Impact of a multidisciplinary medication reconciliation program on clinical outcomes: A pre-post intervention study in surgical patients.

BACKGROUND: Previous studies have evaluated the effects of medication reconciliation (MR) and suggest that it is effective in decreasing medication discrepancies. Nevertheless, a recent overview of systematic reviews concluded that there is no clear evidence in favor of MR in patient-related outcomes and healthcare utilization, and further research about it is needed. OBJECTIVE: To evaluate the impact of a multidisciplinary MR program on clinical outcomes in patients with colorectal cancer presenting other chronic diseases, undergoing elective colorectal surgery. METHODS: We performed a pre-post study. Adult patients scheduled for elective colorectal cancer surgery were included if they presented at least one "high-risk" criteria. The MR program was developed by internists, pharmacists and surgeons, and ended with the obtention of the patient's pre-admission medication list and follow-up care until discharge. The primary outcome was the length of stay (LOS). Secondly, we evaluated mortality, preventable surgery cancellations and risk factors for complications. RESULTS: Three hundred and eight patients were enrolled. Only one patient in the pre-intervention group suffered a preventable surgery cancellation (p = 0.317). The mean LOS was 13 ± 12 vs. 11 ± 5 days in the pre-intervention and the intervention cohort, respectively (p = 0.435). A difference in favor of the intervention group in patients with cardiovascular disease (p = 0.038) and those >75 years old (p = 0.043) was observed. No difference was detected in the mortality rate (p = 0.999) neither most of the indicators of risk factors for complications. However, the management of preoperative systolic blood pressure of hypertensive patients (p = 0.004) and insulin reconciliation in patients with treated diabetes (p = 0.003) were statistically better in the intervention group. CONCLUSIONS: No statistically significant change was observed in the mean global LOS. A statistically significant positive effect on LOS was observed in vulnerable populations: patients >75 years old and those with cardiovascular disease, who presented a 5-day reduction in the mean LOS.

Estratificación pronóstica y abordaje asistencial de los pacientes pluripatológicos / Prognostic stratification and healthcare approach in patients with multiple pathologies

Los pacientes pluripatológicos constituyen una población prevalente y homogénea, caracterizada por su complejidad clínica, vulnerabilidad, consumo de recursos y mortalidad que requiere una asistencia integral y coordinada. Establecer un pronóstico certero en esta población resulta de utilidad para la toma de decisiones clínicas por parte de los profesionales, la planificación de las preferencias de pacientes y familiares, y el diseño de estrategias en el ámbito de la gestión sanitaria. También es importante para la investigación clínica, al facilitar la posible incorporación de estos pacientes a ensayos clínicos y otros estudios de intervención. Los índices PROFUND y PROFUNCTION son 2 instrumentos pronósticos que predicen de manera fidedigna el riesgo de fallecer o de sufrir un deterioro funcional, respectivamente. Para el abordaje asistencial de los pacientes pluripatológicos se propugna la construcción y ejecución de un plan de acción personalizado, consensuado y adaptado a la realidad del paciente. Este tendrá en cuenta el pronóstico, la evidencia y viabilidad de las intervenciones, así como la sinergia de las metas y estrategias del equipo sanitario con los valores y las preferencias de las personas para conseguir un modelo de salud centrado en apoyar la capacidad de las mismas para gestionar sus enfermedades. En este plan los principales ámbitos de intervención son: la promoción y prevención de la salud, la activación y autogestión del paciente y el cuidador, la red de apoyo social, la optimización farmacoterapéutica, la rehabilitación y medidas de preservación funcional y cognitiva, y la planificación anticipada de decisiones (AU)

