Incidence and Predictors of Adverse Drug Reactions Caused by Drug-Drug Interactions in Elderly Outpatients: A Prospective Cohort Study

Purpose. The primary objective of this study was to investigate the incidence of drug-drug interactions (DDIs) related to adverse drug reactions (ADRs) in elderly outpatients who attended public primary healthcare units in a southeastern region of Brazil. The secondary objective was to investigate the possible predictors of DDI-related ADRs. Methods. A prospective cohort study was conducted between November 1, 2010, and November 31, 2011, in the primary public healthcare system in the Ourinhos micro-region in Brazil. Patients who were at least 60 years old, with at least one potential DDI, were eligible for inclusion in the study. Eligible patients were assessed by clinical pharmacists for DDI-related ADRs for 4 months. The causality of DDI-related ADRs was assessed independently by four clinicians using three decisional algorithms. The incidence of DDI-related ADRs during the study period was calculated. Logistic regression analysis was used to study DDI-related ADR predictors. Results. A total of 433 patients completed the study. The incidence of DDI-related ADRs was 6.5%. A multivariate analysis indicated that the adjusted odds ratios (ORs) rose from 0.91 (95% confidence interval [CI] = 0.75-1.12, p = 0.06) in patients aged 65-69 years to 4.40 (95% CI = 3.00-6.12, p < 0.01) in patients aged 80 years or older. Patients who presented two to three diagnosed diseases presented lower adjusted ORs (OR = 0.93 [95% CI = 0.68-1.18, p = 0.08]) than patients who presented six or more diseases (OR = 1.12 [95% CI = 1.02-2.01, p < 0.01]). Elderly patients who took five or more drugs had a significantly higher risk of DDI-related ADRs (OR = 2.72 [95% CI = 1.92-3.12, p < 0.01]) than patients who took three to four drugs (OR = 0.93 [95% CI = 0.74-1.11, p = 0.06]). No significant difference was found with regard to sex (OR = 1.08 [95% CI 0.48-2.02, p = 0.44]). Conclusion. The incidence of DDI-related ADRs in elderly outpatients was significant, and most of the events presented important clinical consequences. Because clinicians still have difficulty managing this problem, highlighting the factors that increase the risk of DDI-related ADRs is essential. Polypharmacy was found to be a significant predictor of DDI-related ADRs in our sample.

Avaliação do processo de acolhimento em Saúde Mental na região centro-oeste do município de São Paulo: a relação entre CAPS e UBS em análise

Este trabalho relata a experiência de avaliação do acolhimento em saúde mental na cidade de São Paulo-SP, utilizando entrevistas com trabalhadores de um Centro de Atenção Psicossocial (CAPS) e duas Unidades Básicas de Saúde (UBS). Objetivou entender o acolhimento, considerando a percepção dos trabalhadores e identificando o vínculo e a articulação da rede nesse processo. Utilizou-se como método a hermenêutica filosófica, para identificar que elementos participantes do processo de acolhimento poderiam ser destacados. Procedeu-se à análise das narrativas a partir de três linhas de argumentação: vínculo, acolhimento e articulação da rede - resultando em quatro categorias: sensação de ausência; mistura de modelos; primazia em tecnologias duras; e ineficiência quanto à integralidade. A discussão apontou uma imbricação dessas categorias, colocando o investimento em tecnologias leves como centro do debate para a superação da sensação de ausência, da mistura dos modelos e para construção da integralidade do cuidado.

Cancer diagnosis disclosure from Portuguese physicians

OBJECTIVE: Doctor-patient communication in oncology, particularly concerning diagnostic disclosure, is a crucial factor related to the quality of the doctor-patient relationship and the psychological state of the patient. The aims of our study were to investigate physicians' opinions and practice with respect to disclosure of a cancer diagnosis and to explore potential related factors. METHOD: A self-report questionnaire developed for our study was responded to by 120 physicians from Coimbra University Hospital Centre and its primary healthcare units. RESULTS: Some 91.7% of physician respondents generally disclosed a diagnosis, and 94.2% were of the opinion that the patient knowing the truth about a diagnosis had a positive effect on the doctor-patient relationship. A need for training about communicating with oncology patients was reported by 85.8% of participants. The main factors determining what information to provide to patients were: (1) patient intellectual and cultural level, (2) patient desire to know the truth, and (3) the existence of family. SIGNIFICANCE OF RESULTS: Our results point to a paradigm shift in communication with cancer patients where disclosure of the diagnosis should be made part of general clinical practice. Nevertheless, physicians still experience difficulties in revealing cancer diagnoses to patients and often lack the skills to deal with a patient's emotional responses, which suggests that more attention needs to be focused on communication skills training programs.

