Primary health care policy and vision for community pharmacy and pharmacists in Portugal

The central role of the Portuguese National Health Service (P-NHS) guarantees virtually free universal coverage. Key policy papers, such as the National Health Plan and the National Plan for Patient Safety have implications for pharmacists, including an engagement in medicines reconciliation. These primary health care reform, while not explicitly contemplating a role for pharmacists, offer opportunities for the involvement of primary care pharmacists in medicines management. Primary care pharmacists, who as employees of the P-NHS work closely with an interdisciplinary team, have launched a pilot service to manage polypharmacy in people living with multimorbidities, involving potential referral to community pharmacy. Full integration of community pharmacy into primary health care is challenging due to their nature as private providers, which implies the need for the recognition that public and private health sectors are mutually complementary and may maximize universal health coverage. The scope of practice of community pharmacies has been shifting to service provision, currently supported by law and in some cases, including the needle and syringe exchange program and generic substitution, remunerated. Key changes envisaged for the future of pharmacists and their integration in primary care comprise the development and establishment of clinical pharmacy as a specialization area, peer clinician recognition and better integration in primary care teams, including full access to clinical records. These key changes would enable pharmacists to apply their competence in medicines optimization for improved patient outcomes

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Psicofármacos y riesgo de caídas en ancianos: resultados preliminares del estudio piloto casocontrol anidado en una residencia de ancianos portuguesa / Psychopharmaceuticals and the risk of falls among elderly people: preliminary results of the nested case-control pilot study in a Portuguese care home

Introducción: Las caídas son frecuentes entre los ancianos, los cuales toman muchos medicamentos y algunos de ellos, como los psicofármacos, pueden aumentar el riesgo de caídas. Objetivos: Investigar la relación entre el uso de psicofármacos y la aparición de caídas en pacientes ancianos institucionalizados e identificar los fármacos más utilizados en estos pacientes. Además, se estudió el riesgo asociado al número de psicofármacos que el paciente estaba tomando y el riesgo de caídas que provocaron. Material y métodos: Se realizó un estudio caso-control anidado a partir de una cohorte de pacientes polimedicados internados en una residencia. Los casos fueron pacientes con caídas, entre agosto de 2014 y diciembre de 2015, y los controles aquellos que no cayeron. La exposición a psicofármacos fue investigada en los 2 grupos retrospectivamente. La información fue recogida de la base de datos de la residencia por personal sanitario. El análisis se centró en las OR de caídas por grupo terapéutico, usando un IC de 95%. Resultados: Se analizó una muestra de 22 pacientes, 9 casos y 13 controles: mayoría mujeres, y edad media 82,3 años (DE=6,5). Cada residente tomó una media de 11 medicamentos (DE=4,6). El grupo farmacoterapéutico y el fármaco más utilizados fueron antipsicóticos y quetiapina (59,1%, n=13; 45,5%, n=10, respectivamente). Los OR calculados demuestran no haber ninguna asociación estadísticamente significativa entre los subgrupos terapéuticos y/o fármacos con un elevado riesgo de caídas (p. ej. quetiapina: OR=4.5; IC=0,730-27,739; antipsicóticos atípicos: OR=3,2; IC=0,540-18,980). Conclusión: Como los resultados fueron obtenidos de una muestra limitada, no se demostraron relaciones significativas, aunque sí una clara relación entre el uso de psicofármacos y el riesgo de caídas, identificando aquellos grupos farmacoterapéuticos más influyentes en caídas (AU)

