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Mahlknecht A, Wiedermann CJ, Sandri M, Engl A, Valentini M, Vögele A, Schmid S, Deflorian F, Montalbano C, Koper D, Bellmann R, Sönnichsen A, Piccoliori G. Expert-based medication reviews to reduce polypharmacy in older patients in primary care: a northern-Italian cluster-randomised controlled trial. BMC Geriatr 2021; 21:659. [PMID: 34814835 PMCID: PMC8609829 DOI: 10.1186/s12877-021-02612-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/01/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Evidence regarding clinically relevant effects of interventions aiming at reducing polypharmacy is weak, especially for the primary care setting. This study was initiated with the objective to achieve clinical benefits for older patients (aged 75+) by means of evidence-based reduction of polypharmacy (defined as ≥8 prescribed drugs) and inappropriate prescribing in general practice. METHODS The cluster-randomised controlled trial involved general practitioners and patients in a northern-Italian region. The intervention consisted of a review of patient's medication regimens by three experts who gave specific recommendations for drug discontinuation. Main outcome measures were non-elective hospital admissions or death within 24 months (composite primary endpoint). Secondary outcomes were drug numbers, hospital admissions, mortality, falls, fractures, quality of life, affective status, cognitive function. RESULTS Twenty-two GPs/307 patients participated in the intervention group, 21 GPs/272 patients in the control group. One hundred twenty-five patients (40.7%) experienced the primary outcome in the intervention group, 87 patients (32.0%) in the control group. The adjusted rates of occurrence of the primary outcome did not differ significantly between the study groups (intention-to-treat analysis: adjusted odds ratio 1.46, 95%CI 0.99-2.18, p = 0.06; per-protocol analysis: adjusted OR 1.33, 95%CI 0.87-2.04, p = 0.2). Hospitalisations as single endpoint occurred more frequently in the intervention group according to the unadjusted analysis (OR 1.61, 95%CI 1.03-2.51, p = 0.04) but not in the adjusted analysis (OR 1.39, 95%CI 0.95-2.03, p = 0.09). Falls occurred less frequently in the intervention group (adjusted OR 0.55, 95%CI 0.31-0.98; p = 0.04). No significant differences were found regarding the other outcomes. Definitive discontinuation was obtained for 67 (16.0%) of 419 drugs rated as inappropriate. About 6% of the prescribed drugs were PIMs. CONCLUSIONS No conclusive effects were found regarding mortality and non-elective hospitalisations as composite respectively single endpoints. Falls were significantly reduced in the intervention group, although definitive discontinuation was achieved for only one out of six inappropriate drugs. These results indicate that (1) even a modest reduction of inappropriate medications may entail positive clinical effects, and that (2) focusing on evidence-based new drug prescriptions and prevention of polypharmacy may be more effective than deprescribing. TRIAL REGISTRATION Current Controlled Trials (ID ISRCTN: 38449870), date: 11/09/2013.
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Affiliation(s)
- Angelika Mahlknecht
- Institute of General Practice and Public Health, College of Health Care Professions, Lorenz Böhler- Street 13, 39100, Bolzano, Italy. .,Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria.
| | - Christian J Wiedermann
- Institute of General Practice and Public Health, College of Health Care Professions, Lorenz Böhler- Street 13, 39100, Bolzano, Italy.,UMIT - Private University for Health Sciences, Medical Informatics and Technology - Tyrol, Eduard-Wallnöfer-Zentrum 1, 6060, Hall in Tirol, Austria
| | - Marco Sandri
- Big & Open Data Innovation Laboratory (BODaI-Lab), University of Brescia, Via S. Faustino 74/B, 25122, Brescia, Italy
| | - Adolf Engl
- Institute of General Practice and Public Health, College of Health Care Professions, Lorenz Böhler- Street 13, 39100, Bolzano, Italy
| | - Martina Valentini
- South Tyrolean Academy of General Practice, Wangergasse 18, 39100, Bolzano, Italy
| | - Anna Vögele
- South Tyrolean Academy of General Practice, Wangergasse 18, 39100, Bolzano, Italy
| | - Sara Schmid
- South Tyrolean Academy of General Practice, Wangergasse 18, 39100, Bolzano, Italy
| | - Felix Deflorian
- South Tyrolean Academy of General Practice, Wangergasse 18, 39100, Bolzano, Italy
| | - Carmelo Montalbano
- Genomedics S.r.L. Health Care Consultants, Via Sestese 61, 50141, Florence, Italy
| | - Dara Koper
- Salzburger Gesundheitsfonds, Sebastian Stief-Gasse 2, 5020, Salzburg, Austria
| | - Romuald Bellmann
- Clinical Pharmacokinetics Unit, Division of Medical Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Peter-Anich- Street 35, 6020, Innsbruck, Austria
| | - Andreas Sönnichsen
- Department of General Practice and Family Medicine, Center for Public Health, Medical University of Vienna, Kinderspitalgasse 15/I, 1090, Vienna, Austria
| | - Giuliano Piccoliori
- Institute of General Practice and Public Health, College of Health Care Professions, Lorenz Böhler- Street 13, 39100, Bolzano, Italy