Cancer diagnosis disclosure from Portuguese physicians

OBJECTIVE: Doctor-patient communication in oncology, particularly concerning diagnostic disclosure, is a crucial factor related to the quality of the doctor-patient relationship and the psychological state of the patient. The aims of our study were to investigate physicians' opinions and practice with respect to disclosure of a cancer diagnosis and to explore potential related factors. METHOD: A self-report questionnaire developed for our study was responded to by 120 physicians from Coimbra University Hospital Centre and its primary healthcare units. RESULTS: Some 91.7% of physician respondents generally disclosed a diagnosis, and 94.2% were of the opinion that the patient knowing the truth about a diagnosis had a positive effect on the doctor-patient relationship. A need for training about communicating with oncology patients was reported by 85.8% of participants. The main factors determining what information to provide to patients were: (1) patient intellectual and cultural level, (2) patient desire to know the truth, and (3) the existence of family. SIGNIFICANCE OF RESULTS: Our results point to a paradigm shift in communication with cancer patients where disclosure of the diagnosis should be made part of general clinical practice. Nevertheless, physicians still experience difficulties in revealing cancer diagnoses to patients and often lack the skills to deal with a patient's emotional responses, which suggests that more attention needs to be focused on communication skills training programs.

A telematic platform towards regional connected healthcare

As tecnologias de informação e comunicação na área da saúde não são só um instrumento para a boa gestão de informação, mas antes um fator estratégico para uma prestação de cuidados mais eficiente e segura. As tecnologias de informação são um pilar para que os sistemas de saúde evoluam em direção a um modelo centrado no cidadão, no qual um conjunto abrangente de informação do doente deve estar automaticamente disponível para as equipas que lhe prestam cuidados, independentemente de onde foi gerada (local geográfico ou sistema). Este tipo de utilização segura e agregada da informação clínica é posta em causa pela fragmentação generalizada das implementações de sistemas de informação em saúde. Várias aproximações têm sido propostas para colmatar as limitações decorrentes das chamadas “ilhas de informação” na saúde, desde a centralização total (um sistema único), à utilização de redes descentralizadas de troca de mensagens clínicas. Neste trabalho, propomos a utilização de uma camada de unificação baseada em serviços, através da federação de fontes de informação heterogéneas. Este agregador de informação clínica fornece a base necessária para desenvolver aplicações com uma lógica regional, que demostrámos com a implementação de um sistema de registo de saúde eletrónico virtual. Ao contrário dos métodos baseados em mensagens clínicas ponto-a-ponto, populares na integração de sistemas em saúde, desenvolvemos um middleware segundo os padrões de arquitetura J2EE, no qual a informação federada é expressa como um modelo de objetos, acessível através de interfaces de programação. A arquitetura proposta foi instanciada na Rede Telemática de Saúde, uma plataforma instalada na região de Aveiro que liga oito instituições parceiras (dois hospitais e seis centros de saúde), cobrindo ~350.000 cidadãos, utilizada por ~350 profissionais registados e que permite acesso a mais de 19.000.000 de episódios. Para além da plataforma colaborativa regional para a saúde (RTSys), introduzimos uma segunda linha de investigação, procurando fazer a ponte entre as redes para a prestação de cuidados e as redes para a computação científica. Neste segundo cenário, propomos a utilização dos modelos de computação Grid para viabilizar a utilização e integração massiva de informação biomédica. A arquitetura proposta (não implementada) permite o acesso a infraestruturas de e-Ciência existentes para criar repositórios de informação clínica para aplicações em saúde.

Prevalence of health promotion programs in primary health care units in Brazil

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Expanded scope roles in primary health – what makes them work?

Introduction The demand for better integration between primary and secondary healthcare frequently leads to discussion about expanded scope of practice for nursing, paramedic and allied health professionals and the role these clinicians could play in facilitating improved access to timely and appropriate healthcare. From workforce perspective, expanded scope of practice has also been advocated as a mean of fostering workforce retention. Models of expanded scope roles in nursing and paramedicine have been trialled nationally and internationally in both acute and community care settings. Where they have been successful, trials have resulted in reduction in hospital presentation and admission; improved patient access and timeliness; and patient satisfaction. This paper will examine the characteristics of successful expanded scope programs. Method Exploratory case-study analysis of successful integration of expanded health care roles across primary healthcare settings in rural Australia. Results & Conclusions One size does not fill all. Successful models of integrated expanded health care roles in primary health care settings are built on stakeholder’s capacity and preference; community need; and political will. Collaborative, congruent, multi-disciplinary care teams that prioritise patient-centred care within a dynamic primary care setting have merit and are more likely to foster flexibility and sustainability.

