Medication review and polypharmacy management in the hospital setting. The cases of Greece and Catalonia

Introduction: Medication review and polypharmacy management, especially in the elderly, are key components of integrated care. Although polypharmacy management is often associated with the primary care setting, hospital clinicians, who are often members of multidisciplinary therapeutic teams, have an opportunity to improve the management of polypharmacy, which has the potential to improve health outcomes in both hospital and primary care.Methods: Mixed-methods (desk reviews, key informant interviews and focus groups) case studies were carried out in Greece and Catalonia, in the framework of the SIMPATHY (Stimulating Innovation Management of Polypharmacy and Adherence in The Elderly) project, in order to describe policies and procedures on the management of polypharmacy and adherence in the elderly and describe implementation strategies. Kotter’s Eight Step Process for transforming change and normalization process theory (NPT) were applied both in data collection tools and in the analysis.Progress report: At both sites there was awareness regarding the need for management of polypharmacy in the elderly, although in Greece awareness had not translated to a sense of urgency, a critical early step in Kotter’s process. Barriers to implementation in Greece included extreme financial pressure, lack or organizational culture supporting multidisciplinary teams and shared decision making, and lack of guidance from central health authorities. However, despite the lack of national guidelines, hospital pharmacists in state (public) hospitals currently review medication for inpatients and out-patients, and interventions regarding inappropriate polypharmacy and reconciliation of care have been piloted. In Catalonia, implementation of an Institutional network sponsored model has been implemented and it is being evaluated. Polypharmacy was integrated as a specific component of a broader patient-centered service model, driven by a small multidisciplinary team, with a focus on global health outcomes. Facilitators, to implementation included an organizational culture of innovation and shared decision making, advanced training requirements of all hospital pharmacists, and regional health policies focusing on improved care for patients with complex chronic disease.Conclusion and future work: Although Greece is a country with no programme of polypharmacy management identified, there are some policies and clinical activities in place that could support future programmes. National guidance will ultimately be needed to mobilize health professionals and ensure consistency of care. The Catalan experience demonstrates that polypharmacy management can occur in the hospital setting. Future challenges include scaling the current model into other units within the hospital and into primary care. Given the pharmacist training and current medicines management activities in Greece, the hospital may be an appropriate entry point for polypharmacy management activities in that country, later scaling up to the community. As other health systems look to address polypharmacy, hospital should be considered a potential starting point for initiating a programme.Funding: This poster is part of the SIMPATHY project (663082) which has received funding from the European Union’s Health Programme (2014-2020)

A case study of polypharmacy management in nine European countries: Implications for change management and implementation

BackgroundMultimorbidity and its associated polypharmacy contribute to an increase in adverse drug events, hospitalizations, and healthcare spending. This study aimed to address: what exists regarding polypharmacy management in the European Union (EU); why programs were, or were not, developed; and, how identified initiatives were developed, implemented, and sustained.MethodsChange management principles (Kotter) and normalization process theory (NPT) informed data collection and analysis. Nine case studies were conducted in eight EU countries: Germany (Lower Saxony), Greece, Italy (Campania), Poland, Portugal, Spain (Catalonia), Sweden (Uppsala), and the United Kingdom (Northern Ireland and Scotland). The workflow included a review of country/region specific polypharmacy policies, key informant interviews with stakeholders involved in policy development and implementation and, focus groups of clinicians and managers. Data were analyzed using thematic analysis of individual cases and framework analysis across cases.ResultsPolypharmacy initiatives were identified in five regions (Catalonia, Lower Saxony, Northern Ireland, Scotland, and Uppsala) and included all care settings. There was agreement, even in cases without initiatives, that polypharmacy is a significant issue to address. Common themes regarding the development and implementation of polypharmacy management initiatives were: locally adapted solutions, organizational culture supporting innovation and teamwork, adequate workforce training, multidisciplinary teams, changes in workflow, redefinition of roles and responsibilities of professionals, policies and legislation supporting the initiative, and data management and information and communication systems to assist development and implementation. Depending on the setting, these were considered either facilitators or barriers to implementation.ConclusionWithin the studied EU countries, polypharmacy management was not widely addressed. These results highlight the importance of change management and theory-based implementation strategies, and provide examples of polypharmacy management initiatives that can assist managers and policymakers in developing new programs or scaling up existing ones, particularly in places currently lacking such initiatives

The Role of Bronchoscopic Findings and Bronchoalveolar Lavage Fluid Cytology in Early Diagnosis of Ventilator-Associated Pneumonia

BACKGROUND: Early diagnosis of ventilator-associated pneumonia (VAP) is necessary to reduce morbidity and improve survival of critically ill patients in the ICU. The purpose of the present study is to examine the performance of macroscopic bronchoscopic findings and cytological analysis of bronchoalveolar lavage fluid (BALF) as an early diagnostic tool for VAP, either alone or in combination with clinically oriented scores (modified Clinical Pulmonary Infection Score [CPIS] or Johanson criteria). METHODS: BAL was performed in 54 consecutive mechanically ventilated subjects. The predictive value of isolated or combined clinical characteristics, BALF, and/or other laboratory measurements in diagnosing VAP was analyzed by logistic regression analysis. A separate diagnostic score was derived from a linear combination of independent variables included in the multivariate model and compared with CPIS, Johanson criteria, and their combinations with BALF cytology (receiver operating characteristic curve analysis). RESULTS: Integrating relative neutrophil cell count in CPIS or Johanson criteria optimized their specificity (>80%) but decreased sensitivity (<70%). Radiographic progression and the presence of distal purulent secretions on bronchoscopy were independently associated with VAP diagnosis. A new score that incorporates clinical, radiographic, and early bronchoscopic findings presented excellent diagnostic accuracy (area under curve = 0.96, sensitivity 94.3%, specificity 84.2%). CONCLUSIONS: The diagnostic performance of classical clinical scores for VAP did not improve after combination with BALF cytology. A new composite score proved to be more accurate than previous scores in early VAP diagnosis

