Report of a traineeship : audit of antidepressant prescribing in Primary and Mental Care: how to address appropriateness and keep a curb on costs. A tool suitable for all contexts?

RESUMO: Este é o relatório de um estágio realizado na Autoridade de Saúde Local de Bolonha com o objectivo de desenvolver capacidades e competências na área de projectos orientados para a avaliação com base epidemiológica. As prescrições de anti-depressivos aumentaram consideravelmente em todo o mundo durante as últimas décadas. O uso cada vez maior dos agentes mais dispendiosos desempenha um papel na subida do custo dos tratamentos. A Autoridade de Saúde Local de Bolonha implementou um processo de auditoria com o objectivo de melhorar a adequação das prescrições de pacientes externos, centrando-se em dois anti-depressivos de marca ainda protegidos por patente, Escitalopram e Duloxetine. Os Departamentos de Cuidados de Saúde Primários e de Cuidados de Saúde Mental, assim como o Departamento Farmacêutico e a Unidade de Gestão Clínica, estiveram envolvidos na fase de planeamento da auditoria. O grupo da auditoria, maioritariamente composto por médicos de clínica geral e psiquiatras, reuniu e analisou provas da eficácia e segurança dos anti-depressivos. Os dados sobre as prescrições das Unidades de Cuidados de Saúde Primários e dos Centros de Saúde Mental Comunitários da Autoridade de Saúde Local (866.294 habitantes) foram comparados, em particular as taxas de consumo de Escitalopram e Duloxetine. O grupo da auditoria definiu os standards a serem abordados, os indicadores a serem avaliados e as medidas a empreender para atingir os objectivos definidos. As directrizes do NICE sobre a depressão foram escolhidas como referência. O objectivo da auditoria foi definido como evitar o Escitalopram e Duloxetine como medicamentos de primeira escolha num tratamento anti-depressivo. De modo a verificar a eficácia das medidas empreendidas foi seleccionado um indicador, consistindo numa redução de 25% das prescrições de ambos os anti-depressivos na prática clínica de pacientes externos e numa redução de 20% da variabilidade nas Unidades de Cuidados de Saúde Primários. O relatório retrospectivo pré-auditoria (Janeiro a Abril de 2012) revelou que os tratamentos com anti-depressivos para pacientes externos eram prescritos pelos médicos de clínica geral em mais de90% dos casos. As medidas da auditoria foram implementadas entre Novembro de 2012 e Maio de 2013. Algumas medidas relevantes foram integradas com a revisão da auditoria, tais como reuniões educacionais de pequena escala com os médicos de clínica geral e psiquiatras, visitas de apoio do assessor de prescrições da Autoridade de Saúde Local aos médicos de clínica geral e Centros de Saúde Mental Comunitários, panfletos para profissionais com informação retirada das directrizes clínicas do NICE, implementação de um serviço de consulta na Web para médicos de clínica geral sobre provas relativas a anti-depressivos. O relatório de feedback é aguardado em Novembro de 2013 depois de se verificar nos standards atingidos a eficácia das medidas implementadas. Foi realizada uma análise SWOT para comprovar as forças e fraquezas, as oportunidades e ameaças do processo. Como identificação de fraquezas poderá ser útil identificar estratégias relevantes para melhoria interna, para que o conhecimento das ameaças possa amortizar factores que possam ter impactos adversos que fujam ao controlo do Departamento de Saúde Mental. Uma melhor compreensão das forças e das oportunidades facilita a consecução dos objectivos estabelecidos no projecto. O primeiro, mas não o último, resultado deste processo consistiu numa maior integração entre os Cuidados de Saúde Primários e de Saúde Mental, permitindo assim que a Autoridade de Saúde Local coloque as alterações em prática.------------ABSTRACT: This is the report of a traineeship held in the Local Health Authority of Bologna with the aim to develop skills and competencies in the field of epidemiogically based evaluation oriented projects. Antidepressants prescriptions have considerably increased all over the world in the last decades. The increasing use of the most expensive agents plays a part in the rising cost of treatments. The Local Health Authority of Bologna has implemented an audit process aimed at improving the appropriateness of outpatient prescriptions focusing on the two branded antidepressants still protected by patent, Escitalopram and Duloxetine. The Primary Care and the Mental Health Care Departments, as well as the Pharmaceutical Department and the Clinical Governance Unit, were involved in the planning phase of the audit. The audit group, mainly composed of general practitioners and psychiatrists, collected and analyzed scientific evidence on effectiveness and safety of antidepressants. Data on prescriptions of Primary Care Units and Community Mental Health Centers of the Local Health Authority (866.294 inhabitants) were compared, in particular consumption rates of Escitalopram and Duloxetine. The audit group defined the standards to be addressed, the indicators to be evaluated and the actions aimed at reaching the defined goals. NICE guidelines on depression were chosen as reference. The aim of the audit was settled as avoiding Escitalopram and Duloxetine as first choice drugs starting an AD treatment. In order to check the efficacy of the actions undertaken an indicator was selected, consisting in a reduction of 25% of prescriptions of both ADs in outpatient practice and in a 20% reduction of To develop skills and competencies across Primary Care Units. The pre-audit retrospective report (January-April 2012) showed that outpatient antidepressant treatments were prescribed by GPs in over 90% of cases. Audit actions were implemented between November 2012 and May 2013. Some relevant actions have been integrated with the audit review, such as small-scale educational meetings with GPs and psychiatrists, outreach visits of the LHA prescribing adviser to GPs and CMHCs,leaflets for professionals with information extracted from NICE clinical guidelines, implementation of a web consultation service for GPs about evidence on antidepressants. The feedback report is expected in November 2013 after checking through the standards attained the effectiveness of actions implemented. A SWOT Analysis was carried out to evidence the strengths and weaknesses, opportunities and threats of the process. As identification of weaknesses may be useful to identify relevant strategies for internal improvement, so the knowledge of threats can amortize factors that may have adverse impacts beyond the control of the Mental Health Department. Better understanding of the strengths and the opportunities facilitates the achievement of the goals set in the project. The first and not least upshot of this process has consisted in further integration between Primary and Mental Health Care, thus enabling the LHA to put the change into practice.

