Relación entre calidad y coste de la prescripción farmacológica en atención primaria

ObjetivoAnalizar la prescripcion farmaceutica de los medicos generales (MG) segun un sistema de indicadores cualitativos y evaluar la relacion de estos con el gasto global de prescripcion farmaceutica por habitante.DisenoEstudio descriptivo, retrospectivo.EmplazamientoAtencion primaria.Mediciones y resultados principalesSe evalua la prescripcion farmaceutica de 285 MG de 32 equipos de atencion primaria, siendo la prescripcion individual de cada medico la unidad de analisis. La prescripcion se clasifico en 3 categorias segun su valor intrinseco (%VIF): bajo (. 75%), medio (76–79%) y alto (. 80%). Como trazadores de hiperprescripcion fueron seleccionados: DHD antibioticos (AB), DHD antiinflamatorios no esteroides (AINE) y DHD antiulcerosos (ULC), y como trazadores de seleccion: %DHD cefalosporinas tercera generacion/DHD cefalosporinas totales (CEF3.aG), %DHD quinolonas amplio espectro/DHD quinolonas totales (QAP), %DHD AINE/DHD (AINE + analgesicos) (ANAL). Los indicadores cuantitativos estudiados fueron: gasto total/poblacion asignada (GPA), coste/receta farmacos de eficacia dudosa y coste/DDD de AB, AINE y ULC. Se aplico el analisis de variancia, incluyendo la prueba de Scheffe para comparaciones multiples y la correlacion lineal de Pearson. Un 26% de las prescripciones tenia un %VIF < 75%, mientras que el 34% lo tenia > 80%. Las medias de DHD AB entre las categorias de VIF eran diferentes (p < 0,0001), al igual que las de DHD de AINE (p < 0,0001) y ULC (p = 0,007), observandose un menor consumo de AB, AINE y ULC en las prescripciones con VIF mas alto. Las CEF3aG, asi como ANAL presentan diferencias significativas con las 3 categorias de VIF (p < 0,0001 y p = 0,041) a diferencia del QAP (p = 0,18). El GPA es menor entre los MG cuyas prescripciones tenian el %VIF mas alto; en cambio, el coste/receta y el coste DDD no presentaron diferencias significativas segun categorias de %VIF.ConclusionesLos medicos con mejor perfil cualitativo segun estos indicadores presentan un menor gasto por habitante. En cambio, no se observan diferencias en el coste por receta ni en el coste/tratamiento entre los distintos medicos. Por tanto, las intervenciones deben priorizar la mejora de la calidad de la prescripcion farmaceutica antes que promover unicamente el cambio al farmaco de menor coste.ObjectivesWith a system of qualitative indicators, to analyse the pharmaceutical prescription of general practitioners (GPs), and to evaluate the relationship of these indicators to the overall pharmaceutical prescription expenditure per inhabitant.DesignRetrospective descriptive study.SettingPrimary care.Measurements and main resultsThe drugs prescription of 285 GPs from 32 primary care teams was evaluated, with the individual prescription of each doctor as the unit of analysis. The prescription was classified in 3 categories according to its intrinsic value (IV): low (. 75%), medium (76–79%) and high (. 80%). Selected as tracers of over-prescription were: daily dose per inhabitant (DDI) of antibiotics (AB), DDI of non-steroid anti-inflammatory drugs (NSAID), and DDI of ulcer drugs (ULC). Selected as tracers of selection were: % DDI third-generation cephalosporins/DDI total cephalosporins; % DDI broad-spectre quinolones/DDI total quinolones; and % DDI NSAID/DDI NSAID plus analgesics. Quantitative indicators studied were: total expenditure per allocated population, cost per drugs prescription of doubtful efficacy, and cost per daily dose of AB, NSAID and ULC. Variance analysis, including the Scheffe test for multiple comparisons and Pearson's linear correlation, was applied. 26% of the prescriptions had an IV below 75%, and 34% had an IV above 80%. The means of DDI of AB among the categories of IV were different (p < 0.0001), as were those of DDI of NSAID (p < 0.0001) and of ULC (p = 0.007). Lower consumption of AB, NSAID and ULC was found in prescriptions with the highest IV %. The third-generation cephalosporins and the NSAID + analgesics showed significant differences in the three IV categories (p < 0.0001 and p = 0.041), unlike broad-spectrum quinolones (p = 0.18). The total expenditure per allocated population was less for GPs whose prescriptions had the highest IV %; whereas the cost per prescription and cost per daily dose showed no significant differences for IV categories.ConclusionsThe doctors with the best qualitative profile on these indicators had less expenditure per inhabitant. However, no differences were found in the cost per prescription or cost per treatment between doctors. Therefore, interventions must prioritise improving drug prescription quality rather than just promoting changes to lower-cost drugs