Introduction: Falls are frequent in the elderly, because they take medication that may increase the risk of falls, including psychotropic drugs. Aims: To explore the relationship between the use of psychotropic drugs and the occurrence of falls in institutionalized patients, and to identify the most used drugs in these patients. In addition, it was studied the risk associated with the psychotropic drugs and the risk of falls that they caused. Methods: A nested case-control study was performed from a cohort of polypharmacy patients residing in a nursing home. Cases were those having suffered a fall from August 2014 to December 2015, and controls were those without falls recorded. The exposure of psychoactive drugs was explored retrospectively in both groups. Information was collected in the database of the nursing home. Analysis focused on the odds ratio of falling per pharmacotherapy group, using confidence intervals set at 95%. Results: A sample of 22 patients, 9 cases and 13 controls, was analyzed: most patients were women, and the mean age was 82.3 years (SD=6.45). Residents used a mean of 11 medicines (SD=4.64). The most used pharmaceutical group and drug respectively were antipsychotics and quetiapine (59.1%, n=13; 45.5%, n=10). The OR determined in this study did not evidence any statistically significant association between the pharmacotherapeutic subgroups and/or drugs and increased risk of falling (quetiapine: OR=4.5; IC=0.730-27.739; atypical antipsychotics: OR=3.2; IC=0.540-18.980). Conclusion: Results were obtained in a restricted sample, leading to the incapacity of demonstrating significant associations. However, a trend between the use of psychotropic drugs and the risk of falls in the elderly was shown, identifying the most influential pharmacotherapeutic groups in falls (AU)

Determinants of self-medication with NSAIDs in a Portuguese community pharmacy

Background: Non-steroid anti-inflammatory drugs (NSAIDs) are a widely used therapeutic group in the world, and particularly in the Portuguese population. Objective: To compare NSAID’s use by prescription and self-medication acquisition and to determine the pattern of indication of NSAIDs, their usage profile and possible implications for patients’ safety. Methods: A cross-sectional design was used where individuals presenting at a community pharmacy requesting NSAIDs during the study period (one month) were invited to answer a face-to-face interview where socio-demographic characteristics, the indication pattern and previous experience of side effects were assessed. A follow-up interview was performed one week later to assess the incidence of adverse effects. The study was ethically approved. Results: A sample of 130 NSAIDs users was recruited, comprising mostly women (n=87; 66.9%), actively employed (n=77; 59.2%) and presenting a mean age of 49.5 years old (SD=20.49). An equal proportion of individuals acquired NSAIDs by self-medication and with medical prescription (n=65; 50%). Over 4/5 of patients (n=57; 87.7%) acquiring NSAIDs without a prescription were self-medicated by their own initiative, and only 10.8% (n=7) had been advised by the pharmacist. The most commonly acquired active substances were ibuprofen and diclofenac. Self-medicated users more frequently resorted to topical NSAIDs following short term treatments. The major underlying condition motivating NSAIDs sought were musculoskeletal disorders (45.0%), regardless of the regimen. An important proportion of prevalent users of NSAIDs reported previous experience of adverse effects (11.3%). One week after initiating NSAID therapy, a small proportion of patients reported incidence of adverse effects. Conclusion: Self-medication with NSAIDs is sought for numerous medical conditions. Reported adverse effects (prevalent and incident) confirm the need for a more rational use of NSAIDs and ongoing pharmacovigilance (AU)

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Validation of a survey tool for use in cross-cultural studies

There is a need for tools to measure the information patients need in order for healthcare professionals in general, and particularly pharmacists, to communicate effectively and play an active part in the way patients manage their medicines. Previous research has developed and validated constructs to measure patients' desires for information and their perceptions of how useful their medicines are. It is important to develop these tools for use in different settings and countries so that best practice is shared and is based on the best available evidence. Objectives: this project sought to validate of a survey tool measuring the «Extent of Information Desired» (EID), the «Perceived Utility of Medicines» (PUM), and the «Anxiety about Illness» (AI) that had been previously translated for use with Portuguese patients. Methods: The scales were validated in a patient sample of 596: construct validity was explored in Factor analysis (PCA) and internal consistency analysed using Cronbach’s alpha. Criterion validity was explored correlating scores to the AI scale and patients' perceived health status. Discriminatory power was assessed using ANOVA. Temporal stability was explored in a sub-sample of patients who responded at two time points, using a T-test to compare their mean scores. Results: Construct validity results indicated the need to remove 1 item from the Perceived Harm of Medicines (PHM) and Perceived Benefit of Medicines (PBM) for use in a Portuguese sample and the abandon of the tolerance scale. The internal consistency was high for the EID, PBM and AI scales (alpha>0.600) and acceptable for the PHM scale (alpha=0.536). All scales, except the EID, were consistent over time (p>0.05; p<0.01). All the scales tested showed good discriminatory power. The comparison of the AI scale with the SF-36 indicated good criterion validity (p<0.05). Conclusion: The translated tool was valid and reliable in Portuguese patients- excluding the Tolerance scale. Some of the scales may benefit from further refinement, such as the PHM subscale (AU)

