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4d. Chronic Care: Prescribing Behaviors in Treating Chronic Diseases with Particular Focus on Care of Elderly Patients
Rational Use of Antidepressants Combined with Benzodiazepines
University of Sorocaba, Brazil
Problem statement: Combinations of antidepressants and benzodiazepines are often used to treat major depression and evidence suggests that combination is more effective than monotherapy with antidepressants. However, the benefits of such combination only occur in the beginning of the treatment (up to 4 weeks), reducing by 50% or more depression symptoms and the dropout rate. The prolonged use of combined therapy should be balanced because there is a significant increase in addiction risks, tolerance, propensity to accidents, teratogenicity, and costs.
Objectives: Evaluating the rational use of antidepressants/benzodiazepines combinations in major depression patients who were attended in the public health care system of Porto Feliz, São Paulo State, Brazil, and relating it to risk factors in the development of adverse drug reactions.
Design:Observational, transversal, retrospective, analytical study
Study population:Patients under treatment with antidepressants, whether combined with benzodiazepines or not, from January 2008 to December 2009
Outcome measure: Users’ profile as far as gender, age, comorbidities, and the use of other drugs are concerned and the relationship to the rational use of antidepressants (indication, dose, frequency, duration of use, and safety)
Results: 265 patients were analyzed, namely 86.4% women, 60.7% married, 70.6% between 21 and 59 years of age, 62.3% diagnosed with depression for at least 5 years, 52.8% presenting comorbidities, and 50.6% using other medicines chronically; 1601 prescriptions were made for such patients, namely 53.7% for combined therapy and 42.3% for monotherapy. In monotherapy, fluoxetine at 65.4% and amitriptyline at 17.8% were the most prescribed drugs, and 68.8% of the patients remained under treatment for at least 180 days. In combined therapy, the biggest prevalence was for fluoxetine plus diazepam at 23.7%, fluoxetine plus clonazepam at 14.4% and sertraline plus clonazepam at 11.2%. Only 22.9% of the prescriptions presented a duration of up to 4 weeks. Aproximately 64.4% of patients remained under combined treatment for at least 360 days. Psychotropic polypharmacy was found in 91.4% of prescriptions. Associations prevailed with benzodiazepines at 58.8%, antipsychotics at 19.4%, which resulted in 9% of severe interactions. In 98.8% of cases, the clinical indication justified the prescription and 98% of dosages and frequency were recommended.
Conclusions:Most depressed patients treated by the public health care system usually receive a long, combined therapy treatment. Such a pattern is irrational and inconsistent with recommendations based on evidence, which exposes patients to significant and possibly unnecessary risks.
Funding sources: No funding
Prevalence of and Factors Associated with Potentially Inappropriate Medications Use in the Elderly Population in Thailand
1Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University , Phitsanulok , Thailand; 2School of Population Health, University of Queensland , Brisbane , Australia; 3School of Pharmacy, University of Wisconsin-Madison , Madison , WI , USA; 4Department of Pharmacy, Buddhachinaraj Hospital , Muang, Phitsanulok ,
Problem statement: The elderly population are vulnerable to medical misadventures, as they change in both pharmacokinetics and pharmacodynamics and become disabled and dependent. Older people are more likely to take several medications to treat concomitant diseases and therefore may have an increased risk of adverse drug reactions (drug-drug and drug-disease interactions). Improving prescribing quality in the elderly means reducing inappropriate prescribing, thereby resulting in better health outcomes. It is important to examine the magnitude of potentially inappropriate medication (PIMs) use among elderly and identify factors associated with inappropriate use.
Objective: To determine the prevalence and factors associated with PIMs in the elderly population in Thailand
Design: Retrospective descriptive study
Setting: We retrospectively examined an electronic patient database in a provincial hospital.
Study population: Patients aged 65 years or older who visited the outpatient department in 2008 were included. The outpatient pharmacy database, patient demographic database, and diagnosis database containing ICD-10 were linked using a hospital number.
Intervention: We adopted the criteria for high-risk medication use that was developed by Winit-Watjana and colleagues. The criteria identify PIMs in the Thai context using delphi technique and geriatric medicine expert consensus.
Outcomes measure: Descriptive statistics were used to describe patients’ demographic and determine the prevalence of PIMs among them. Factors associated with the use of PIMs were evaluated using generalized estimating equations.
Results: Of 14,994 elderly patients included in this study, 58% were prescribed at least 1 PIM. The most common PIMs, which are rarely appropriate for elderly patients, were NSAIDs (17%). NSAIDs prescribing with peptic ulcer patients (5%) and NSAIDs prescribing with aspirin (8%) were the most prescribed pairs of drug-disease and drug-drug interaction in elderly Thai patients. The adjusted odd ratio of receiving PIMs was more than triple in elderly patients taking 6-9 medications compared with taking < 5 medications; for more than 10, the value was 6 times. There was an increasing trend of PIMs in patients with higher morbidities (adjusted OR, 5.04; 95% CI, 4.69 – 5.51 for charlsons’ co-morbidities index [CCI] score of 2-3 and adjusted OR, 8.78; 95% CI, 8.86 – 8.90) for CCI > 4, compared to CCI 0-1. PIMs are also a problem for patients with universal coverage (adjusted OR, 1.77; 95% CI, 1.72 – 1.82) and those under the care of prescribers in training (residents or interns; adjusted OR, 1.95; 95% CI, 1.81-2.11).
Conclusions: The prevalence of PIMs in the elderly population was high. Both individual and system factors were associated with PIMs. Careful management is needed especially among those with co-morbidities. Future research is needed to target extended, clinical practice and policy implementation to reduce PIMs.