Impact of sex, age, and risk factors for venous thromboembolism on the initial presentation of first isolated symptomatic acute deep vein thrombosis

Thrombosis and Hemostasi

Impact of sex, age, and risk factors for venous thromboembolism on the initial presentation of first isolated symptomatic acute deep vein thrombosis

BACKGROUND AND AIMS: Sex-specific differences exist for the initial presentation of acute venous thromboembolism (VTE): men are more likely to present with proximal deep vein thrombosis (DVT) in the lower limbs (versus pulmonary embolism [PE] or isolated distal DVT [IDDVT]) than women. We studied in detail the influence of sex, age, and VTE risk factors on the initial presentation of IDDVT versus proximal DVT. METHODS: A total of 24,911 patients with a first episode of objectively diagnosed acute symptomatic lower-limb DVT (without symptomatic PE) were enrolled in RIETE (years 2000-2017) and included in the present analysis. RESULTS: A total of 4266 (17.1%) patients had IDDVT. No trend for more IDDVT diagnoses was observed over time. Women aged 40-69 had a higher proportion of IDDVT, especially between 40 and 49 years (+6.7%; 95CI +3.7%; +9.9%), whereas men had more often proximal DVT. The presenting location of first acute DVT depended on sex, age, and the prevalence and type of VTE risk factors. Recent surgery was independently associated with a diagnosis of IDDVT in both women and men, whereas active cancer and pregnancy were associated with proximal DVT. CONCLUSIONS: The interaction between age and VTE risk factors influences the presenting location (distal versus proximal) of the first acute lower-limb DVT observed in women and men. Our observations extend to IDDVT the concept that different clinical manifestations of acute VTE may not fully share the same pathophysiological mechanisms: this contributes to explain sex-specific prognostic differences.status: publishe

Early use of echocardiography in patients with acute pulmonary embolism: Findings from the RIETE registry

Background\u2014Transthoracic echocardiography (TTE) is often considered for risk stratification of patients with acute pulmonary embolism (PE). We sought to determine the contemporary utilization of early TTE (within 72 hours of PE diagnosis) and explored the association between TTE findings and PE-related mortality. Methods and Results\u2014Data from the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry, a multicenter registry of consecutive patients with acute PE, were used (2001-July 2017). We used a generalized linear mixed model to determine predictors of early TTE performance. Moreover, the association between 3 TTE variables (right atrial enlargement, right ventricular hypokinesis, and presence of right heart thrombi) and 30-day PE-related mortality was assessed in generalized linear mixed models adjusted for PE severity index, and other comorbidities. Among 35 935 enrollees with acute PE, 15 375 (42.8%) underwent early TTE. There was an increase in early TTE utilization rate over time (P&lt;0.001 for trend). Younger age, female sex, enrollment in countries other than Spain, history of coronary disease, heart failure, atrial fibrillation, tachycardia, and hypotension were the main predictors of early TTE (P&lt;0.01 for all). In multivariable analyses, right atrial enlargement (adjusted odds ratio: 3.74; 95% confidence interval, 2.10-6.66), right ventricular hypokinesis (adjusted odds ratio: 3.11, 95% confidence interval: 1.85-5.21) and right heart thrombi (adjusted odds ratio: 4.39, 95% confidence interval, 1.99-9.71) were associated with increased odds for PErelated mortality. Conclusions\u2014Early TTE is commonly performed for acute PE and utilization rates have increased over time. Right atrial enlargement, right ventricular hypokinesis, and right heart thrombi are predictive of worse outcomes. Clinical Trial Registration\u2014URL: http://www.clinicaltrials.gov. Unique identifier: NCT02832245

