In-hospital mortality of high-risk pulmonary embolism: a nationwide population-based cohort study in Portugal from 2010 to 2018

BACKGROUND

The mortality associated with high-risk pulmonary embolism (PE) is remarkably high, and reperfusion to unload right ventricle should be a priority. However, several registries report reperfusion underuse. In Portugal, epidemiological data about the incidence, rate of reperfusion and mortality of high-risk PE are not known.

METHODS

Nationwide population-based temporal trend study in the incidence and outcome of high-risk PE, who were admitted to hospitals of the National Health Service in Portugal between 2010 and 2018. High-risk PE was defined as patients with PE who developed cardiogenic shock or cardiac arrest. International Classification of Diseases (ICD), 9th and 10th revision, Clinical Modification codes, were used for data from the period between 2010 and 2016 (ICD-9-CM) and 2017-2018 (ICD-10-CM), respectively. The assessment focused on trends in the use of reperfusion treatment, which was defined by application of thrombolysis or pulmonary embolectomy. A comparison was made between the use or non-use of reperfusion therapy in order to examine trends in in-hospital mortality among high-risk PE cases.

RESULTS

From 2010 and 2018, there were 40.311 hospitalization episodes for PE in adult patients at hospitals of the National Health Service in mainland Portugal. There was a significant increase in the annual incidence of PE (41/100.000 inhabitants in 2010 to 46/100.000 in 2018; R2=0.582, p = 0.010). The average annual incidence was 45/100.000 inhabitants/year, with 2,7% of the PE episodes (1104) categorized as high-risk. The mortality rate associated with high-risk PE was high, although it has decreased over the years (74.2% in 2010 to 63.6% in 2018; R2=0.484; p = 0.022). Thrombolytic therapy was underused in high-risk PE, and its usage has not increased in recent years (17.3% in 2010 to 21.1% in 2018, R2=-0.127; p = 0.763). Surgical pulmonary embolectomy was used in 0.27% of cases, and there was no registry of catheter-directed thrombolysis. Patients with high-risk PE undergoing reperfusion therapy had lower in-hospital mortality compared to non-reperfused patients (OR=0.52; IC95% 0.38-0.70).

CONCLUSION

In Portugal, between 2010 and 2018, very few patients with PE developed high-risk forms of the disease, but the mortality rate among those patients was high. The low reperfusion rate could be associated with high in-hospital mortality and highlights the need to implement advanced therapies, as an alternative to systemic thrombolysis.

Characteristics of Oral Corticosteroid Users Among Persons with Asthma on GINA Step 3 Therapy and Above: A Cross-Sectional Study in Portuguese Community Pharmacies

PURPOSE

Oral corticosteroids (OCS) are frequently used in asthma management but have an important risk-profile. The aim of the study is to characterize and compare the sociodemographic and clinical characteristics, treatment regimen and asthma control between OCS users and non-users among the population of asthma patients (≥18 years) at GINA step 3 and above treated with a fixed combination of an inhaled corticosteroid and a long-acting beta-agonist (ICS/LABA).

METHODS

Cross-sectional study in Portuguese community pharmacies. Data was collected via paper-based interview delivered at the pharmacy (sociodemographic characteristics and asthma treatment regimen, namely ICS/LABA and OCS utilization), followed by a telephonic interview collecting smoking history, comorbidities, body mass index (BMI), history of exacerbations and asthma-related healthcare resource utilization (HCRU) in the previous 12 months, as well as asthma control using the Control of Allergic Rhinitis and Asthma Test (CARAT®).

RESULTS

A total of 347 patients recruited in 98 pharmacies were included in the analysis. Of those, 328 had completed both questionnaires. A quarter of the individuals reported OCS use in the previous 12 months (OCS users), either as add-on therapy (6%) or exacerbation treatment (19%). Patients were mostly females (72%), with an average age of 59.5 years (SD=15.4). OCS users were significantly older and reported more frequently having conjunctivitis (25.9% vs 15.0%), osteoporosis (25.9% vs 13.4%), arthritis (14.6% vs 6.9%), and gastrointestinal disease (16.1% vs 8.1%). OCS users also reported greater urgent HCRU: unscheduled consultations (33.3% vs 9.3%) and emergency department (ED) visits (32.1% vs 12.1%). Both groups presented poor disease control (85.2% of OCS users vs 72.9% of non-OCS users).

CONCLUSION

These results highlight the burden of OCS therapy to asthma patients and the need to improve asthma management, by adopting OCS sparing strategies in this subgroup of patients.

Real-World Impact of Transferring the Dispensing of Hospital-Only Medicines to Community Pharmacies During the COVID-19 Pandemic

OBJECTIVES

In Portugal, the dispensing of most outpatient specialty medicines is performed exclusively through hospital pharmacies and totally financed by the National Health Service. During the COVID-19 first wave, the government allowed the transfer of the dispensing of hospital-only medicines (HOMs) to community pharmacies (CPs). This study aimed to measure the value generated by the intervention of CP in the dispensing of HOM.