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Piccoliori G, Mahlknecht A, Abuzahra ME, Engl A, Breitenberger V, Vögele A, Montalbano C, Sönnichsen A. Quality improvement in chronic care by self-audit, benchmarking and networking in general practices in South Tyrol, Italy: results from an interventional study. Fam Pract 2021; 38:253-258. [PMID: 33184661 DOI: 10.1093/fampra/cmaa123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Systematic strategies promoting quality of care in general practice are yet under-represented in several European countries. OBJECTIVE This interventional study assessed whether a combined intervention (self-audit, benchmarking, quality circles) improved quality of care in Salzburg, Austria and South Tyrol, Italy. The present publication reports the Italian results. METHODS We developed quality indicators for general practice in a consensus process based on pre-existing quality programmes. The indicators addressed diagnosis and treatment regarding eight common chronic conditions. A quality score comprising 91 indicators was calculated (0-5 points per indicator depending on fulfilment, maximum 455 points). We collected anonymous data from the electronic health records of the participating physicians in 2012, 2013 and 2014. Wilcoxon signed-rank tests were used for pre-post analysis. RESULTS Thirty-six GPs participated in the study. The median quality score increased significantly from 177.0 points at baseline to 272.0 points at the second follow-up (P = 0.000). Improvements concerned process and intermediate outcome indicators particularly between baseline and the first follow-up. CONCLUSION Performance was relatively low at baseline and improved considerably, mainly in the first study period. The intervention investigated in this study can serve as a model for future quality programmes. A customized electronic health record for the implementation of this intervention as well as standardized and consistent documentation by GPs is a prerequisite. Use of a limited set of quality indicators (QIs) and regular QI modification is probably advisable to increase the benefits. Long-term prospective studies should investigate the impact of QI-based interventions on end-result outcomes.
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Affiliation(s)
- Giuliano Piccoliori
- South Tyrolean Academy of General Practice, Bolzano, Italy.,Institute of General Practice, College of Health Care Professions, Bolzano, Italy
| | - Angelika Mahlknecht
- Institute of General Practice, College of Health Care Professions, Bolzano, Italy.,Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Muna E Abuzahra
- Institute for General Medicine and Evidence-Based Health Services Research, Medical University of Graz, Graz, Austria
| | - Adolf Engl
- South Tyrolean Academy of General Practice, Bolzano, Italy.,Institute of General Practice, College of Health Care Professions, Bolzano, Italy
| | - Vera Breitenberger
- Institute of General Practice, College of Health Care Professions, Bolzano, Italy
| | - Anna Vögele
- South Tyrolean Academy of General Practice, Bolzano, Italy
| | | | - Andreas Sönnichsen
- Department of General Practice and Family Medicine, Center of Public Health, Medical University of Vienna, Vienna, Austria
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Calcaterra V, Montalbano C, Miceli E, Luinetti O, Albertini R, Vinci F, Regalbuto C, Larizza D. Anti-gastric parietal cell antibodies for autoimmune gastritis screening in juvenile autoimmune thyroid disease. J Endocrinol Invest 2020; 43:81-86. [PMID: 31264142 DOI: 10.1007/s40618-019-01081-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Patients with autoimmune thyroid disease (ATD) have a higher prevalence of autoimmune gastritis (AIG) compared with the general population. The association between ATD and AIG is poorly characterized in the pediatric age. We reviewed the prevalence of anti-gastric parietal cell antibodies (PCA) in young patients with ATD to evaluate its usefulness as a marker for AIG screening. METHODS We evaluated 220 children and adolescents (11.28 ± 6.37 years) with ATD (186 with autoimmune thyroiditis (AT) and 34 with Graves' disease (GD). At ATD diagnosis and annually thereafter, blood counts and PCA levels were measured. In patients positive for PCA, plasma gastrin, chromogranin A, vitamin B12, iron and ferritin levels and H. pylori antigen were measured. PCA-positive patients > 18 years were invited to undergo a gastroscopic exam. RESULTS PCA positivity was detected in ten (4.5%) subjects (5F/5M; 12.6 ± 3.4 years). The prevalence of PCA positivity was not significantly different in the comparison of GD and AT patients (p = 0.9). PCA positivity was detected after 2.7 ± 2.7 years of follow-up in AT and 4.4 ± 4.0 years in GD (p = 0.4). Autoantibody positivity was more prevalent in female patients, in both AT and GD (p = 0.02 and p = 0.03, respectively). At detection of PCA positivity, five out of ten PCA-positive patients had iron deficiency, four vitamin B12 deficiency, two anemia, three hypergastrinemia and two elevated chromogranin values. Two patients had H. pylori infection. Gastroscopy was performed in the five ATD patients and in all patients, AIG was confirmed. CONCLUSION In the juvenile population, ATD and AIG may also be associated. PCA screening is useful to detect subjects at risk for this condition. Due to the longer life expectancy of the pediatric population and considering the relatively high risk of malignant transformation, early surveillance monitoring is mandatory for children and adolescents with ATD.
