New version of the Quarterly Model of Banco de España (MTBE)

El Modelo Trimestral del Banco de España (MTBE) es un modelo macroeconómico de gran escala utilizado en las previsiones a medio plazo de la economía española, así como para la simulación de escenarios. El modelo está especificado como un conjunto de ecuaciones de corrección del error, y, especialmente en el corto plazo, responde principalmente a los canales de demanda. Este documento presenta una actualización del modelo, estimada con datos de 1995 a 2014. En esta iteración se ha implementado una mejora sustancial de las técnicas econométricas utilizadas en la estimación. Pese a ello, los cambios en los coeficientes y en los resultados de simulación, en comparación con la versión anterior del modelo, son menores de lo observado en actualizaciones anteriores. Comparado con el MTBE-2014, esta nueva versión (MTBE-2017) muestra una respuesta menor de la demanda a los tipos de interés y a la bolsa, pero mayor al créditomenos respuesta del PIB a la demanda mundial, pero más a los precios mundiales y al precio del petróleoefectos más positivos sobre output y empleo de la moderación de precios y salariosy multiplicadores fiscales algo mayores y más rápidos para algunas medidas (consumo e inversión públicos, impuestos directos a hogares), pero menores para otras (impuestos indirectos, impuesto sobre sociedades)The Quarterly Model of Banco de España (MTBE, Modelo Trimestral del Banco de España), is a large-scale macro-econometric model used for medium term macroeconomic forecasting of the Spanish economy, as well as for performing scenario simulations. The model is specified as a large set of error correction equations, and, especially in the short run, is mostly demand driven. This paper presents an update of the model, estimated with data from 1995 to 2014. In this iteration, a big revamp to the econometric techniques used in estimation has been implemented. Despite that, changes in coefficients and simulation results with respect to the previous version of the model are smaller than what we saw in earlier updates. Compared with MTBE-2014, this new version (MTBE-2017) shows less response of demand to interest rates and stock market prices but more to credit, less response of GDP to world demand but more to world prices and to the price of oil, more positive effects to output and employment from price and wage moderation, and slightly faster and bigger fi scal multipliers for some shocks (government consumption and investment, direct taxes to households) but smaller for others (indirect taxes, direct taxes to firms

Comparaciones indirectas en los informes de evaluación de medicamentos en la web del grupo GENESIS de la SEFH

An active comparator was present in 95% of the 337 analysed reports; 50% included a direct comparative study vs comparator. In 114 reports (34%), an IC was used; 69% of the ICs were made by the report author. Most ICs were narrative and none were adjusted. An IC could have been made in an additional 16% of the cases and possibly in 24% more. Conclusions: Most evaluated drugs have an active comparator but studies comparing them directly are not as common. ICs could be included in more reports along with quality control criteria. © 2011 SEFH. Publishe

Información de medicamentos a la población desde el Servicio de Farmacia a través de Internet

Objectives: To describe and discuss the work of a Pharmacy Department for the health-care portal www.viatusalud.com. Methods: Using a web portal, a Pharmacy Department develops and updates a vademecum on drugs, and answers enquiries by end-users. Results: On December 31, 2002 more than 750 records on drugs were available, and 3030 enquiries had been answered. Conclusions: With this drug information and online enquiry service, our Pharmacy Department helps meet the demand of health-care information posed by the community and by patients previously seen at Clínica Universitaria. In addition, it allows areas of improvement to be detected in the information to be offered to patients fron a Pharmacy Department, and represents a tertiary source of information for health-care professionals

Errores de medicación: evaluación de un sistema de notificación y análisis de los errores en un hospital universitario

