Profile, cost and pattern of prescriptions for polymedicated patients in Catalonia (Spain).

OBJECTIVES: Polypharmacy is one of the main management issues in public health policies because of its financial impact and the increasing number of people involved. The polymedicated population according to their demographic and therapeutic profile and the cost for the public healthcare system were characterised. DESIGN: Cross-sectional study. SETTING: Primary healthcare in Barcelona Health Region, Catalonia, Spain (5 105 551 inhabitants registered). PARTICIPANTS: All insured polymedicated patients. Polymedicated patients were those with a consumption of ≥16 drugs/month. MAIN OUTCOMES MEASURES: The study variables were related to age, gender and medication intake obtained from the 2008 census and records of prescriptions dispensed in pharmacies and charged to the public health system. RESULTS: There were 36 880 polymedicated patients (women: 64.2%; average age: 74.5±10.9 years). The total number of prescriptions billed in 2008 was 2 266 830 (2 272 920 total package units). The most polymedicated group (up to 40% of the total prescriptions) was patients between 75 and 84 years old. The average number of prescriptions billed monthly per patient was 32±2, with an average cost of 452.7±27.5. The total cost of those prescriptions corresponded to 2% of the drug expenditure in Catalonia. The groups N, C, A, R and M represented 71.4% of the total number of drug package units dispensed to polymedicated patients. Great variability was found between the medication profiles of men and women, and between age groups; greater discrepancies were found in paediatric patients (5-14 years) and the elderly (≥65 years). CONCLUSIONS: This study provides essential information to take steps towards rational drug use and a structured approach in the polymedicated population in primary healthcare.

Stress ulcer prophylaxis in non-critically ill patients: a prospective evaluation of current practice in a general surgery department.

RATIONALE, AIMS AND OBJECTIVES: There is little evidence regarding the benefit of stress ulcer prophylaxis (SUP) outside a critical care setting. Overprescription of SUP is not devoid of risks. This prospective study aimed to evaluate the use of proton pump inhibitors (PPIs) for SUP in a general surgery department. METHOD: Data collection was performed prospectively during an 8-week period on patients hospitalized in a general surgery department (58 beds) by pharmacists. Patients with a PPI prescription for the treatment of ulcers, gastro-oesophageal reflux disease, oesophagitis or epigastric pain were excluded. Patients admitted twice during the study period were not reincluded. The American Society of Health-System Pharmacists guidelines on SUP were used to assess the appropriateness of de novo PPI prescriptions. RESULTS: Among 255 patients in the study, 138 (54%) received a prophylaxis with PPI, of which 86 (62%) were de novo PPI prescriptions. A total of 129 patients (94%) received esomeprazole (according to the hospital drug policy). The most frequent dosage was at 40 mg once daily. Use of PPI for SUP was evaluated in 67 patients. A total of 53 patients (79%) had no risk factors for SUP. Twelve and two patients had one or two risk factors, respectively. At discharge, PPI prophylaxis was continued in 33% of patients with a de novo PPI prescription. CONCLUSIONS: This study highlights the overuse of PPIs in non-intensive care unit patients and the inappropriate continuation of PPI prescriptions at discharge. Treatment recommendations for SUP are needed to restrict PPI use for justified indications.

Processus intégratifs et gouvernance clinique dans la psychiatrie institutionnelle [Integration processes and clinical governance in the psychiatric network]

The Swiss Medical Insurance Act (LAMaL) requires the planning of psychiatric care. This necessitates a coordination between the Department of Public Health and the institutional governance. Given the difficulties to draw comparisons between a wide range of systems in a federal country, the Swiss Conference of the State Directors of Health (CDS) proposed as a first step that each canton present some of the key programs they had developed. In the canton Vaud, the implementation of mobile community treatment teams and of an early intervention program for psychosis was chosen. The main challenges faced were to go past traditional divides within the organisation of the Swiss Health system and to conciliate the requirements of public health with the needs of treating teams, in order to promote early intervention in mental health disorders.

Systems medicine and integrated care to combat chronic noncommunicable diseases

We propose an innovative, integrated, cost-effective health system to combat major non-communicable diseases (NCDs), including cardiovascular, chronic respiratory, metabolic, rheumatologic and neurologic disorders and cancers, which together are the predominant health problem of the 21st century. This proposed holistic strategy involves comprehensive patient-centered integrated care and multi-scale, multi-modal and multi-level systems approaches to tackle NCDs as a common group of diseases. Rather than studying each disease individually, it will take into account their intertwined gene-environment, socio-economic interactions and co-morbidities that lead to individual-specific complex phenotypes. It will implement a road map for predictive, preventive, personalized and participatory (P4) medicine based on a robust and extensive knowledge management infrastructure that contains individual patient information. It will be supported by strategic partnerships involving all stakeholders, including general practitioners associated with patient-centered care. This systems medicine strategy, which will take a holistic approach to disease, is designed to allow the results to be used globally, taking into account the needs and specificities of local economies and health systems.