Se necesitan herramientas para medir la información que necesitan los pacientes para que los profesionales de la salud en general, y los farmacéuticos en particular, comuniquen efectivamente y jueguen un papel activo en como los pacientes manejan su medicación. Anteriores estudios han desarrollado instrumentos para medir los deseos de los pacientes de información y sus percepciones sobre la utilidad de los medicamentos. Es importante desarrollar estas herramientas en diferentes escenarios y países para compartir la mejor práctica y que se base en la evidencia disponible. Objetivos: Este proyecto trató validar una herramienta de encuesta que mide la «Cantidad de Información Deseada» (CID), la «Utilidad Percibida de la Medicación» (UPM), y la «Ansiedad sobre la Enfermedad» (AE) que fueron previamente traducidos para el uso con pacientes portugueses. Métodos: Las escalas se validaron en una muestra de 596 pacientes: la validez de constructo fue explorada en un análisis factorial y la consistencia interna se analizó usando un alfa de Cronbach. La validez de criterio se exploró correlacionando las puntuaciones a la escala AE y al estado de salud percibido de los pacientes. El poder discriminante se evaluó utilizando un ANOVA. La estabilidad temporal se exploró en una sub-muestra de pacientes que respondieron en dos momentos, usando un test-T para comparar sus puntuaciones medias. Resultados: La validez de constructo indicó la necesidad de retirar un ítem de Daño Percibido de los Medicamentos (DPM) y de Beneficio Percibido de los Medicamentos (BPM) para el uso en una muestra portuguesa y el abandono de la escala de tolerancia. La consistencia interna fue alta para las escalas CDI, UPM y AE (alfa>0,06) y aceptable para DPM (alfa=0,536). Todas las escalas, excepto CID fueron estables en el tiempo (p>0.05; p<0.01). Todas las escalas probadas mostraron alta capacidad discriminante. La comparación de la escala AE con el SF-36 indicó una buena validez de criterio (p<0,05). Conclusión: La herramienta traducida fue valida y fiable en pacientes portugueses, excluyendo la escala de tolerancia. Algunas de las escalas pueden beneficiarse de un refinamiento posterior, como la sub-escala DPM (AU)

Análisis de la calidad de vida relacionada con la diabetes (ADDQoL) para Portugal: exploración de la validez y la fiabilidad / An Audit of Diabetes Dependent Quality of Life (ADDQoL) for Portugal: exploring validity and reliability