Reporting systems are a valuable tool for detecting errors, analysing them, and for designing initiatives to promote patient safety. The aims of this study were: to describe the design and implementation of a medication error reporting system in the clinical practice context and included in a hospital quality plan, to evaluate the reporting system as an improvement tool, and to analyse notified medication errors in order to propose measures to increase patient safety. We retrospectively analysed all medication errors reported since the introduction of the system, the root cause analyses carried out, and the proposed and implemented improvement actions. We evaluated the tool validity and utility analysing the congruence between narrative descriptions and options selected from pull-down menus on the medication errors forms, and between information on the report and reality, as well as analysing the possibility of classifying medication errors based on the information included in the tool and concordance between different evaluators. We evaluated user satisfaction through a questionnaire given to nurses and doctors. In addition, we used two multivariable logistic regression models to determine independent factors associated with errors reaching the patient and with errors causing harm, respectively. A total of 2,578 medication errors were reported from May 2004 to December 2014. Of these, 94.0% caused no harm, 2.7% caused harm and 1.7% were potential errors. Nurses reported 71.3% of errors, 24.8% were notified by pharmacists and 3.9% by doctors. Regarding the process involved, 44.6% were prescription errors, 33.5% were related to preparation/dispensing and 17.6% to preparation/administration. After the root cause analyses some improvement actions affecting different processes were proposed, 69% of them were implemented. At least one discrepancy between narrative text and options selected from pull-down menus on the reporting form was present in almost 50% of the analysed reports. In those medication errors followed in depth, some discrepancy with reality existed in 40% of the reports. Concordance between evaluators was lower in recurrence probability, severity and identification of causes or contributing factors. However, discrepancies were not critical and did not hindered medication errors classification. Professionals consider the tool easy to use but tend to underreport. Multivariable models indicated that medication errors with higher odds of reaching the patient were: incorrect dose or drug, omission of a dose or a drug, wrong patient, wrong administration technique, medication errors in preparation/manipulation/packaging, those with various persons involved, errors in preparation/administration, and those with anticancer or anti-infective drugs. Therefore, the medication errors reporting system was successfully implemented, in addition, improvement actions were also introduced. Simple medication error reporting tools, as the one presented and analysed here, are valid and useful. Adding more pull-down menus and helping tools will increase identification of medication error causes and contributing factors. Narrative section in the reporting form is useful. Increasing hospital personnel training and offering more feed-back information would motivate reporting. Additional safety measures are necessary to check the right drug, dose and administration technique

Errores de medicación: evaluación de un sistema de notificación y análisis de los errores en un hospital universitario

Reporting systems are a valuable tool for detecting errors, analysing them, and for designing initiatives to promote patient safety. The aims of this study were: to describe the design and implementation of a medication error reporting system in the clinical practice context and included in a hospital quality plan, to evaluate the reporting system as an improvement tool, and to analyse notified medication errors in order to propose measures to increase patient safety. We retrospectively analysed all medication errors reported since the introduction of the system, the root cause analyses carried out, and the proposed and implemented improvement actions. We evaluated the tool validity and utility analysing the congruence between narrative descriptions and options selected from pull-down menus on the medication errors forms, and between information on the report and reality, as well as analysing the possibility of classifying medication errors based on the information included in the tool and concordance between different evaluators. We evaluated user satisfaction through a questionnaire given to nurses and doctors. In addition, we used two multivariable logistic regression models to determine independent factors associated with errors reaching the patient and with errors causing harm, respectively. A total of 2,578 medication errors were reported from May 2004 to December 2014. Of these, 94.0% caused no harm, 2.7% caused harm and 1.7% were potential errors. Nurses reported 71.3% of errors, 24.8% were notified by pharmacists and 3.9% by doctors. Regarding the process involved, 44.6% were prescription errors, 33.5% were related to preparation/dispensing and 17.6% to preparation/administration. After the root cause analyses some improvement actions affecting different processes were proposed, 69% of them were implemented. At least one discrepancy between narrative text and options selected from pull-down menus on the reporting form was present in almost 50% of the analysed reports. In those medication errors followed in depth, some discrepancy with reality existed in 40% of the reports. Concordance between evaluators was lower in recurrence probability, severity and identification of causes or contributing factors. However, discrepancies were not critical and did not hindered medication errors classification. Professionals consider the tool easy to use but tend to underreport. Multivariable models indicated that medication errors with higher odds of reaching the patient were: incorrect dose or drug, omission of a dose or a drug, wrong patient, wrong administration technique, medication errors in preparation/manipulation/packaging, those with various persons involved, errors in preparation/administration, and those with anticancer or anti-infective drugs. Therefore, the medication errors reporting system was successfully implemented, in addition, improvement actions were also introduced. Simple medication error reporting tools, as the one presented and analysed here, are valid and useful. Adding more pull-down menus and helping tools will increase identification of medication error causes and contributing factors. Narrative section in the reporting form is useful. Increasing hospital personnel training and offering more feed-back information would motivate reporting. Additional safety measures are necessary to check the right drug, dose and administration technique

Impacto clínico y económico de las intervenciones del farmacéutico clínico sobre antimicrobianos en el paciente crítico