Quelle perception ont les médecins de famille en Suisse de leur rôle dans la prévention et la promotion de la santé? : comprendre les barrières à l'implémentation

Introduction: The importance of health promotion and prevention and the potential of general practitioners (GPs) to conduct individual prevention procedures have been demonstrated in several studies. Clinical recommendations for screening and prevention activities, an important condition for success, are published regularly, but their implementation into daily practice does not necessarily follow. Information is lacking about the actual conditions of how prevention is carried out on a daily basis by Swiss GPs, about their perceptions and needs, their attitudes and the present barriers they face. Such information is essential for the development of new tools and programs targeting better implementation of clinical recommendations for prevention in primary care in Switzerland. Objectives: The objectives of the study were to analyze how Swiss GPs perceive their role in prevention by obtaining information regarding the following issues: What do disease prevention and health promotion mean to them? What are the current incentives and barriers they face? What are their ideas and suggestions to deal with these barriers? What are their needs and expectations regarding prevention guidelines and tools? Methods: We conducted a qualitative research project using focus groups to examine the questions mentioned above. A total of 13 focus groups took place including GPs from eight cantons: five groups in German- speaking Switzerland and eight in French- speaking Switzerland. Each group was composed of 4-11 GPs, making in total 102 participants, who were paid expenses to cover their participation. The sessions were audio-recorded and transcribed verbatim. Data analysis: Content analysis of the transcriptions began by classifying the data according to a typology, the first level of which was developed in line with the structure of the interview guide. This typology was extended by successively regrouping similar statements. Synopsis and interpretation was then performed on each category thus obtained. This research report is based on the results from the French-speaking cantons. Results: Physicians perceive a change in their role as a consequence of changes in society and the health system. They emphasize the importance of a personalized and long lasting relationship between the family doctor and his/her patient; a privileged position allowing them to perform individualized prevention activities, considered to be more effective, as they are appropriate to the specific situation and needs of the patient. They point out their need for training and for better information concerning prevention and health promotion interventions, and stress difficulties arising from the lack of a clear political signal conferring them with a mandate for prevention. -- INTRODUCTION L'importance de la prévention et de la promotion de la santé et le potentiel des médecins de famillea à mettre en oeuvre des mesures individuelles de prévention, de dépistage et de conseils, a été démontrée dans plusieurs études. Régulièrement durant les dernières années, de nombreuses associations médicales ont publié des recommandations cliniques concernant les activités de dépistage et de prévention qui sont une condition essentielle pour le succès, mais ne sont pas forcément appliquées de manière systématique dans la pratique médicale quotidienne. Des contraintes spécifiques contribuent à l'écart entre le désir des médecins de pratiquer une médecine préventive et la réalité d'un cabinet médical. Nous n'avons que peu de données sur les conditions actuelles dans lesquelles la prévention et la promotion de la santé sont réalisées par les médecins de famille suisses dans leur travail quotidien. Des informations précises et représentatives sur leurs perceptions et leurs besoins, leurs attitudes et les contraintes auxquelles ils sont confrontés manquent. Or ces données sont essentielles dans le développement de nouveaux outils et programmes visant une meilleure implémentation des recommandations cliniques dans le domaine de la prévention et la promotion de la santé dans la médecine de famille en Suisse. OBJECTIFS Le développement de concepts pour une prévention systématique ainsi que d'outils adéquats, tout comme l'amélioration des conditions qui permettent une implémentation à grande échelle, implique, avant tout, l'analyse de la perception que les médecins de famille suisses ont de leur rôle dans la prévention. Par conséquent, cette étude a eu pour objectif d'obtenir des informations concernant les questions suivantes : ? Que signifient la prévention et la promotion de la santé pour les médecins de famille suisses ? ? Quelles sont leurs incitations et les barrières rencontrées ? ? Quelles sont leurs idées et leurs suggestions pour faire face à ces contraintes ? ? Quels sont leurs besoins et leurs attentes concernant les outils pour la prévention ? METHODES Nous avons mené un projet de recherche qualitative en utilisant la technique des focus groups pour examiner les questions mentionnées ci-dessus. Une telle technique de collecte de données est particulièrement adaptée à un domaine où l'on connaît mal les perceptions des parties prenantes. Nous avons mené 13 focus groups au total, comprenant des médecins issus de huit cantons: cinq groupes ont eu lieu en Suisse alémanique et huit groupes en Suisse romande. Chaque groupe était composé de 4 à 11 médecins de famille, avec au total 102 participants qui ont été défrayés pour leur participation. Les séances ont été audio-enregistrées et transcrites. ANALYSE DES DONNEES L'analyse du contenu des transcriptions a commencé par la classification des données selon une typologie dont le premier niveau a été développé à partir de la structure de la grille d'entretiens. Cette typologie a été affinée et élargie en regroupant successivement des propos similaires. Une synthèse a été effectuée pour chaque catégorie. Ce rapport est basé sur les résultats de l'analyse des données des cantons francophones. RESULTATS Les médecins perçoivent un changement de leur rôle dans une société et dans un système de santé qui évoluent. Ils soulignent l'importance de la relation personnalisée et durable du médecin de famille avec son patient, atout précieux, qui leur permet de réaliser des activités de prévention individualisées et adaptées à la situation et aux besoins du patient, considérées plus efficaces. Afin de surmonter leur doutes et découragement par rapport aux interventions de prévention, ils pointent la nécessité d'une formation aux nouvelles connaissances en prévention et promotion de la santé et d'une meilleure information aux médecins quant à leur efficacité et importance. Ils montrent le besoin d'un signal clair des politiques par rapport à l'attribution de ce mandat aux médecins de famille et de leur reconnaissance en tant qu'acteur de prévention dans le système de santé.