Polypathological patients constitute a prevalent, fairly homogeneous population, which is characterised by high clinical complexity, substantial vulnerability and significant resource consumption, in addition to high mortality and the need for comprehensive, coordinated care. It is particularly important to establish a reliable prognosis in these patients. It is also extremely useful for professionals involved in the decision-making process for patients and their families in vital planning and their preferences, for strategic health planning in management fields, and for clinical research, by facilitating their incorporation into clinical trials and other intervention studies. Two prognostic instruments stand out in terms of suitability for polypathological patients: PROFUND and PROFUNCTION. The former faithfully stratifies the risk of dying at 12 months and four years and the latter, the risk of suffering a significant functional deterioration at 12 months. In terms of the healthcare approach in patients with multiple pathologies, creating and executing a consensual, personalised action plan that is adapted to the patient's reality is encouraged. The plan will consider the prognosis, and the evidence and viability of interventions; its ultimate aim will be to ensure the synergy and alignment of the health team's goals and strategies with peoples’ values and preferences, in order to achieve a more proactive health model focused on supporting patients in their ability to manage their illnesses. In the personalised action plan, the main areas of intervention are: health promotion and prevention; patient and caregiver activation and self-management; activation of a social support network and social support; optimisation of pharmacotherapy; rehabilitation, functional and cognitive preservation measures; and anticipated decision planning (AU)

Prognostic stratification and healthcare approach in patients with multiple pathologies. / Estratificación pronóstica y abordaje asistencial de los pacientes pluripatológicos.

Polypathological patients constitute a prevalent, fairly homogeneous population, which is characterised by high clinical complexity, substantial vulnerability and significant resource consumption, in addition to high mortality and the need for comprehensive, coordinated care. It is particularly important to establish a reliable prognosis in these patients. It is also extremely useful for professionals involved in the decision-making process for patients and their families in vital planning and their preferences, for strategic health planning in management fields, and for clinical research, by facilitating their incorporation into clinical trials and other intervention studies. Two prognostic instruments stand out in terms of suitability for polypathological patients: PROFUND and PROFUNCTION. The former faithfully stratifies the risk of dying at 12 months and four years and the latter, the risk of suffering a significant functional deterioration at 12 months. In terms of the healthcare approach in patients with multiple pathologies, creating and executing a consensual, personalised action plan that is adapted to the patient's reality is encouraged. The plan will consider the prognosis, and the evidence and viability of interventions; its ultimate aim will be to ensure the synergy and alignment of the health team's goals and strategies with peoples' values and preferences, in order to achieve a more proactive health model focused on supporting patients in their ability to manage their illnesses. In the personalised action plan, the main areas of intervention are: health promotion and prevention; patient and caregiver activation and self-management; activation of a social support network and social support; optimisation of pharmacotherapy; rehabilitation, functional and cognitive preservation measures; and anticipated decision planning.

Validation of PROFUND prognostic index over a four-year follow-up period.

BACKGROUND/OBJECTIVES: The PROFUND index stratifies accurately the 12-month mortality risk of polypathological patients (PPs), but its fitness over a longer follow-up period remains unknown. We aimed to explore the calibration and discrimination power of PROFUND index over 4-years, in order to assess its follow-up interval generalizability. DESIGN: Multicenter prospective cohort-study. SETTING: 33 Spanish hospitals. PARTICIPANTS: PPs included after hospital discharge, outpatient clinics, or home hospitalization. MEASUREMENTS: Mortality over a 4-year follow-up period. METHODS: PROFUND index calibration was assessed by risk-quartiles predicted/observed mortality (Hosmer-Lemeshow goodness-of-fit test), and its discrimination power by ROC curves. RESULTS: A total of 768 patients were included (630 [82%] of them completed the 4-year follow-up). Global mortality rate was 63.5%. When assessing individual patient scores, mortality was 52% in the lowest risk group (0-2 points in PROFUND score); 73.5% in the low-intermediate risk group (3-6 points), 85% in the intermediate-high group (7-10 points); and 92% in the highest risk group (≥11 points). Accuracy testing of the PROFUND index showed good calibration (P=.8 in the Hosmer-Lemeshow goodness-of-fit test), and also a good discrimination power (AUC=0.71 [0.67-0.77] in ROC curve). CONCLUSIONS: The PROFUND index maintained its accuracy in predicting mortality of polypathological patients over a 4-year follow-up period. This index may be of potential usefulness in deciding the most appropriate health-care interventions in populations with multimorbidity.