METHODS

A single-arm, before-and-after study with 3-month follow-up was conducted enrolling a randomly selected sample of patients or caregivers with at least 1 dispensation of HOM through CP. Data were collected by telephone interview. Main outcomes were patients' self-reported adherence (Measure Treatment Adherence), health-related quality of life (EQ-5D 3-Level), satisfaction with the service, and costs related to HOM access.

RESULTS

Overall 603 subjects were recruited to participate in the study (males 50.6%) with mean 55 years old (SD = 16). The already high mean adherence score to therapy improved significantly (P < .0001), and no statistically significant change (P > .5757) was found in the mean EQ-5D score between baseline (0.7 ± 0.3) and 3-month follow-up (0.8 ± 0.3). Annual savings account for €262.1/person, arising from travel expenses and absenteeism reduction. Participants reported a significant increase in satisfaction levels in all evaluated domains-pharmacist's availability, opening hours, waiting time, privacy conditions, and overall experience.

CONCLUSIONS

Changing the dispense setting to CP may promote better access and satisfaction. Moreover, it ensures the persistence of treatments, promotes savings for citizens, and reduces the burden of healthcare services, representing a crucial public health measure.

Effectiveness of a pharmacist-led intervention on inhalation technique for asthma and COPD patients: The INSPIRA pilot cluster-randomized controlled trial

INTRODUCTION

Asthma and COPD are leading causes of disability-adjusted life-years worldwide representing a huge burden on the health system and among patients. One of the reasons for the lack of disease control is poor inhalation technique, with impact on quality of life and symptom control.

OBJECTIVE

To assess the effectiveness of a community pharmacist-led educational intervention on asthma and COPD patients' inhalation technique.

METHODS

The INspira study is a 6-month pilot cluster randomized controlled trial, conducted in community pharmacies of Portugal, enrolling adults aged 18 years or older, with a self-reported diagnosis of asthma or COPD and on inhaled therapy. Pharmacies were randomly allocated to Intervention or Control group. Intervention focused mainly on inhalation technique education via demonstration and repetition. Primary outcome was the proportion of patients scoring 100% in at least one inhaler.

RESULTS

From January to November 2019, 48 pharmacies recruited 201 asthma and COPD patients, of which 132 completed the 6-month follow-up. At the end of follow-up, the odds of intervention group patients score 100% compared to the control group were 5.63 (95% CI, [2.21; 14.35]) in all inhalers in use and 6.77 (95% CI, [2.52; 18.20]) considering at least one inhaler. Intervention group patients reported having a significantly lower number of scheduled appointments compared with the control group (OR = 0.17; 95% CI, [0.037; 0.79]; p = 0.0135). No other significant differences were found between groups.

CONCLUSION

This pilot study suggested that pharmacist interventions can improve patients' inhalation technique, with possible positive impact in healthcare resource use.

MisuMedPT - Morbi-mortality consequences of misuse of psychoactive prescription drugs in Portugal

Background

In Portugal, there are no published data on the health-related consequences of prescription drug misuse, which is therefore a public health issue of unknown dimension in our country. Poison control centres and other pharmacoepidemiological sources can be part of a surveillance system for monitoring medicine's use and misuse.

Methods

Retrospective observational study of intentional exposures to opioid analgesics, antiepileptics, antidepressants, anxiolytics, hypnotics and sedatives reported to the Portuguese Poison Information Centre (CIAV) between 2014 and 2018. Variables studied were demographic characteristics of individuals, geographic distribution of calls, co-exposure to alcohol or illicit drugs, call origin, case evaluation and guidance.

Results

CIAV received 24624 calls reporting 34203 intentional exposures to any medicine, 31169 (91.1%) of which involving one of the studied psychoactive medicines and 20906 exposures having emergency room advice or effective hospitalisation. The most frequently involved medicines were benzodiazepines (62.0%) - alprazolam (15.4%) and diazepam (12.0%) - with trazodone ranking fifth (6.0%). Combination with non-medicinal products was seen in 2169 calls (9.4%), 2052 (94.6%) of which with alcohol.

Conclusions

There is female predominance in the poisonings reported involving any of the medicines studied. Benzodiazepines and antidepressants are the top classes reported. The rate of intentional exposures to psychoactive medicines is higher in Coimbra district, whose significant university student population requires further analysis of data. To adjust for the variability in the level of medicines' use in the population, work is undergoing to include rates of intentional poisonings in patients prescribed the studied medicines. To better characterise the potential consequences of misuse of psychoactive prescription drugs in Portugal, additional data on deaths involving these medicines will also be included in the project.

Key messages

First published Portuguese data on prescription drug poisoning reported to CIAV. First Portuguese project to analyse prescription drug poisoning, forensic and hospitalisation data.