Up close and personal with those experiencing homelessness: Pharmacist involvement in a multidisciplinary healthcare team

Introduction. The Brisbane City Council holds a biannual Homeless Connect event which brings together business and community groups on one day to provide free services to people experiencing or at risk of homelessness. Pharmacists were involved in this initiative and provided health services in a multidisciplinary healthcare environment building on the lessons of previous Homeless Connect events (Chan et al, 2015) Aims. To explore pharmacists reflections on their role in a multidisciplinary healthcare team providing services at a community outreach event for those experiencing homelessness. Methods. The pharmacists (n=2) documented the types of services provided during the Homeless Connect event. A semi-structured interview was conducted post-event to investigate barriers, facilitators and changes that would be recommended for future events. Their perceptions of their role in the multidisciplinary healthcare team were also explored. Results. Primarily, the services provided included delivery of primary healthcare, advice on accessing cost effective pharmacy services and addressing medication enquiries. The pharmacists also provided moisturiser samples and health information leaflets. Interdisciplinary referrals were primarily between the pharmacists and podiatrists; no pharmacist-medical practitioner referrals occurred. The pharmacists did believe they had a positive role in this health initiative but improvements could be implemented to improve the delivery of these services in future events. Discussion. Pharmacists can play an important role in providing services to people experiencing or at risk of homelessness and the overall experience was positive for the pharmacists. They were able to integrate into a multidisciplinary healthcare team in this setting but strategies for further collaboration were identified. The possibility of involving pharmacy students in future events was identified.

Development of a Complex Intervention for Secondary Prevention of Coronary Heart Disease in Primary Care Using the UK Medical Research Council Framework

Objective: To apply the UK Medical Research Council (MRC) framework for development and evaluation of trials of complex interventions to a primary healthcare intervention to promote secondary prevention of coronary heart disease. Study Design: Case report of intervention development. Methods: First, literature relating to secondary prevention and lifestyle change was reviewed. Second, a preliminary intervention was modeled, based on literature findings and focus group interviews with patients (n = 23) and staff (n = 29) from 4 general practices. Participants’ experiences of and attitudes toward key intervention components were explored. Third, the preliminary intervention was pilot-tested in 4 general practices. After delivery of the pilot intervention, practitioners evaluated the training sessions, and qualitative data relating to experiences of the intervention were collected using semistructured interviews with staff (n = 10) and patient focus groups (n = 17). Results: Literature review identified 3 intervention components: a structured recall system, practitioner training, and patient information. Initial qualitative data identified variations in recall system design, training requirements (medication prescribing, facilitating behavior change), and information appropriate to the prospective study participants. Identifying detailed structures within intervention components clarified how the intervention could be tailored to individual practice, practitioner, and patient needs while preserving the theoretical functions of the components. Findings from the pilot phase informed further modeling of the intervention, reducing administrative time, increasing practical content of training, and omitting unhelpful patient information. Conclusion: Application of the MRC framework helped to determine the feasibility and development of a complex intervention for primary care research.

Steps to a better Belfast: physical activity assessment and promotion in primary care

BACKGROUND: Low physical activity (PA) levels which increase the risk of chronic disease are reported by two-thirds of the general UK population. Promotion of PA by primary healthcare professionals is advocated but more evidence is needed regarding effective ways of integrating this within everyday practice. This study aims to explore the feasibility of a randomised trial of a pedometer-based intervention, using step-count goals, recruiting patients from primary care. METHOD: Patients, aged 35-75, attending four practices in socioeconomically deprived areas, were invited to complete a General Practice PA Questionnaire during routine consultations. Health professionals invited 'inactive' individuals to a pedometer-based intervention and were randomly allocated to group 1 (prescribed a self-determined goal) or group 2 (prescribed a specific goal of 2500 steps/day above baseline). Both groups kept step-count diaries and received telephone follow-up at 1, 2, 6 and 11 weeks. Step counts were reassessed after 12 weeks. RESULTS: Of the 2154 patients attending, 192 questionnaires were completed (8.9%). Of these, 83 were classified as 'inactive'; 41(10 men; 31 women) completed baseline assessments, with the mean age of participants being 51 years. Mean baseline step counts were similar in group 1 (5685, SD 2945) and group 2 (6513, SD 3350). The mean increase in steps/day was greater in groups 1 than 2 ((2602, SD 1957) vs (748, SD 1997) p=0.005). CONCLUSIONS: A trial of a pedometer-based intervention using self-determined step counts appears feasible in primary care. Pedometers appear acceptable to women, particularly at a perimenopausal age, when it is important to engage in impact loading activities such as walking to maintain bone mineral density. An increase of 2500 steps/day is achievable for inactive patients, but the effectiveness of different approaches to realistic goal-setting warrants further study.