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Affiliation(s)
- V Calcaterra
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, Pavia, Italy.
- Pediatric Endocrinology Unit, Department of Maternal and Children's Health, Fondazione IRCCS Policlinico San Matteo, P.le Golgi n.2, 27100, Pavia, Italy.
| | - C Montalbano
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, Pavia, Italy
- Pediatric Endocrinology Unit, Department of Maternal and Children's Health, Fondazione IRCCS Policlinico San Matteo, P.le Golgi n.2, 27100, Pavia, Italy
| | - E Miceli
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - O Luinetti
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Pathology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - R Albertini
- Laboratory of Clinical Chemistry, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - F Vinci
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, Pavia, Italy
- Pediatric Endocrinology Unit, Department of Maternal and Children's Health, Fondazione IRCCS Policlinico San Matteo, P.le Golgi n.2, 27100, Pavia, Italy
| | - C Regalbuto
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, Pavia, Italy
- Pediatric Endocrinology Unit, Department of Maternal and Children's Health, Fondazione IRCCS Policlinico San Matteo, P.le Golgi n.2, 27100, Pavia, Italy
| | - D Larizza
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, Pavia, Italy
- Pediatric Endocrinology Unit, Department of Maternal and Children's Health, Fondazione IRCCS Policlinico San Matteo, P.le Golgi n.2, 27100, Pavia, Italy
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Moretta P, Masotta O, Crispino E, Castronovo G, Ruvolo S, Montalbano C, Loreto V, Trojano L, Estraneo A. Psychological distress is associated with altered cognitive functioning in family caregivers of patients with disorders of consciousness. Brain Inj 2017; 31:1088-1093. [PMID: 28414249 DOI: 10.1080/02699052.2017.1290278] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To analyse the possible presence of reduced cognitive efficiency in family caregivers of patients with prolonged disorders of consciousness (DOC). SUBJECTS The participants were 27 caregivers of 25 patients with DOC admitted to the severe brain injury units of the ICS Maugeri, Institutes of Telese Terme and Sciacca, Italy. METHODS We examined cognitive functions such as short- and long-term memory, executive functions and attention by means of standardized tests. We also assessed features of psychological distress such as anxiety, depression, psychophysiological symptoms, prolonged grief disorder, psychological burden and quality of life. All scores on neuropsychological tests were compared with those of the 15 matched control subjects. RESULTS Enrolled family caregivers showed high frequency of clinically relevant depressive symptoms and anxiety; half of them met the criteria for prolonged grief disorder. Caregivers achieved scores lower than the matched controls on tests for selective attention, verbal fluency and long-term spatial memory. CONCLUSIONS Family caregivers' burden is associated with a reduced efficiency of selected executive measures and visuospatial learning. These results emphasize the need for appropriate psychological and cognitive supporting therapies for family caregivers of patients with DOC, also considering their delicate involvement in clinical decision-making and in providing care.