Up to 52% of the patients in acute care hospitals may receive an antibiotic, and 30-50% of the treatments are estimated to be inadequate. Pharmacists have an important role in their optimization. In addition, critically ill patients may benefit more from pharmacist interventions (PIs). Few comparative studies have evaluated the clinical and the economic impact of PIs on antimicrobials in these patients, and none of them was conducted in Europe. Moreover, there have been no reviews analyzing the clinical and economic impact of interventions on antimicrobials conducted specifically by pharmacists (not by a multidisciplinary group, even though it includes a pharmacist) in the hospital setting. Therefore, our main objective was to determine the clinical and economic impact of PIs related to antimicrobials in critical care. Firstly we conducted a review of the evidence in Pubmed from 2003 to March 2016 of the clinical and economic impact of PIs in the hospital setting, in general. Secondly, we developed a retrospective observational study in the Critical Care Area (CCA) of our university hospital to analyze the clinical and economic impact of the clinical pharmacist (CP) interventions (CPI) on antimicrobials over a 5-month period. Thirdly, we conducted another retrospective observational cohort study to determine the effectiveness of a specific intervention promoted by the CP, which consisted of adding inhaled antibiotics in critically ill patients with respiratory infections, as the role of this therapy in these patients remained uncertain. In the review, 23 studies were included. All of them had high risk of bias. Patient-specific recommendations were included in every study; five also included policy strategies and four education. Significant impact of PIs was found in 14 of the 18 studies (77.8%) that evaluated costs, 15 of the 20 (75.0%) that assessed treatment related outcomes, 12 of the 22 (54.5%) that analyzed clinical outcomes and 1 of the 2 studies (50.0%) that evaluated microbiological outcomes. None of the studies found significant negative impact of PIs. It could not be concluded that adding other strategies to patient-specific recommendations improves results. Acceptance of recommendations varied from 70 to 97.5%. Therefore, PIs on antimicrobials in the hospital setting improve clinical and treatment related outcomes, and decrease costs. This positive clinical and economic impact of the PIs was confirmed in our CCA. The CP performed 212 interventions in response to 212 Drug Related Problems (DRPs) detected during the study period, corresponding to 114 patients. Eighteen DRPs (8.5%) were medication errors. A total of 96.2% of the CPIs were considered important with improvement in patient care. None of the CPIs had any negative impact on patients. Physicians accepted 98% of the CPIs. We estimated a 10,905 decrease in costs as a result of CPIs (the estimation could vary from 374 to 127,772 in the worst and best case scenarios, respectively). This means that 4.8 were avoided per euro invested in the CP. The CP initiative of adding inhaled antibiotics to critically ill patients was also positive. We analyzed data from adults admitted to the CCA during a 2-year period with respiratory infections in which respiratory fluid samples were obtained. A total of 136 patients were included: 43 in the treated group (that received inhaled antibiotics in addition to systemic antimicrobials), 93 in the control group (that only received systemic antimicrobials). After adjusting for confounders, treated group had higher odds of clinical improvement (adjusted odds ratio: 7.13; 95% confidence interval: 1.17-43.3). There were no significant differences in creatinine clearance reduction between groups. In conclusion, clinical pharmacist interventions on antimicrobials in the hospital and critical care setting have a positive impact on clinical and treatment related outcomes, and decrease costs

Minimización de costes del mantenimiento con rituximab a intervalos fijos o individualizados en vasculitis por anticuerpos contra el citoplasma de los neutrófilos

[Objective]: Patients included in MAINRITSAN2 trial received either an individually tailored or a fixed-schedule therapy with rituximab as maintenance treatment of antineutrophil cytoplasm antibody associated vasculitides. The aim of this study was to compare the real-world costs of both arms. [Method]: We performed a cost-minimization analysis over an 18-month time period, estimating direct costs –drug acquisition, preparation, administration and monitoring costs– from the health system perspective. We conducted a number of additional sensitivity analyses with different assumptions for unit costs, with further scenarios including the interquartile range of the tailored-infusion group results, different number of monitoring visits for fixed-schedule regimen and different number of reported severe adverse events. A cost-effectiveness analysis was conducted as a sensitivity analysis using the absolute difference in the relapse rate and its confidence interval. Results: The individually tailored maintenance therapy with rituximab was shown to be a cost-saving treatment compared to the fixed-schedule therapy (6,049 euros vs. 7,850 euros). Savings resulted primarily from lower drug acquisition costs (2,861 vs. 4,768 euros) and lower preparation and administration costs (892 vs. 1,486 euros), due to the lower number of infusions per patient in the tailored-infusion regimen. The tailoredinfusion regimen presented higher monitoring costs (2,296 vs. 1,596 euros). This result was replicated in all assumptions considered in the sensitivity analysis of cost-minimization approach. [Conclusions]: From the perspective of the health system, the tailoredtherapy regimen seems to be the preferable option in terms of direct costs. Further studies assessing all the effects and costs associated to vasculitides maintenance treatment with rituximab are needed to support clinical management and healthcare planning.[Objetivo]: Los pacientes incluidos en el ensayo MAINRITSAN2 recibieron una pauta individualizada o un esquema fijo de rituximab como tratamiento de mantenimiento para la vasculitis asociada con anticuerpos contra el citoplasma de los neutrófilos. El objetivo de este estudio es comparar los costes reales de ambos esquemas de tratamiento. [Método]: Se llevó a cabo un análisis de minimización de costes sobre un periodo de 18 meses, estimando los costes directos —adquisición del fármaco, preparación, administración y costes de monitorización— desde la perspectiva del sistema de salud. Se realizaron varios análisis de sensibilidad con diferentes supuestos para los costes unitarios, añadiendo escenarios que incluían el rango intercuartílico de los resultados en el grupo de la pauta individualizada, diferente número de visitas de control para el grupo que seguía el esquema fijo y distinto número de eventos adversos registrados. Se realizó un análisis de coste-efectividad como parte del análisis de sensibilidad usando la diferencia absoluta en la tasa de recaída y su intervalo de confianza. [Resultados]: El esquema de tratamiento con la pauta individualizada demostró una reducción del coste en comparación con el esquema de dosis fijas (6.049 versus 7.850 euros). El ahorro se debió principalmente a un menor coste en la adquisición del fármaco (2.861 versus 4.768 euros) y a menos costes de preparación y administración (892 versus 1.486 euros), debido al menor número de infusiones por paciente en el brazo del esquema individualizado. Este esquema individualizado presentó mayores costes de monitorización (2.296 versus 1.596 euros). Este resultado se repitió en todos los supuestos considerados en el análisis de sensibilidad desde el enfoque de minimización de costes. [Conclusiones]: Desde la perspectiva del sistema de salud, la pauta individualizada parece ser la opción preferible en términos de costes directos. No obstante, son necesarios más estudios que evalúen todos los efectos y costes asociados al tratamiento de mantenimiento con rituximab de la vasculitis por anticuerpo anticitoplasma de neutrófilo para respaldar el manejo clínico y la asistencia sanitaria