Wind Power in the Portuguese Landscape: Global Concerns and Local Costs

Wind turbines and solar panels are becoming second nature in Portugal, as its occurrence in the country becomes ubiquitous. Somehow, one could argue that renewable energy in Portugal is in the process of ‘naturalisation’ as part of a new – mechanised, but environmentally benign – landscape. Portuguese Institute for the Conservation of Nature and Biodiversity (ICNB) has shown an ambiguous stance on this issue, defending global concerns towards renewable energy, while at the same time attempting to engage locals in the preservation of extensive ‘classified areas’. In the course of this research, we tried to focus on these incongruities and to analyse how they are impacting local communities during the process of wind power installation.

How much cultural events are "worth" for host communities: Case of Faz Música Lisboa

This paper studies the economic and social impact of Faz Música Lisboa on the segment of society that feels from any direct or indirect consequence due to its existence. A qualitative research based on surveys and interviews is made to retract a list of the benefits and costs that each stakeholder perceives. Relying on the quantifiable variables, it is performed a cost-benefit analysis to measure how much the event is “worth” for the community. I conclude this is a viable project, as it brings a positive net benefit to the society, value that could increase with a higher institutional support.

Competition policy costs to firms

The existence of competition policy forces companies to adjust their behaviour. This is also costly. Using a database from a company on contracts, I will try to estimate if a specific competition policy disposition, supply contracts cannot be longer than 60 months, has costs for the coffee suppliers operating in the Portuguese “on-trade” coffee market. The estimation method used in this paper will be OLS. The results suggest that limiting the duration of exclusivity contracts to 60 months can be harmful to the coffee suppliers and it can even seriously affect the market functioning. Key

Healthcare- Associated infections: An analysis of costs in a Portuguese Hospital

Hospital-acquired infections (HAIs) delay healing, prolong Hospital stay, and increase both Hospital costs and risk of death. This study aims to estimate the extra length of stay and mortality rate attributable to each of the following HAIs: wound infection (WI); bloodstream infection (BSI); urinary infections (UI); and Hospital-acquired pneumonia (HAP). The study population consisted of patients discharged in CHLC in 2014. Data was collected to identify demographic information, surgical operations, development of HAIs and its outputs. The study used regressions and a matched strategy to compare cases (infected) and controls (uninfected). The matching criteria were: age, sex, week and type of admission, number of admissions, major diagnostic category and type of discharge. When compared to matched controls, cases with HAI had a higher mortality rate and greater length of stay. WI related to hip or knee surgery, increased mortality rate by 27.27% and the length of stay by 74.97 days. WI due to colorectal surgery caused an extra mortality rate of 10.69% and an excess length of stay of 20.23 days. BSI increased Hospital stay by 28.80 days and mortality rate by 32.27%. UI caused an average additional length of stay of 19.66 days and risk of death of 12.85%. HAP resulted in an extra Hospital stay of 25.06 days and mortality rate of 24.71%. This study confirms the results of the previous literature that patients experiencing HAIs incur in an excess of mortality rates and Hospital stay, and, overall, it presents worse results comparing with other countries.

Ethical leadership and reputation: Combined indirect effects on organizational deviance

This is a pre-copyedited, author-produced PDF of an article accepted for publication in Journal of Business Ethics following peer review. The version of record Neves, P., & Story, J. (2015). Ethical Leadership and Reputation: Combined Indirect Effects on Organizational Deviance. Journal of Business Ethics, 127(1), 165–176. “The final publication is available at Springer via http://dx.doi.org/10.1007/s10551-013-1997-3”.

Firing and training costs and labour market segmentation

This dissertation consists of three essays on the labour market impact of firing and training costs. The modelling framework resorts to the search and matching literature. The first chapter introduces firing costs, both liner and non-linear, in a new Keynesian model, analysing business cycle effects for different wage rigidity degrees. The second chapter adds training costs in a model of a segmented labour market, accessing the interaction between these two features and the skill composition of the labour force. Finally, the third chapter analyses empirically some of the issues raised in the second chapter.

Context costs and comparative advantages in the telecommunications sector in Portugal and China

This Work Project aims to discuss the Context Costs and Comparative Advantages of the Telecommunications sector both in Portugal and China. The work was built mostly on primary research by interviews with relevant people (business persons, University Professors and Agencies directors), and by economic data publicly available. A list of context costs and comparative advantages was drawn for each country and possible resolutions suggestions were made in the end. The context costs depend heavily on the economic situation of the countries and it should be taken into account when assessing the degree of magnitude of each cost of context. The competitive advantages of each country were drawn in comparison with one another. Some key results stand out: firstly, Portugal’s costs of context depend mainly on governmental decisions, uncertainties and instability and China’s cost of context depend primarily on cultural norms, mainly the Guanxi; second, the telecommunications sector shares most of its context costs and advantages with other sectors; third, China as an economic power could use the telecommunications sector as a way to further develop and boost its economy.