones sanitarias destinan escasos recursos para mejorar la prescripción antimicrobiana. Un programa de asesoramiento sobre el uso de antimicrobianos centrado en los pacientes dados de alta una unidad de cuidados intensivos (UCI) podría constituir una herramienta eficiente para mejorar este problema. Métodos. Durante este estudio de seis meses de duración se realizó una intervención consistente en una revisión programada, por expertos en enfermedades infecciosas, de las prescripciones antimicrobiana en pacientes trasladados a una sala de hospitalización desde UCI. En el caso de prescripción inadecuada se realizaba una recomendación en la historia electrónica. Resultados. Se revisaron de 437 prescripciones de antimicrobianos en 286 pacientes. En total, 271 prescripciones (62%) en 183 pacientes se consideran inapropiadas. Las razones más comunes identificadas fueron el tratamiento de infecciones no confirmadas clínicamente (43%), espectro antibacteriano inadecuado (34%) y el empleo de la vía intravenosa en casos que podían ser tratados por vía oral (11%). Las recomendaciones propuestas fueron aceptadas en 212 casos (78 %). No hubo diferencia significativa en la adherencia a la recomendación por parte del clínico responsable ni con el tipo de recomendación (p = 0,417). Durante el año en que realizó el estudio se redujo la prescripción antibiótica en un 5% en comparación con el año anterior. Conclusiones. La revisión del tratamiento antimicrobiano en pacientes dados de alta de UCI puede ser una estrategia eficiente para mejorar el uso de estos fármacos (AU)