Trans-arterial chemoembolization with doxorubicin-eluting particles versus conventional trans-arterial chemoembolization in unresectable hepatocellular carcinoma: A study of effectiveness, safety and costs

OBJECTIVES

To compare the effectiveness, survival and cost in patients with unresectable hepatic cell carcinoma (HCC) treated with trans-arterial chemoembolization using doxorubicin-eluting beads (DEB-TACE) versus conventional TACE (cTACE) in clinical practice.

MATERIAL AND METHODS

This single-centered retrospective observational study compared 60 consecutive HCC unresectable patients: 30 were treated with DEB-TACE and 30 used cTACE. Comparisons were with χ(2) test, Student t-test, and Kaplan Meier method.

RESULTS

Of the 60 patients with HCC in non-curative stage, baseline characteristics were similar for both groups of treatment, and of these we observed lower survival in male patients and those who had hepatitis C virus (p=0.014 and p=0.003, respectively). No statistically significant differences were observed as a function of treatment employed with respect to overall survival (OS) at 5 years (29.99 months; 95%CI: 21.38-38.60 versus 30.67 months; 95%CI:22.65-38.70; p=0.626) and progression free survival (PFS) median of 11.57 months (95%CI: 0.97-22.18) versus 12.80 months (95%CI:0.00-32.37; p=0.618). The median length of hospital admission were 2.6 and 5.4 days (p<0.001) for DEB(-)TACE and cTACE, respectively. Toxicities grade 2-4 were higher in cTACE group (54 versus 31; p<0.001). The cost of the treatment was 1581 € for DEB(-)TACE and 514.63 € for cTACE. The overall mean cost of intervention was 3134 € and 3694.35 €, respectively (p=0.173).

CONCLUSIONS

Chemoembolization in patients with unresectable HCC achieved OS close to 30 months at 5 years, independent of the technique employed. Similar overall costs but better tolerance of the DEB-TACE justified the higher costs of the procedure.

[Effectiveness and adequacy of tolvaptan prescription in hospitalized patients]

PURPOSE

To analyse the effectiveness of the use of Tolvaptan and the adequacy of Tolvaptan prescription at a tertiary level hospital.

METHODS

Prospective observational study of Tolvaptan prescrip - tion from October of 2010 to December of 2011.

RESULTS

30 patients (60.0% males) were included, 50.0% of which were diagnosed with heart failure and 30.0% with SIADH. Tolvaptan allowed achieving sodium levels higher than 135 mEq/L in 53.3% of the patients with a mean baseline value of 125.3±7.3 mEq/L. The median treatment duration was 5.0 days (interquartile range=3-45). A significant increase of uric acid associated to Tolvaptan treatment was observed. The prescription was in agreement to what has been established in GFT in 63.3% of the cases.

CONCLUSIONS

Tolvaptan increases sodium levels by 7.5 mEq/L, both in SIADH-associated hyponatremia and in heart failure, with an appropriate safety profile.

[Analysis of the causes leading to withdrawal of the treatment with triple antiviral therapy for hepatitis C patients]

OBJECTIVE

To assess causes of suspension of hepatitis C treatment in patients receiving triple antiviral therapy (peginterferon+ ribavirin + protease inhibitor).

METHODS

Retrospective observational study of patients who received triple antiretroviral therapy against hepatitis C between January 2012 - March 2013 and discontinued their treatment.

RESULTS

Of 156 patients who initiated therapy, 41 discontinued treatment: Nineteen due to adverse events, being dermatological events in seven patients ( 36.8 %), intolerance in six(31.6%) and hematologic toxicity in four (15.8%) . Sixteen patients discontinued treatment for being ineffectiveness.Patients with higher inefficacy failure rate were "null-responders"(32.3% ) while the group of "relapsers" were the one with the highest rate of toxicity suspensions (15.6%). Two patients died during treatment for pneumonia.

CONCLUSIONS

Triple therapy with boceprevir and telaprevir is associated with a significant number of treatment failures due to toxicity and ineffectiveness.

Clinical experiences with cannabinoids in spasticity management in multiple sclerosis

INTRODUCTION

Spasticity is a common symptom among patients with multiple sclerosis (MS). This study aims to assess the effectiveness and safety of the combination of delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) in clinical practice for the treatment of spasticity in MS.

METHODS

Retrospective observational study with patients treated with inhaled THC/CBD between April 2008 and March 2012. Descriptive patient and treatment variables were collected. Therapeutic response was evaluated based on the doctor's analysis and overall impression.