Prescripción en pacientes con alergia a medicamentos: análisis crítico de un sistema de alertas integrado en la historia clínica

The prevalence of drug allergies is increasing, with as many as 25% of the general adult population affected in USA. In hospitals, drug-allergy interactions are one important cause of adverse drug events (ADEs). These events are preventable when the patient had a previous documented allergy to the drug that is prescribed. Computerized physician order entry (CPOE) with clinical decision support (CDS) has been implemented in most Health Care Systems to improve patient safety and the quality of care. These systems generate alert warnings regarding potential ADEs. CPOE with a drug allergy alert system (DAAS) is an important tool to prevent the prescription of medications to which the patient has a documented allergy and allergy-related medication events. However, these systems are not free of drawbacks (e.g. alert fatigue, unnecessary alerts) and their evaluation is necessary to improve their effectiveness. In our hospital, a homemade DAAS was implemented in 2007 and its evaluation was warranted. The objectives of this study were to review the evidence regarding DAAS, and to evaluate the DAAS of our information system (Clínica Universidad de Navarra Information System (SI-CUN)) analysing drug allergy alerts triggered by our DAAS, and the clinical consequences of drug allergy alert overrides. A PubMed and Cochrane databases search was conducted looking for articles describing electronic DAAS. Seventeen different DAAS were identified. Systems differ in recorded drug allergy information, rule bases that generate the alerts, type of matches or the information shown in the alerts. We found no comparative studies between them to identify the most effective system. However, we can extract some general recommendations. For example, to codify drug allergies information and override reasons and to register reactions suffered by patients. Alerts information has to be easy to understand. To evaluate SI-CUN drug allergy system, we conducted a retrospective observational study of DAA generated from 2014 to 2016. A total of 6,123 drug allergy alerts were triggered and after duplicated alerts were eliminated, 4,564 alerts remained for analysis. DAA were more frequently triggered by a non-exact match and when ordering antiinfectives and nervous system drugs. The override rate was 44.8% and the main reasons given by prescribers were that the patient had tolerated the ordered drug or had not allergy or the allergy was uncertain, and that the patient had a prior administration of the drug or was taking it already. Clinical consequences of alert overrides were analysed in a retrospective observational study of a random sample of 194 overridden DAA generated between 2014 and 2016. A chart review was conducted to identify allergic ADEs. Six (3.09%) allergic ADEs were identified. Most ADEs were cutaneous and were classified as mild. Most alerts were appropriately overridden. The literature analysis together with the SI-CUN drug allergy alerts analysis and the clinical consequences of overrides evaluation allow making recommendations for systems improvement. Drug allergy information has to be to be accurate, codified and updated. It is necessary to identify important and clinical value alerts to reduce alert override and alert fatigue; some alerts that are frequently overridden with no clinical consequences, such as non-antibiotic sulfonamide alerts, can be eliminated or changed to non-interruptive information. Every medication has to be prescribed through the standard procedure to generate alerts when needed. Intelligent systems, that automatically update the information and change to non-interruptive information those alerts that are continuously overridden, would make the process easier. A committee must be created to regularly analyse the system, implement improvements and evaluate their impact as part of a quality control process to improve patients safety