Análise comparativa do impacto das ULS (Unidade Locais de Saúde) e dos ACeS (Agrupamentos de Centros de Saúde) no processo de articulação entre os cuidados de saúde primários e os cuidados de saúde hospitalares

RESUMO - Introdução: O presente trabalho, desenvolvido ao longo dos últimos meses, teve como objetivo analisar comparativamente o impacto das Unidades Locais de Saúde e dos Agrupamentos de Centros de Saúde no processo de articulação entre cuidados de saúde primários e hospitais. Para tal, foram avaliadas as seguintes variáveis: frequência de contacto entre médicos de família e especialistas; percentagem de informação de retorno recebida pelos médicos de família; percentagem de recusas recebida pelos médicos de família; e tempo de espera entre o pedido das consultas hospitalares e a efetivação das mesmas para as especialidades mais referenciadas. As instituições escolhidas para o estudo foram a Unidade Local de Saúde de Castelo Branco e o ACeS Cova da Beira. Metodologia: O instrumento de medida utilizado para este estudo foi um questionário, com questões de resposta aberta e fechada, dirigido a médicos de família da Unidade Local de Saúde de Castelo Branco e do ACeS Cova da Beira, pretendendo assim averiguar a perceção que os mesmos têm em relação às variáveis descritas no tópico da Introdução. Resultados: Segundo dados estatísticos, meramente descritivos, os médicos de família da ULSCB apresentaram uma frequência de contacto inferior aos médicos de família do ACeS com os médicos hospitalares, e a percentagem de informação de retorno recebida pelos médicos de família da ULSCB revelou ser também inferior à recebida pelos médicos de família do ACeS. No entanto, as diferenças encontradas não puderam ser confirmadas para a amostra existente, uma vez que o teste Qui-quadrado foi inconclusivo. Quanto à percentagem de recusas recebida pelos médicos de família de ambas as instituições, e aos tempos de espera para a realização das consultas das especialidades mais referenciadas pelo ACeS Cova da Beira e pela ULSCB, a ULSCB não mostrou desvantagem significativa, mas também não revelou superioridade. Conclusão: As principais conclusões extraídas deste estudo vão no sentido de questionar a eficácia do modelo de organização institucional das ULS | Unidades Locais de Saúde no que diz respeito à articulação entre cuidados de saúde primários e cuidados de saúde hospitalares, em particular, no que se refere à partilha de informação clínica e à eficiência do processo de referenciação para consultas hospitalares.

A qualitative exploration of the underlying causes of preventable drug-related morbidity in primary care, resulting in hospitalisation

This study has explored the underlying causes of preventable drug-related admissions to hospital, from primary care through semi-structured interviews and review of patients’ medical records. Analysis of the data has revealed that communication failures between different groups of healthcare professionals and between healthcare professionals and patients contribute to preventable drug-related admissions, as do knowledge gaps about medication in both healthcare professionals and patients. In addition, working conditions for community pharmacists severely limit their ability to effectively act as a safety barrier to patients receiving inappropriate medication. Limitations include heavy workloads, lack of access to patients’ clinical information, poor relationships with general practitioners and time restrictions. The results of this study represent an important addition to our understanding of the contribution of human error as an underlying cause of preventable drug-related morbidity, and the factors which contribute to errors occurring in the primary healthcare setting.

Avaliação da satisfação das usuárias sobre a atenção à saúde da mulher no Rio Grande do Norte

