Effectiveness of an intervention for improving drug prescription in primary care patients with multimorbidity and polypharmacy:Study protocol of a cluster randomized clinical trial (Multi-PAP project)

This study was funded by the Fondo de Investigaciones Sanitarias ISCIII (Grant Numbers PI15/00276, PI15/00572, PI15/00996), REDISSEC (Project Numbers RD12/0001/0012, RD16/0001/0005), and the European Regional Development Fund ("A way to build Europe").Background: Multimorbidity is associated with negative effects both on people's health and on healthcare systems. A key problem linked to multimorbidity is polypharmacy, which in turn is associated with increased risk of partly preventable adverse effects, including mortality. The Ariadne principles describe a model of care based on a thorough assessment of diseases, treatments (and potential interactions), clinical status, context and preferences of patients with multimorbidity, with the aim of prioritizing and sharing realistic treatment goals that guide an individualized management. The aim of this study is to evaluate the effectiveness of a complex intervention that implements the Ariadne principles in a population of young-old patients with multimorbidity and polypharmacy. The intervention seeks to improve the appropriateness of prescribing in primary care (PC), as measured by the medication appropriateness index (MAI) score at 6 and 12months, as compared with usual care. Methods/Design: Design:pragmatic cluster randomized clinical trial. Unit of randomization: family physician (FP). Unit of analysis: patient. Scope: PC health centres in three autonomous communities: Aragon, Madrid, and Andalusia (Spain). Population: patients aged 65-74years with multimorbidity (≥3 chronic diseases) and polypharmacy (≥5 drugs prescribed in ≥3months). Sample size: n=400 (200 per study arm). Intervention: complex intervention based on the implementation of the Ariadne principles with two components: (1) FP training and (2) FP-patient interview. Outcomes: MAI score, health services use, quality of life (Euroqol 5D-5L), pharmacotherapy and adherence to treatment (Morisky-Green, Haynes-Sackett), and clinical and socio-demographic variables. Statistical analysis: primary outcome is the difference in MAI score between T0 and T1 and corresponding 95% confidence interval. Adjustment for confounding factors will be performed by multilevel analysis. All analyses will be carried out in accordance with the intention-to-treat principle. Discussion: It is essential to provide evidence concerning interventions on PC patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes. Trial registration: Clinicaltrials.gov, NCT02866799Publisher PDFPeer reviewe

Diagnóstico para generar una estrategia de comunicación efectiva

En este Proyecto de Aplicación Profesional se trabajó con el Centro Cultural Constitución y se atendió la problemática de la carencia de comunicación bilateral entre el centro y la colonia. Se llevaron a cabo juegos de lotería con los integrantes de la colonia para obtener información y así poder generar una estrategia de comunicación

Occupancy models reveal potential of conservation prioritization for Central American jaguars

Understanding species-environment relationships at large spatial scales is required for the prioritization of conservation areas and the preservation of landscape connectivity for large carnivores. This endeavour is challenging for jaguars (Panthera onca), given their elusiveness, and the local nature of most jaguar studies, precluding extrapolation to larger areas. We developed an occupancy model using occurrence data of jaguars across five countries of Central America, collected from camera-trap studies of 2–12 months' duration, deployed over an area of 14 112 km 2 from 2005 to 2018. Our occupancy model showed that habitat use of jaguars increased with primary net productivity and distance to human settlements, and decreased with distance to rivers. Detection of the species was related to survey effort and research team identity. Within the jaguar extent of occurrence, 73% was deemed suitable for the species, with 47% of it lying within Jaguar Conservation Units (JCU) and 59% of JCU land being legally protected. Suitable areas were divided into four distinct clusters of continuous habitat shared across country borders. However, large areas of predicted low habitat suitability may constrict connectivity in the region. The reliability of these spatial predictions is indicated by the model validation using an independent dataset (AUC = 0.82; sensitivity = 0.766, specificity = 0.761), and concordance of our results with other studies conducted in the region. Across Central America, we found that human influence has the strongest impact on jaguar habitat use and JCUs are the main reservoirs of habitat. Therefore, conservation actions must focus on preventing habitat loss and mitigating human pressure, particularly within the clusters of continuous areas of high suitability, and on restoring habitat to foster connectivity. The long-term persistence of jaguars in the region will depend on strong international cooperation that secures jaguar populations and their habitat across Central American borders. </p