Funding source: No funding
Effectiveness of a Medical Education Intervention to Treat Hypertension in Primary Care
1Center for Social and Economic Studies on Health. Hospital Infantil de México Federico Gomez.; 2Center for Health Systems Research, Instituto Nacional de Salud Pública.; 3Epidemiology and Health Services Research Unit, Instituto Mexicano del Seguro Social.
Problem statement: In Mexico, hypertension (HT) is among the top five causes for visits to primary care clinics; its complications are among the main causes of emergency and hospital care.
Objectives: To evaluate the effectiveness of a continuing medical education (CME) intervention to improve appropriate care for hypertension and on blood pressure control of hypertensive patients in primary care clinics
Design: A secondary data analysis was carried out using data of hypertensive patients treated by family physicians who participated in the CME intervention. The evaluation was designed as a pre- and post-intervention study with control group in six primary care clinics.
Setting: The study was conducted at a national level in six family medical clinics belonging to the Mexican Institute of Social Security (IMSS), the largest public health care system in Mexico.
Study population: The analysis included 193 patients with hypertension (intervention group: n = 101 patients; control group: n = 92 patients), who were treated by 90 physicians. The patients were recruited and informed consent was obtained from them in the waiting room at the clinic, where trained nurses interviewed them before and after the medical visit. One or two patients per participating family physician were chosen. This was done in accordance with the number of hypertensive patients visiting the clinic during a typical working day.
Intervention(s): The intervention was based on three sequential stages that lasted 3 months. In each setting, a general internal medicine specialist was trained to coordinate the interventions and to work as a clinical instructor. An evidence-based clinical guideline was previously designed and adapted to the family medicine context and served as the groundwork for the intervention.
Outcome measure(s): Proportion of patients with uncontrolled blood pressure in the intervention and control groups at baseline and final stages. The operational definition of uncontrolled blood pressure states that the systolic/diastolic figures should be ≥140/90 mm Hg. The effect of the CME intervention was analyzed using multiple logistic regression modeling in which the dependent variable was uncontrolled blood pressure in the post-intervention patient measurement.
Results: The model results were that being treated by a family physician who participated in the CME intervention reduced by 53% the probability of lack of control of blood pressure [OR=0.47 (95% CI, 0.24–0.90)]; receiving dietary recommendations reduced by 57% the probability of uncontrolled blood pressure [OR=0.43 (95% CI, 0.22–0.87)]. Having uncontrolled blood pressure at the baseline stage increased the probability of lack of control in 166%, [OR=2.66 (95% CI, 1.31–5.38)] and per each unit of increase in body mass index, the lack of control increased 7%, [OR=1.07 (95% CI, 1.001–1.143)].
Conclusions: CME intervention improved the medical decision-making process to manage hypertension, thus increasing the probability that hypertensive patients would have blood pressure under control.
Funding source(s): Information not provided
Patient Behavior When Prescribed Non-Affordable Drugs in University Hospitals of Alexandria, Egypt
Faculty of Medicine, University of Alexandria, Egypt
Problem statement: Increasing drug costs is a constant challenge to health care delivery, and patients respond in turn by employing various cost-reducing strategies. By far, cost-related nonadherence (CRN) is the main strategy described. In Egypt, many factors contribute to a high prevalence of CRN. A careful analysis of these factors should allow better interventional recommendations tailored to the Egyptian community. Inadequate doctor–patient interaction regarding drug costs (DPI) is a major factor in CRN. This study investigates the impact of drug costs on patients’ behavior, most notably CRN, and DPI’s role in minimizing it.
Objectives: (1) Identify cost-reducing strategies, including CRN, employed by chronically-ill patients presenting to Alexandria University Hospitals; (2) examine factors affecting prevalence of CRN; (3) explore impact of better DPI on CRN; and (4) pinpoint best DPI methods that minimized CRN
Design: Cross-sectional study
Setting and population: Study included 5 public hospitals serving all classes and districts of Alexandria. A randomly selected sample of 300 patients aged 18 years or more, treated as either inpatients or outpatients, that are publicly, privately, or noninsured. To be eligible, patients must have used prescription medication during the past 6 months for any of these chronic diseases: hypertension, heart disease, diabetes, depression, chronic lung disease, or chronic liver disease. Data were collected over 4 months via an interviewer-administered questionnaire.
Outcome measures: Frequency of CRN methods; impact of factors such as education, insurance, income, and DPI, on CRN rates; frequency of DPI methods
Results: Data gathered from 300 questionnaires showed that 84% of patients employed at least 1 method of CRN (termed CRN+). Of those, up to 66% postpone buying prescriptions, 58% skip their doses, and 26% ignore buying it altogether. CRN+ patients were then given a score according to the number of different CRN methods used. We found significant relationships between lower CRN scores and higher education (p < .001), better insurance coverage (p < .001), lower values of “drug cost to monthly income” ratios (p = .001), lower number of prescribed drugs (p = .003), and better DPI regarding drug costs (p = .004). Only 54% of CRN+ patients reported having DPI. In CRN = 1 patients who reported having DPI, the most common methods were doctors showing sympathy towards patients’ drug costs (78%), ensuring patients’ affordability of drugs (55%), and mentioning drugs that must not be skipped (50%). And in those who reported not having DPI, the most cited cause was “being embarrassed” to ask about drug costs (75%).
Conclusions: Future policies should focus on improving DPI, a modifiable factor, to lower CRN. Ensuring patient education on drug costs, showing strong emotional support, and reducing polypharmacy can significantly lower CRN. Encouraging patients to ask for cheaper alternatives can also help.
Funding source: Self-funded