This work discusses the evaluation of the satisfaction of the users on the women health care focusing on the quality of the primary care in the State of Rio Grande do Norte-BR. The main objective of this research is evaluate the satisfaction of the users about the actions applied to women health in the primary health care in Rio Grande do Norte, observing the information available through the Programa de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB). The specific objectives are: the evaluation of aspects related to women health; the evaluation of the specific actions related to welcoming the pregnant and; the evaluation of the information related to the postpartum. This dissertation is characterized as an evaluative research made through a multicentric transversal study, using a quantitative approach, which is part of the External Evaluation of the PMAQ-AB in the State of Rio Grande do Norte, made by the Federal University of Rio Grande do Norte. Some secondary data of the interviews with the users who were in the Basic Health Units were used during the External Evaluation of the PMAQ-AB in Rio Grande do Norte. The sample was collected following these criteria: the users that were in the Basic Health Units to attend to any procedure; they must had used the services for at least one year; and they must had agreed to participate the research. The ones that were attending to the services for the first time and the ones that did not use the services for at least 12 months were excluded from the sample. To the data collection it was used a chart of variables/indicators with the following information to the analysis: Women Health Care, Specific Care of the Pregnant and Information about he postpartum. The descriptive analysis of the data were made through absolute and relative frequencies of the variables using the software Statistic Package for Social Sciences (SPSS) for Windows, version 22.0.0. The results show a positive picture of the satisfaction of the users about the actions of the primary healthcare in women health in the State of the Rio Grande do Norte. Another important analysis is the integration of the primary health care with other points of the Healthcare System aiming to reorient the Model of Healthcare as a starter of the access and quality of the services given to the users. Therefore, the evaluation of the satisfaction of the users in health care is essential among all the agents involved in the process of consolidation of the Unified Health System SUS. Also having the need of rethinking the professional practice, reorganizing the processes of work of the multiprofessional teams in health care, enabling financial resources, inputs and materials, planning and systematizing new actions of healthcare aiming to ensure a perfect health care to the people

Qualidade de vida em mulheres na pós-menopausa, usuárias e não usuárias de terapia hormonal

OBJETIVO: avaliar a qualidade de vida (QV) de mulheres na pós-menopausa usuárias e São Paulo. MÉTODOS: foi conduzido estudo clínico transversal, com 250 mulheres na pós-menopausa, idade entre 45 a 70 anos, atendidas em uma Unidade Básica de Saúde (UBS), de setembro de 2007 a agosto de 2008. As participantes foram divididas em dois grupos: usuárias de terapia hormonal (TH, n=70) e não usuárias (n=180). Consideraram-se como usuárias de TH aquelas que faziam uso contínuo dessa terapia há pelo menos seis meses. Foram avaliadas as características sociodemográficas e clínicas. Aplicou-se o Índice Menopausal de Blatt e Kupperman (IMBK), para avaliar a intensidade dos sintomas climatéricos, e o Questionário de Saúde da Mulher (QSM), para a avaliação da QV. A análise estatística foi realizada pelo teste do χ2 ou exato de Fisher, teste de Mann-Whitney e de Kruskal-Wallis. RESULTADOS: não foram encontradas diferenças significativas na comparação entre os grupos quanto à idade, menarca, menopausa, paridade e índice massa corpórea. Observou-se que 67,2% eram casadas, 83,2% com ensino fundamental e 53,2% se ocupavam com os trabalhos domésticos, não diferindo entre os grupos. As usuárias de TH relataram menor frequência de sintomas climatéricos (IMBK) de intensidade moderada e acentuada, comparadas a não usuárias (p<0,001). Na avaliação do QSM, verificou-se, entre as usuárias de TH, menor escore médio quanto ao déficit cognitivo (p<0,001), sintomas vasomotores (p=0,04), problemas com o sono (p<0,001) e atratividade (p=0,02), contudo, sem diferença no escore total quando comparadas a não usuárias. CONCLUSÕES: as mulheres na pós-menopausa usuárias e não usuárias de TH, atendidas em UBS, não apresentaram diferenças na QV global.

The burden of physical activity on type 2 diabetes public healthcare expenditures among adults: a retrospective study

Background: Determinants of public healthcare expenditures in type 2 diabetics are not well investigated in developing nations and, therefore, it is not clear if higher physical activity decreases healthcare costs. The purpose of this study was to analyze the relationship between physical activity and the expenditures in public healthcare on type 2 diabetes mellitus treatment.Methods: Cross-sectional study carried out in Brazil. A total of 121 type 2 diabetics attended to in two Basic Healthcare Units were evaluated. Public healthcare expenditures in the last year were estimated using a specific standard table. Also evaluated were: socio-demographic variables; chronological age; exogenous insulin use; smoking habits; fasting glucose test; diabetic neuropathy and anthropometric measures. Habitual physical activity was assessed by questionnaire.Results: Age (r = 0.20; p = 0.023), body mass index (r = 0.33; p = 0.001) and waist-to-hip ratio (r = 0.20; p = 0.025) were positively related to expenditures on medication for the treatment of diseases other than diabetes. Insulin use was associated with increased expenditures. Higher physical activity was associated with lower expenditure, provided medication for treatment of diseases other than diabetes (OR = 0.19; p = 0.007) and medical consultations (OR = 0.26; p = 0.029).Conclusions: Type 2 diabetics with higher enrollment in physical activity presented consistently lower healthcare expenditures for the public healthcare system.