Cryptogenic organizing pneumonia in Sweet's syndrome: case report and review of the literature

Background and AimsSweet's syndrome or acute febrile neutrophilic dermatosis is characterized by fever, leukocytosis and tender erythematous plaques, which show infiltration by mature neutrophils on histological examination. Pulmonary involvement is rare in Sweet's syndrome. MethodWe describe the case of a 17-year-old man with a myelodysplastic syndrome following therapy for Hodgkin's lymphoma who developed Sweet's syndrome and cryptogenic organizing pneumonia. In addition, we conducted a review of the related English literature. ResultsLiterature review yielded six similar reports of biopsy-proven cryptogenic organizing pneumonia associated with Sweet's syndrome. We present the clinical and laboratory characteristics, as well as the response to treatment, of all cases of cryptogenic organizing pneumonia reported in patients with Sweet's syndrome. ConclusionsCryptogenic organizing pneumonia is a rare manifestation of Sweet's syndrome, which may be complicated by respiratory failure. Prompt treatment with corticosteroids usually leads to clinical and radiographic improvement

Surgical correction of acquired unilateral diaphragmatic paralysis by plication technique

Summary: Acquired diaphragmatic paralysis may compromise lung mechanics and cause dyspnoea and/or lead to respiratory failure in the long term. A 76 year-old female patient presented with progressive worsening of dyspnoea and spirometric indices, and imaging studies revealed elevation of the left hemidiaphragm. Surgical correction was carried out by diaphragmatic plication technique, through a mini-thoracotomy approach. Immediate alleviation (within days) of her symptoms was observed, while improvement of radiological and pulmonary function tests occurred some weeks later. Pneumon 2013,26(2

Comparison of advanced closed-loop ventilation modes with pressure support ventilation for weaning from mechanical ventilation in adults: A systematic review and meta-analysis

Purpose: To compare neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV), adaptive support ventilation (ASV) and Smartcare pressure support (Smartcare/PS) with standard pressure support ventilation (PSV) regarding their effectiveness for weaning critically ill adults from invasive mechanical ventilation (IMV). Methods: Electronic databases were searched to identify parallel-group randomized controlled trials (RCTs) comparing NAVA, PAV, ASV, or Smartcare/PS with PSV, in adult patients under IMV through July 28, 2021. Primary outcome was weaning success. Secondary outcomes included weaning time, total MV duration, reintubation or use of non-invasive MV (NIMV) within 48 h after extubation, in-hospital and intensive care unit (ICU) mortality, in-hospital and ICU length of stay (LOS) (PROSPERO registration No:CRD42021270299). Results: Twenty RCTs were finally included. Compared to PSV, NAVA was associated with significantly lower risk for in-hospital and ICU death and lower requirements for post-extubation NIMV. Moreover, PAV showed significant advantage over PSV in terms of weaning rates, MV duration and ICU LOS. No significant differences were found between ASV or Smart care/PS and PSV. Conclusions: Moderate certainty evidence suggest that PAV increases weaning success rates, shortens MV duration and ICU LOS compared to PSV. It is also noteworthy that NAVA seems to improve in-hospital and ICU survival. (c) 2021 Elsevier Inc. All rights reserved

Benign Metastasizing Leiomyoma Presenting as Cavitating Lung Nodules

Benign metastasizing leiomyoma (BML) was initially used to describe single or multiple pulmonary nodules composed of proliferating smooth muscle cells (lacking cellular atypia) in premenopausal females 3 months to 20 y after hysterectomy for uterine leiomyoma. The lung is the most commonly involved site, thus including many malignant and benign entities in the differential diagnosis. The present case refers to a 47-y-old premenopausal woman with a history of subtotal hysterectomy for a uterine leiomyoma presenting with bilateral cavitating pulmonary nodules. A number of nodules were resected by video-assisted thoracoscopic surgery. The histological findings in correlation with the immunohistochemical results were consistent with the diagnosis of BML. A bilateral salpingooophorectomy was performed, combined with complete removal of the remaining cervix. One year later, the subject remains asymptomatic, and the pulmonary nodules are stable with regard to number, size, location, and morphology

Focus group participant characteristics.

<p>1) The total number of key informants and the total number of profile characteristics are not equal, as more than one characteristic could be applied to the same key informant (e.g. one informant could be both a physician and a manager); 2) Those working in governing bodies or agencies overseeing health systems at a regional or national level; 3) Includes hospital CEO’s, primary care center directors, and department managers; 4) Geriatricians, hospitalists, general practitioners; 5) Hospital, primary care, and community; 6) Departments of pharmacy and medicine, also includes research and clinical faculty; 7) Medicine and pharmacy; 8) Patients and representatives of patient associations. UK: United Kingdom.</p

Major themes categorized by NPT and Kotter.

<p>Major themes categorized by NPT and Kotter.</p