Timing and characteristics of venous thromboembolism after noncancer surgery

Background: Venous thromboembolism (VTE) is a major cause of morbidity and mortality postoperatively. The use of pharmacologic prophylaxis is effective in reducing the incidence of VTE. However, the prophylaxis is often discontinued at hospital discharge, especially for those with benign disease. The implications of this practice are not known. We assessed the data from a large, ongoing registry regarding the time course of VTE and outcomes after noncancer surgery. Methods: We analyzed the RIETE (Computerized Registry on Venous Thromboembolism) registry, which includes data from consecutive patients with symptomatic confirmed VTE. In the present study, we focused on general surgical patients who had developed symptomatic postoperative VTE in the first 8 weeks after noncancer surgery. The main objective was to assess the interval between surgery and the occurrence of VTE. Additional variables included the clinical presentation associated with the event, the use of thrombosis prophylaxis, and unfavorable outcomes. Results: The data from 3296 patients were analyzed. The median time from surgery to the detection of VTE was 16 days (interquartile range, 8-30 days). Of the VTE events, 77% were detected after the first postoperative week and 27% after 4 weeks. Overall, 43.9% of the patients with VTE had received pharmacologic prophylaxis after surgery for a median of 8 days (interquartile range, 5-14 days), and three quarters of the VTE events were detected after pharmacologic prophylaxis had been discontinued. Overall, 54% of the patients with VTE had presented with pulmonary embolism. For 15% of the patients, the clinical outcome was unfavorable, including 4% who had died within 90 days. Conclusions: The risk of VTE after noncancer general surgery remains high for ≤2 months. More than one half of the patients had presented with symptomatic PE as the VTE event, and 15% had had unfavorable outcomes. Only 44% of these patients had received pharmacologic prophylaxis for around 1 week

Incidence of major adverse cardiovascular events among patients with provoked and unprovoked venous thromboembolism: Findings from the Registro Informatizado de Enfermedad Tromboemb\uf3lica Registry

Objective: Overlap exists between the risk factors for coronary artery disease and venous thromboembolism (VTE). However, a paucity of data is available on the incidence of major acute cardiovascular events (MACE) and major adverse limb events (MALE) among patients presenting with VTE. Moreover, it is unknown whether the rate of cardiovascular outcomes differs among patients with unprovoked vs provoked VTE. Methods: We analyzed the data from 2009 to 2017 in the Registro Informatizado de Enfermedad Tromboemb\uf3lica registry, an ongoing, multicenter, international registry of consecutive patients with a diagnosis of objectively confirmed VTE. The query was restricted it to patients with data entry for the arterial outcomes. The baseline prevalence of coronary artery disease risk factors was compared between patients with provoked (ie, immobility, cancer, surgery, travel &gt;6 hours, hormonal causes) and unprovoked VTE. After the initial VTE event, we followed up patients for the composite primary outcome of incident MACE (ie, stroke, myocardial infarction, unstable angina) and/or MALE (ie, major limb events). We used the \u3c72 test for baseline associations and a Cox proportional hazard for multivariate analysis. We used IBM SPSS, version 24 (IBM Corp, Armonk, NY) for statistical analysis. A P value of &lt;.05 was considered statistically significant. Results: We analyzed the data from 41,259 patients with VTE, of whom 22,633 (55.6%) had experienced a provoked VTE. During follow-up, the patients with provoked VTE were more likely to develop MACE or MALE than were patients with unprovoked VTE (hazard ratio [HR], 1.3; 95% confidence interval [CI], 1.1-1.5). The association of arterial events with recent immobility (HR, 1.4; 95% CI, 1.5-12.1) and cancer (HR, 1.7; 95% CI, 1.4-1.9) was strong. After adjusting for multiple conventional cardiovascular risk factors, provoked VTE, compared with unprovoked VTE, was significantly associated with an increased hazard for MACE (HR, 1.4; 95% CI, 1.1-1.7). Cancer remained a significant adjusted predictor for both MACE (HR, 1.7; 95% CI, 1.4-2.1) and MALE (HR, 2.1; 95% CI 1.01-4.6) in those with provoked VTE. Conclusions: Among patients with VTE, provoked cases, specifically those with cancer-associated VTE, have an increased risk of major arterial events