Involvement of family physicians in structured programs for chronic diseases or multi-morbidity in Switzerland.

The increasing prevalence of chronic diseases and multi-morbidity represents challenges for health systems worldwide. In that perspective, the current organization of healthcare delivery, fragmentation of care, limited use of evidence-based guidelines and patients'insufficient empowerment are some reasons explaining the current limited effectiveness of the management of chronically ill patients. Based on theoretical models such as the Chronic Care Model (CCM), initiatives targeting improvements in the care of patients with chronic diseases have been implemented worldwide since more than a decade. Their development in Switzerland, a health system where more than half of practices are still single handed [6], is only recent and infrequent. Structured programs for patients with chronic diseases or multimorbidity usually propose patient-centered interventions and consider an integrative multidisciplinary approach. Currently, little is known on the existence of such programs and on the role of family physicians (FPs)within these programs, in Switzerland. The objective of this study was to identify and describe current structured programs targeting chronic diseases or multi-morbidity in Switzerland. This may help in examining innovative approaches that are only developed locally but would deserve wider interest for further implementation. We conducted a telephone-based survey between June and November 2013 and contacted systematically key institutions, informants and stakeholders nationwide and in the 26 cantons...

Pharmacoeconomics of Cyclamen europaeum in the management of Acute Rhinosinusitis

Objective. To carry out a pharmacoeconomic analysis of Cyclamen europaeum (CE) in the management of acute rhinosinusitis (ARS) in Spain using data from the PROSINUS study. Study Design. This was a prospective observational study to compare the effectiveness and cost-effectiveness between therapies including CE vs. other therapies in the management of ARS. Methods. The study was carried out as a secondary analysis of the PROSINUS, combining healthcare resource use, productivity loses, and health outcomes from the observational study with costs representative of the Spanish Health System. Results. CE given as monotherapy appears to be more effective (cure rate) than other monotherapies (15.3% higher, p<0.05) and combination (10.3% higher, p<0.05) therapies. The addition of CE to other single-drug or combination therapies showed a statistically significant improvement in terms of cure rates when adding CE to 2-drug combinations (93.9% vs. 76.5%; p<0.05), and no significant effect when added to combinations of three or more drugs (81.1% vs. 79.8; NS). CE based therapies generally showed lower indirect costs, although only the comparison of CE alone vs. other monotherapies, with a net cost savings of 101 per patient, reached statistical significance (331 vs. 432 , p<0.05). In addition, CE-based therapies show lower cost per cured patient in all comparisons except when CE was used in combination with three or more other drugs. Conclusions. The use of Cyclamen europaeum may be associated to better clinical outcomes at no additional cost for the healthcare system, respect to treatments commonly used for ARS in clinical practice.

Systems Medicine and Integrated Care to Combat Chronic Noncommunicable Diseases.