Recalibración del Palliative Prognostic Index en pacientes con enfermedades médicas avanzadas / Adaptation of the Palliative Prognostic Index in patients with advanced medical conditions

Objetivo. Analizar el rendimiento del Palliative Prognostic Index (PPI) en los pacientes con enfermedades médicas en estadio avanzado, y recalibrarlo para adaptarlo al perfil de estos pacientes. Métodos. Estudio prospectivo observacional multicéntrico. Se incluyeron pacientes con una o más enfermedades médicas avanzadas. Se analizó la calibración (bondad de ajuste de Hosmer-Lemeshow) y el poder discriminativo (curva ROC y área bajo la curva [AUC]) del PPI en la predicción de la mortalidad a los 180 días. La recalibración se llevó a cabo analizando las puntuaciones en el PPI de cada cuartil ascendente de probabilidad de fallecer. Se comparó la precisión del PPI con la obtenida con el índice de Charlson. Resultados. La mortalidad global de los 1.788 pacientes fue del 37,5%. La calibración en la predicción de mortalidad fue buena (bondad de ajuste con p=0,21), oscilando la probabilidad pronosticada entre 0-0,25 en el primer cuartil de riesgo, y 0,48-0,8 en el último cuartil. El poder discriminativo fue aceptable (AUC=0,69; p<0,0001). En los grupos recalibrados, la mortalidad de los pacientes con 0/1-2/2,5-9,5 >=10 puntos fue del 13, 23, 39 y 68%, respectivamente. La sensibilidad y el valor predictivo negativo del punto de corte de la escala por encima de 0 fueron 96 y 87%, respectivamente; la especificidad y el valor predictivo positivo del punto de corte de la escala por encima de 9,5 fueron del 95 y 68%. La calibración del índice de Charslon fue buena (p=0,2), y el poder discriminativo subóptimo (AUC=0,52; p=0,06). Conclusiones. El PPI en los pacientes con enfermedades médicas en estadio avanzado puede ser de utilidad para el pronóstico de supervivencia a 6 meses (AU)

Objective. To analyze the accuracy of the Palliative Prognostic Index (PPI) in patients with advanced medical diseases and to recalibrate it in order to adapt it to the profile of these patients. Methods. Multicenter, prospective, observational study that included patients with one or more advanced medical diseases. Calibration (Hosmer-Lemeshow goodness of fit) and discriminative power (ROC and area under the curve [AUC]) of PPI were analyzed in the prediction of mortality at 180 days. Recalibration was carried out by analyzing the scores on the PPI of each quartile upward of dying probability. Accuracy of PPI was compared with that obtained for the Charlson index. Results. Overall mortality of the 1.788 patients was 37.5%. Calibration in the prediction of mortality was good (goodness of fit with P=.21), the prognostic probabilities ranging from 0-0,25 in the first quartile of risk and from 0,48-0,8 in the last quartile. Discriminative power was acceptable (AUC=69; P=.0001). In recalibrated groups, mortality of patients with 0/1-2/2.5-9.5/>=10 points was 13, 23, 39 and 68%, respectively. Sensitivity (S) and negative predicative value (NPF) of the cutoff point above 0 points were 96 and 87%, respectively; while specificity (sp) and positive predictive value (PPV) of the cutoff point above 9.5 points were 95 and 68%. Calibration of the Charlson index was good (P=.2), and its discriminative power (AUC=.52; P=.06) was suboptimal. Conclusions. PPI can be a useful tool in predicting 6-month survival of patients with advanced medical conditions (AU)

Adaptation of the Palliative Prognostic Index in patients with advanced medical conditions.