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Affiliation(s)
- P Moretta
- a Disorders of Consciousness Laboratory, ICS Maugeri, IRCCS , Scientific Institute of Telese Terme , Telese Terme , Italy
| | - O Masotta
- a Disorders of Consciousness Laboratory, ICS Maugeri, IRCCS , Scientific Institute of Telese Terme , Telese Terme , Italy
| | - E Crispino
- a Disorders of Consciousness Laboratory, ICS Maugeri, IRCCS , Scientific Institute of Telese Terme , Telese Terme , Italy
| | - G Castronovo
- b ICS Maugeri, Neurorehabilitation Unit , Presidio Sanitario di Sciacca , Sciacca , Italy
| | - S Ruvolo
- b ICS Maugeri, Neurorehabilitation Unit , Presidio Sanitario di Sciacca , Sciacca , Italy
| | - C Montalbano
- b ICS Maugeri, Neurorehabilitation Unit , Presidio Sanitario di Sciacca , Sciacca , Italy
| | - V Loreto
- a Disorders of Consciousness Laboratory, ICS Maugeri, IRCCS , Scientific Institute of Telese Terme , Telese Terme , Italy
| | - L Trojano
- a Disorders of Consciousness Laboratory, ICS Maugeri, IRCCS , Scientific Institute of Telese Terme , Telese Terme , Italy.,c Neuropsychology Laboratory, Department of Psychology , University of Campania 'Luigi Vanvitelli' , Caserta , Italy
| | - A Estraneo
- a Disorders of Consciousness Laboratory, ICS Maugeri, IRCCS , Scientific Institute of Telese Terme , Telese Terme , Italy
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Gini R, Schuemie MJ, Mazzaglia G, Lapi F, Francesconi P, Pasqua A, Bianchini E, Montalbano C, Roberto G, Barletta V, Cricelli I, Cricelli C, Dal Co G, Bellentani M, Sturkenboom M, Klazinga N. Automatic identification of type 2 diabetes, hypertension, ischaemic heart disease, heart failure and their levels of severity from Italian General Practitioners' electronic medical records: a validation study. BMJ Open 2016; 6:e012413. [PMID: 27940627 PMCID: PMC5168667 DOI: 10.1136/bmjopen-2016-012413] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES The Italian project MATRICE aimed to assess how well cases of type 2 diabetes (T2DM), hypertension, ischaemic heart disease (IHD) and heart failure (HF) and their levels of severity can be automatically extracted from the Health Search/CSD Longitudinal Patient Database (HSD). From the medical records of the general practitioners (GP) who volunteered to participate, cases were extracted by algorithms based on diagnosis codes, keywords, drug prescriptions and results of diagnostic tests. A random sample of identified cases was validated by interviewing their GPs. SETTING HSD is a database of primary care medical records. A panel of 12 GPs participated in this validation study. PARTICIPANTS 300 patients were sampled for each disease, except for HF, where 243 patients were assessed. OUTCOME MEASURES The positive predictive value (PPV) was assessed for the presence/absence of each condition against the GP's response to the questionnaire, and Cohen's κ was calculated for agreement on the severity level. RESULTS The PPV was 100% (99% to 100%) for T2DM and hypertension, 98% (96% to 100%) for IHD and 55% (49% to 61%) for HF. Cohen's kappa for agreement on the severity level was 0.70 for T2DM and 0.69 for hypertension and IHD. CONCLUSIONS This study shows that individuals with T2DM, hypertension or IHD can be validly identified in HSD by automated identification algorithms. Automatic queries for levels of severity of the same diseases compare well with the corresponding clinical definitions, but some misclassification occurs. For HF, further research is needed to refine the current algorithm.
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Affiliation(s)
- Rosa Gini
- Agenzia regionale di sanità della Toscana, Osservatorio di epidemiologia, Florence, Italy
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Martijn J Schuemie
- Department of EpidemiologyJanssen Research & Development, Titusville, New Jersey, USA
- Observational Health Data Sciences and Informatics (OHDSI), New York, New York, USA
| | - Giampiero Mazzaglia
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Francesco Lapi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Paolo Francesconi
- Agenzia regionale di sanità della Toscana, Osservatorio di epidemiologia, Florence, Italy
| | - Alessandro Pasqua
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Elisa Bianchini
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | | | - Giuseppe Roberto
- Agenzia regionale di sanità della Toscana, Osservatorio di epidemiologia, Florence, Italy
| | - Valentina Barletta
- Agenzia regionale di sanità della Toscana, Osservatorio di epidemiologia, Florence, Italy
| | | | - Claudio Cricelli
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Giulia Dal Co
- Agenzia Nazionale per il Servizi Sanitari Regionali, Rome, Italy
| | | | - Miriam Sturkenboom
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Niek Klazinga
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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