We propose an innovative, integrated, cost-effective health system to combat major non-communicable diseases (NCDs), including cardiovascular, chronic respiratory, metabolic, rheumatologic and neurologic disorders and cancers, which together are the predominant health problem of the 21st century. This proposed holistic strategy involves comprehensive patient-centered integrated care and multi-scale, multi-modal and multi-level systems approaches to tackle NCDs as a common group of diseases. Rather than studying each disease individually, it will take into account their intertwined gene-environment, socio-economic interactions and co-morbidities that lead to individual-specific complex phenotypes. It will implement a road map for predictive, preventive, personalized and participatory (P4) medicine based on a robust and extensive knowledge management infrastructure that contains individual patient information. It will be supported by strategic partnerships involving all stakeholders, including general practitioners associated with patient-centered care. This systems medicine strategy, which will take a holistic approach to disease, is designed to allow the results to be used globally, taking into account the needs and specificities of local economies and health systems.

Treatment of Prosthetic Joint Infections

Prosthetic joint replacement is one of the most successful surgical procedures of the last century and the number of implanted artificial joints is rapidly growing. While the result of the procedure is generally positive, infections may occur leading to patient suffering, surgeon's frustration and important costs to the health system. Infection after prosthetic joint replacement is thus a feared complication as healing rates can be low, functional result poor and satisfaction of the patient abysmal. However, if a patient-adapted treatment of infected total joints is used, an overall success rate of above 90 % can be obtained. The patient-adapted treatment concept is based on five strong pillars: teamwork, understanding biofilm, proper diagnostics, proper definition and classification and patient-tailored treatment.

Quality of life in simultaneous pancreas-kidney transplant recipients

Currently, simultaneous pancreas-kidney transplantation (SPK Tx) is the treatment of choice in selected patients with type 1 diabetes mellitus (DM1) and terminal kidney failure (TRF). A functioning SPK transplant allows dialysis and insulin therapy to be discontinued and stabilizes or improves the complications of DM1. Nevertheless, to a greater or lesser degree, these complications (physical and psychological alterations, secondary effects of immunosuppressive therapy and the need for lifelong medication and medical follow-up) can persist after SPK Tx. Health professionals have mainly investigated the clinical features of transplant recipients. However, in the last few years, interest in analyzing perceived health and health-related quality of life (QoL) has increased. This latter concept includes the features of QoL most closely associated with a particular disease, its treatment and follow-up and therefore those elements most susceptible to modification by the health system. The general aim of this study was to measure health-related QoL in our population with SPK Tx and to determine whether there are significant differences between these patients and those with DM1 and TRF who continue to receive renal replacement therapy (RRT) and insulin therapy. More specific aims were to evaluate whether there are significant differences between the study groups and the means of the Spanish reference population in the distinct dimensions of a QoL questionnaire and whether other variables such as age, sex, years" duration of DM1, length of dialysis, and time since SPK Tx significantly affect health-related QoL.

Patient-adapted treatment for prosthetic hip joint infection.

Hip joint replacement is 1 of the most successful surgical procedures of the last century and the number of replacements implanted is steadily growing. An infected hip arthroplasty is a disaster, it leads to patient suffering, surgeon's frustration and significant costs to the health system. The treatment of an infected hip replacement is challenging, healing rates can be low, functional results poor with decreased patient satisfaction. However, if a patient-adapted treatment of infected hip joints is used a success rate of above 90% can be obtained.Patient-adapted treatment is based on 5 important concepts: teamwork; understanding the biofilm; diagnostic accuracy; correct definition and classification of PJI; and patient-tailored treatment.This review presents a patient-adapted treatment strategy to prosthetic hip infection. It incorporates the best aspects of the single and staged surgical strategies and promotes the short interval philosophy for the 2-stage approach.

Serious games for rehabilitation using head-mounted display and haptic devices

In the health domain, the field of rehabilitation suffers from a lack specialized staff while hospital costs only increase. Worse, almost no tools are dedicated to motivate patients or help the personnel to carry out monitoring of therapeutic exercises. This paper demonstrates the high potential that can bring the virtual reality with a platform of serious games for the rehabilitation of the legs involving a head-mounted display and haptic robot devices. We first introduce SG principles and the current context regarding rehabilitation interventions followed by the description of an original haptic device called Lambda Health System. The architecture of the model is then detailed, including communication specifications showing that lag is imperceptible for user (60Hz). Finally, four serious games for rehabilitation using haptic robots and/or HMD were tested by 33 health specialists.