OBJECTIVE: To analyze the accuracy of the Palliative Prognostic Index (PPI) in patients with advanced medical diseases and to recalibrate it in order to adapt it to the profile of these patients. METHODS: Multicenter, prospective, observational study that included patients with one or more advanced medical diseases. Calibration (Hosmer-Lemeshow goodness of fit) and discriminative power (ROC and area under the curve [AUC]) of PPI were analyzed in the prediction of mortality at 180 days. Recalibration was carried out by analyzing the scores on the PPI of each quartile upward of dying probability. Accuracy of PPI was compared with that obtained for the Charlson index. RESULTS: Overall mortality of the 1.788 patients was 37.5%. Calibration in the prediction of mortality was good (goodness of fit with P=.21), the prognostic probabilities ranging from 0-0,25 in the first quartile of risk and from 0,48-0,8 in the last quartile. Discriminative power was acceptable (AUC=69; P=.0001). In recalibrated groups, mortality of patients with 0/1-2/2.5-9.5/≥10 points was 13, 23, 39 and 68%, respectively. Sensitivity (S) and negative predicative value (NPF) of the cutoff point above 0 points were 96 and 87%, respectively; while specificity (sp) and positive predictive value (PPV) of the cutoff point above 9.5 points were 95 and 68%. Calibration of the Charlson index was good (P=.2), and its discriminative power (AUC=.52; P=.06) was suboptimal. CONCLUSIONS: PPI can be a useful tool in predicting 6-month survival of patients with advanced medical conditions.

Development of a new predictive model for polypathological patients. The PROFUND index.

BACKGROUND: There is a concern about the accuracy of the available prognostic indexes when applying them to the emergent population of polypathological patients (PP). METHODS: To develop a 1-year mortality predictive index on PP, we developed a multicenter prospective cohort-study recruiting 1.632 PP after hospital discharge, outpatient clinics, or home hospitalization, from 33 hospitals. Potential risk factors were obtained in the 1.525 PP who completed follow-up. Each factor independently associated with mortality in the derivation cohort (757 PP from western hospitals) was assigned a weight, and risk scores were calculated by adding the points of each factor. Accuracy was assessed in the validation cohort (768 PP from eastern hospitals) by risk quartiles calibration, and discrimination power, by ROC curves. Finally, accuracy of the index was compared with that of the Charlson index. RESULTS: Mortality in the derivation/validation cohorts was 35%/39.5%, respectively. Nine independent mortality predictors were identified to create the index (age ≥85 years, 3 points; No caregiver or caregiver other than spouse, 2 points; active neoplasia, 6 points; dementia, 3 points; III-IV functional class on NYHA and/or MRC, 3 points; delirium during last hospital admission, 3 points; hemoglobinemia <10 g/dl, 3 points; Barthel index <60 points, 4 points; ≥4 hospital admissions in last 12 months, 3 points). Mortality in the derivation/validation cohorts was 12.1%/14.6% for patients with 0-2 points; 21.5%/31.5% for those with 3-6 points; 45%/50% for those with 7-10 points; and 68%/61.3% for those with ≥11 points, respectively. Calibration was good in derivation/validation cohorts, and discrimination power by area under the curve was 0.77/0.7. Calibration of the Charlson index was good, but discrimination power was suboptimal (area under the curve, 0.59). CONCLUSIONS: This prognostic index provides an accurate and transportable method of stratifying 1-year death risk in PP.

A multi-institutional, hospital-based assessment of clinical, functional, sociofamilial and health-care characteristics of polypathological patients (PP).