Objetivo: Este artículo describe el proceso realizado para asegurar que un cuestionario de calidad de vida específico para diabetes [el «Audit of Diabetes Dependent Quality of Life» (ADDQoL)] mantiene sus propiedades psicométricas después de una adaptación transcultural del inglés al portugués. Métodos: Usando farmacias comunitarias de Lisboa, se reclutó a 100 pacientes mediante un diseño transversal. Se pidió a los pacientes que respondieran el cuestionario una vez. Se sometió a los datos a un análisis factorial, y se realizaron análisis de consistencia interna y de poder discriminatorio. Resultados: En la muestra portuguesa, 17 ítems se incluyeron en un factor con pesos de más de 0,43. El ítem «preocupaciones sobre el futuro» peso poco en este factor, pero si se retiraba la consistencia interna sufría un muy ligero incremento (alfa de Cronbach=0,89 a 0,90). Se detectó un mayor impacto negativo en 16 de los 18 dominios de calidad de vida para los pacientes tratados con insulina, y también se encontró un mayor impacto negativo en 14 de los 18 dominios en pacientes con complicaciones diabéticas. El dominio «libertad para comer» mostró el mayor impacto negativo en todos los subgrupos de pacientes, tal y como describía la versión original, así que se conservaron las propiedades psicométricas. Además, los pacientes sin complicaciones diabéticas comunicaron peor calidad de vida (mayor impacto negativo) en el primer ítem, calidad de vida actual (Z=-2,25; p=0,024); mientras que los pacientes con insulina comunicaron un mayor impacto negativo de la diabetes en su calidad e vida (Z=-1,94; p=0,053). Conclusión: Generalmente, la versión portuguesa para Portugal del ADDQoL ha demostrado mantener sus propiedades psicométricas originales y podría recomendarse para su uso y posterior evaluación en posteriores estudios (AU)

Objective: This paper describes the processes involved to ensure a diabetes-specific quality of life questionnaire [the «Audit of Diabetes Dependent Quality of Life» (ADDQoL)] retained the psychometric properties following cross-cultural adaptation from English to Portuguese. Methods: One hundred patients were recruited through community pharmacies located in Lisbon through a cross sectional study design. Patients were asked to respond to the questionnaire on one occasion in time. Data were subjected to factor analysis, and internal consistency and discriminatory power analyses were undertaken. Results: In the Portuguese sample, 17 items loaded into one factor, with factor loadings above 0.43. The item «worries about the future» loaded weekly into this factor but if removed its internal consistency estimate increased very slightly (Cronbach's alpha=0.89 to 0.90). A greater negative impact of diabetes on 16 of the 18 quality of life domains was detected for insulin-treated patients, together with a greater negative impact on 14 of the 18 quality of life domains for patients with diabetic complications. The domain «freedom to eat» revealed the greatest negative impact in all patient subgroups, as described in its original version, so the psychometric properties were retained. Additionally, patients without diabetic complications reported a worse quality of life (greater negative impact) on the first overview item, present quality of life (Z=-2.25; p=0.024); whilst patients on insulin reported a greater negative impact of diabetes on their quality of life (Z=-1.94; p=0.053). Conclusion: Generally, the Portuguese version for Portugal of the ADDQoL has shown to maintain its original psychometric properties, and could be recommended for use and further evaluation in subsequent studies (AU)

Como medir (o no medir) la adhesión en el tratamiento de erradicación / How to measure (or not) compliance to eradication therapy

Este estudio tuvo como objetivo probar un novedoso método de medición del cumplimiento en farmacias comunitarias portuguesas con pacientes con Helicobacter pylori. Se utilizó un diseño de serie de casos en los que se medían electrónicamente los indicadores del cumplimiento, a la vez que los informes de los pacientes. También se midieron las reacciones adversas medicamentosas, los beneficios del tratamiento percibidos y la calidad de vida. La proporción media de cumplimiento fue del 56% y se encontró un impacto positivo en el estado de salud percibido e los pacientes. El método utilizado fue bien acogido por los farmacéuticos comunitarios, además de que tuvo una influencia en la actuación normal de los pacientes (AU)

This study aimed to test a novel method of compliance measurement in Portuguese community pharmacy in Helicobacter pylori patients. A case series design was used where compliance indicators were electronically measured, aside with patients’ reports. Experienced adverse drug reactions, perceived benefit of therapy and quality of life were also measured. Mean compliance proportion was 56% and a positive impact on patients’ perceived health status was found. The method used was welcomed by community pharmacists, albeit having an influence on patients normal behaviour (AU)