Quality of life in simultaneous pancreas-kidney transplant recipients

Currently, simultaneous pancreas-kidney transplantation (SPK Tx) is the treatment of choice in selected patients with type 1 diabetes mellitus (DM1) and terminal kidney failure (TRF). A functioning SPK transplant allows dialysis and insulin therapy to be discontinued and stabilizes or improves the complications of DM1. Nevertheless, to a greater or lesser degree, these complications (physical and psychological alterations, secondary effects of immunosuppressive therapy and the need for lifelong medication and medical follow-up) can persist after SPK Tx. Health professionals have mainly investigated the clinical features of transplant recipients. However, in the last few years, interest in analyzing perceived health and health-related quality of life (QoL) has increased. This latter concept includes the features of QoL most closely associated with a particular disease, its treatment and follow-up and therefore those elements most susceptible to modification by the health system. The general aim of this study was to measure health-related QoL in our population with SPK Tx and to determine whether there are significant differences between these patients and those with DM1 and TRF who continue to receive renal replacement therapy (RRT) and insulin therapy. More specific aims were to evaluate whether there are significant differences between the study groups and the means of the Spanish reference population in the distinct dimensions of a QoL questionnaire and whether other variables such as age, sex, years" duration of DM1, length of dialysis, and time since SPK Tx significantly affect health-related QoL.

Quality of life in simultaneous pancreas-kidney transplant recipients

Currently, simultaneous pancreas-kidney transplantation (SPK Tx) is the treatment of choice in selected patients with type 1 diabetes mellitus (DM1) and terminal kidney failure (TRF). A functioning SPK transplant allows dialysis and insulin therapy to be discontinued and stabilizes or improves the complications of DM1. Nevertheless, to a greater or lesser degree, these complications (physical and psychological alterations, secondary effects of immunosuppressive therapy and the need for lifelong medication and medical follow-up) can persist after SPK Tx. Health professionals have mainly investigated the clinical features of transplant recipients. However, in the last few years, interest in analyzing perceived health and health-related quality of life (QoL) has increased. This latter concept includes the features of QoL most closely associated with a particular disease, its treatment and follow-up and therefore those elements most susceptible to modification by the health system. The general aim of this study was to measure health-related QoL in our population with SPK Tx and to determine whether there are significant differences between these patients and those with DM1 and TRF who continue to receive renal replacement therapy (RRT) and insulin therapy. More specific aims were to evaluate whether there are significant differences between the study groups and the means of the Spanish reference population in the distinct dimensions of a QoL questionnaire and whether other variables such as age, sex, years" duration of DM1, length of dialysis, and time since SPK Tx significantly affect health-related QoL.

Development of a population-based cost-effectiveness model of chronic graft versus host disease in Spain

Chronic graft-versus-host disease (cGvHD) is the leading cause of late nonrelapse mortality (transplant-related mortality) after hematopoietic stem cell transplant. Given that there are a wide range of treatment options for cGvHD, assessment of the associated costs and efficacy can help clinicians and health care providers allocate health care resources more efficiently. OBJECTIVE: The purpose of this study was to assess the cost-effectiveness of extracorporeal photopheresis (ECP) compared with rituximab (Rmb) and with imatinib (Imt) in patients with cGvHD at 5 years from the perspective of the Spanish National Health System. METHODS: The model assessed the incremental cost-effectiveness/utility ratio of ECP versus Rmb or Imt for 1000 hypothetical patients by using microsimulation cost-effectiveness techniques. Model probabilities were obtained from the literature. Treatment pathways and adverse events were evaluated taking clinical opinion and published reports into consideration. Local data on costs (2010 Euros) and health care resources utilization were validated by the clinical authors. Probabilistic sensitivity analyses were used to assess the robustness of the model. RESULTS: The greater efficacy of ECP resulted in a gain of 0.011 to 0.024 quality-adjusted life-year in the first year and 0.062 to 0.094 at year 5 compared with Rmb or Imt. The results showed that the higher acquisition cost of ECP versus Imt was compensated for at 9 months by greater efficacy; this higher cost was partially compensated for ( 517) by year 5 versus Rmb. After 9 months, ECP was dominant (cheaper and more effective) compared with Imt. The incremental cost-effectiveness ratio of ECP versus Rmb was 29,646 per life-year gained and 24,442 per quality-adjusted life-year gained at year 2.5. Probabilistic sensitivity analysis confirmed the results. The main study limitation was that to assess relative treatment effects, only small studies were available for indirect comparison. CONCLUSION: ECP as a third-line therapy for cGvHD is a more cost-effective strategy than Rmb or Imt.