Little is known about the main features of the emergent population of PP. Our objective was to determine the clinical, care and social characteristics of a multi-institutional population of PP, by means of a cross-sectional study including a reference population of hospital-based PP from 36 hospitals. The main clinical, functional, mental and social features and their associated factors were assessed: 1632 PP (53% males, mean age 77.9±9.8 years) were included. An informal caregiver was required by 52% (78% of caregivers were close female relatives). The mean inclusion criteria (Cat): were 2.7±0.8 (49.5% presented ≥3 Cat). The most frequent inclusion Cat were heart (77.5%), lung (45.6%), neurological (38.2%), and kidney diseases (32.2%), whereas the mean of other comorbidities was 4.5±2.7 per PP. The mean Charlson comorbidity index (CCI) was 4; 47.6%, and 52.4% presented dyspnea ≥3 on the NYHA, and on the MRC, respectively; nearly 19% required home oxygen therapy, 19% had suffered >1 fall in previous year, and 11% suffered an active neoplasia. The mean hospital admissions in last 12/3 months, and chronically prescribed drugs were 2/1, and 8±3, respectively. More than 70% presented obesity, while 60% had hypoalbuminemia. The basal/inclusion Barthel index (BI) score was 69±31/58±34 (BI score<60 was present in 31.5%/44%, respectively); and the mean Pfeiffer score was 2.94±3.2 (43% answered with ≥3 errors). More than half of the subjects were at risk or already had established social problems. This emergent population is considerably homogeneous, highly complex, clinically vulnerable, functionally impaired, dependent on caregivers and socially fragile. They need to receive more attention in clinical research and more support in health interventions based on comprehensive attention and continuity of care.

[Medication errors and non-compliance in polymedicated elderly patients]. / Errores de medicación e incumplimiento terapéutico en ancianos polimedicados.

OBJECTIVE: To detect and describe medication errors and adherence to therapy in polymedicated (> 5 drugs) elderly patients (> 65 years). METHOD: A descriptive, observational study using a phone survey to polymedicated elderly outpatients. Sociodemographic, clinical, and pharmacotherapeutic data were collected, as well as information on their functional and mental capability. The number, type and severity of medication errors were measured, as was non-adherence. RESULTS: Errors were detected in 42.5% of 73 responders, with a total of 55 errors, and a mean 1.77 errors per patient. Most commonly found errors included inappropriate administration frequency and therapeutic duplicity. Regarding adherence, 43.8% were non-compliants, being sporadic in 68.8% and sequential in 31.2% of the cases. A positive relationship between error number and drug number or adherence was found. CONCLUSIONS: Actions are required from a multidisciplinary standpoint to reduce this high percentage of errors.

Errores de medicación e incumplimiento terapéutico en ancianos polimedicados / No disponible

Objetivo: Detectar y describir los errores de medicación y laadherencia al tratamiento en ancianos (> 65 años) y polimedicados(> 5 fármacos).Método: Estudio observacional, descriptivo, llevado a cabomediante cuestionario telefónico a una muestra de pacientesancianos y polimedicados no ingresados. Se recogieron datossociodemográficos y la capacidad funcional y mental, datos clínicosy farmacoterapéuticos. Se midió el número, tipo y gravedadde los errores de medicación y la adherencia.Resultados: Se detectó algún error en el 42,5% de los 73pacientes entrevistados, con un total de 55 errores, media de1,77 errores por paciente. Los errores más frecuentes fueron losde frecuencia de administración incorrecta y duplicidad terapéutica.En cuanto a la adherencia se detectó un 43,8% de incumplimiento,siendo esporádico en un 68,8% y secuencial en un31,2%. Se encontró una relación positiva entre el número deerrores y el número de medicamentos o la adherencia.Conclusiones: Es necesario, desde un punto de vista multidisciplinar,realizar actuaciones encaminadas a disminuir este altoporcentaje de errores

Objective: To detect and describe medication errors andadherence to therapy in polymedicated (> 5 drugs) elderly patients(> 65 years).Method: A descriptive, observational study using a phone surveyto polymedicated elderly outpatients. Sociodemographic, clinical,and pharmacotherapeutic data were collected, as well asinformation on their functional and mental capability. The number,type and severity of medication errors were measured, as wasnon-adherence.Results: Errors were detected in 42.5% of 73 responders, witha total of 55 errors, and a mean 1.77 errors per patient. Mostcommonly found errors included inappropriate administration frequencyand therapeutic duplicity. Regarding adherence, 43.8%were non-compliants, being sporadic in 68.8% and sequential in31.2% of the cases. A positive relationship between error numberand drug number or adherence was found.Conclusions: Actions are required from a multidisciplinarystandpoint to reduce this high percentage of errors

[Malignant syphilis in patient with human immunodeficiency virus (HIV): case report and literature review]. / Sífilis maligna en el paciente infectado por el virus de la inmunodeficiencia humana (VIH): descripción de un caso y revision de la literatura.

Malignant syphilis is an infrequent manifestation of syphilis in HIV infected patients. Only 21 cases have been published in medical literature. Most frequent in men, 62%, the mean age of presentation is 34 years. The most frequent symptoms are: 100% ulcerative cutaneous lesions, 47% fever and 33% ocular affectation. About 80% of the patients have a CD4 count >200. Lues serological test was 100% positive and 81% responded to penicillin. We report a 18 year old woman diagnosed of HIV infection, admitted to our service because of fever, painful oral sores, over-elevated eritematous lesions and cratered ulcers all over the body, with the initial suspicion of chickenpox. Lues serology turned out to be positive, as well as the Warthin Starry stain. After penicillin treatment was initiated, skin lesions improved, although residual lesions currently persist. Malignant syphilis should be considered in infected HIV patients with fever and ulcerated skin injuries as a possible diagnosis. Eventhough serological tests allow diagnosis confirmation, Warthin Starry stain can be useful when serology is negative. The first choice of treatment is penicillin and in case of penicillin allergy, a third generation cefalosporine should be used.

Sífilis maligna en el paciente infectado por el virus de la inmunodeficiencia humana (VIH):descripción de un caso y revisión de la literatura / Malignant syphilis in patient with human immunodeficiency virus (HIV): case report and literature review

La sífilis maligna es una manifestación infrecuente de la sífilis en personas infectadas por el VIH. Sólo existen 21 casos publicados en la literatura. Con un 62 por ciento de predominio en hombres, la edad media de presentación es de 34 años. Los síntomas predominantes son lesiones cutáneas ulceradas en el 100 por ciento de los casos, fiebre en el 47 por ciento y afectación ocular en el 33 por ciento. El 80 por ciento tienen CD4 >200. La serología luética resultó positiva en todos los casos y el 81 por ciento respondieron a penicilina.Presentamos el caso de una mujer de 18 años, diagnosticada de infección VIH, que ingresa por fiebre, úlceras orales dolorosas, lesiones eritematosas sobreelevadas y úlceras con crater por todo el cuerpo, con la sospecha inicial de varicela. La serología luética resultó positiva, así como la tinción de Warthin Starry. Tras la instauración de tratamiento con penicilina mejoraron las lesiones, aunque persisten lesiones residuales cutáneas en la actualidad. En pacientes infectados por el VIH con fiebre y lesiones cutáneas ulceradas hay que considerar la sífilis maligna entre las posibilidades diagnósticas. Aunque los test serologicos permiten confirmar el diagnóstico, la tinción de Warthin Starry puede ser de utilidad cuando la serología es negativa. El tratamiento de primera elección es la penicilina y en caso de alergia una cefalosporina de tercera generación (AU)

Malignant syphilis is an infrequent manifestation of syphilis in HIV infected patients. Only 21 cases have been published in medical literatu re. Most frequent in men, 62%, the mean age of presentation is 34 years. The most frequent symptoms are: 100% ulcerative cutaneous lesions, 47% fever and 33% ocular affectation. About 80% of the patients have a CD4 count >200. Lues serological test was 100% positive and 81% responded to penicillin. We report a 18 year old woman diagnosed of HIV infection, admitted to our service because of fever, painful oral sores, over-elevated eritematous lesions and cratered ulcers all over the body, with the initial suspicion of chikenpox. Lues serology turned out to be positive, as well as the Warthin Starry stain. After penicillin treatment was initiated, skin lesions improved, although residual lesions currently persist. Malignant syphilis should be considered in infected HIV patients with fever and ulcerated skin injuries as a possible diagnosis. Even though serological tests allow diagnosis confirmation, Warthin Starry stain can be useful when serology is negative. The first choice of treatment is penicillin and in case of penicillin allergy, a third generation cefalosporine should be used (AU)