RESULTS

Of the 56 patients who started treatment with THC/CBD, 6 were excluded because of missing data. We evaluated 50 patients (42% male) with a median age 47.8 years (25.6-76.8); 38% were diagnosed with primary progressive MS, 44% with secondary progressive MS, and 18% with relapsing-remitting MS. The reason for prescribing the drug was spasticity (44%), pain (10%), or both (46%). Treatment was discontinued in 16 patients because of ineffectiveness (7 patients), withdrawal (4), and adverse effects (5). The median exposure time in patients whose treatment was discontinued was 30 days vs 174 days in those whose treatment continued at the end of the study. THC/CBD was effective in 80% of patients at a median dose of 5 (2-10) inhalations/day. The adverse event profile consisted of dizziness (11 patients), somnolence (6), muscle weakness (7), oral discomfort (2), diarrhoea (3), dry mouth (2), blurred vision (2), agitation (1), nausea (1), and paranoid ideation (1).

CONCLUSIONS

THC/CBD appears to be a good alternative to standard treatment as it improves refractory spasticity in MS and has an acceptable toxicity profile.

[Assessment of a reconciliation and information programme for heart transplant patients]

INTRODUCTION

The objective is to assess a pharmaceutical care programme for heart transplant patients upon patient admission and discharge.

MATERIAL AND METHODS

Observational study of heart transplant patients, performed during the first quarter of 2007. Upon admission, the patient was interviewed regarding home treatments, adherence, allergies and adverse effects, and his/her prescriptions were compared with the last discharge report (drug reconciliation). At time of discharge, treatment was checked against the last hospital prescription (reconciliation) and an informative report was drawn up and personally delivered to the patient. Subsequently, a satisfaction questionnaire was carried out by telephone. Drug-related problems were recorded using Atefarm software.

RESULTS

The programme was applied to 24 patients upon admission and 23 upon discharge. No drug interactions were detected. Treatment adherence was higher than 90%. 37.5% of patients informed of an adverse reaction. Medication-related problems were identified in 16 patients (45.7%) for 6.6% of medications, most of which (38%) were for infection prophylaxis; medication omission was the most frequently-detected error. Positive evaluation of the information that was received was higher than 90%.

CONCLUSIONS

Pharmacotherapeutic follow-up upon admission and discharge resolves and prevents problems while improving patient information and satisfaction. Limitations on personnel prevent the population's requests from being met.

[Quality of drug treatment process through medication errors in a tertiary hospital]

OBJECTIVE

To assess the quality of drug treatment process in a unit-dose and assisted electronic prescription system in a tertiary hospital, by looking at medication errors.

METHODS

A prospective, observational study into medication errors was carried out on 308 hospitalised patients. This was done by assessing medical prescriptions, pharmaceutical validation, prepared and dispensed medication and by directly observing drug administration. The variable, i.e. the medication error, was analysed in the drug treatment process so as to decipher the type and cause of the error. Quality indicators were defined at each stage (percentage relationship between errors and opportunities for error).

RESULTS

Of the 308 patients studied, 107 had at least 1 medication error (34.7%). There were a total of 137 errors: omission of allergy and prescription description (20.4%), prescription/validation (28.5%), dispensing (23.4%) and drug administration (27.7%). The most frequent error was dose omission (19.7%) and choice of pharmaceutical product (16.1%). The most common cause of error was forgetfulness or a lack of attention to detail (53.3%). The quality indicators by stage were: 2.3% for omission of the patient's allergies; 0.9% for prescription; 1.6% for prescription/validation; 8.2% for dispensing, and 2.1% for drug administration.

CONCLUSIONS

It is estimated that 35 patients in every 100 experience errors in their drug treatment process. Opportunities for improvement are identified based on standardisation and training for professionals in carrying out technical tasks and using technology.

[Medication errors in a tertiary hospital with three different drug delivery systems]

OBJECTIVE

To estimate the proportion of medication errors in a tertiary hospital, global and for each delivery medication system, to describe the error types and the implied medications, and to analyze the factors associated to the same ones.

METHODS

Errors were identified from direct observation of 2,242 opportunities for error (administered doses or prescribed doses not given) by 6 couples of observers. Delivery medication systems were stock in ward, unit dose with electronic prescription and unit dose with computerized transcription. Logistic regression was used to evaluate the association between errors and certain factors.

RESULTS

The medication error rate was of 7.2% (CI 95%: 6.1-8.3), and 4.4% (CI 95%: 3.6-5.3) of them reached the patient. For delivery systems, the error rate was of 9.5% (CI 95%: 7.4-11.9) for stock in ward, 7.8% (CI 95%: 5.9-10.0) for electronic prescription and 4.7% (CI 95%: 3.4-6.4) for computerized transcription. The highest error frequency was observed in the administration phase (58.4%) and the omitted dose was the most prevalent error (31.7%). The error rate was associated to the pharmacotherapeutic process, the schedule of administration and the unit of hospitalization.

CONCLUSIONS

In one of each 14 opportunities for error a medication error takes place. The different delivery medication systems have different error rates.

[Daptomycin: revitalizing a former drug due to the need of new active agents against grampositive multiresistant bacterias]

The development of mechanisms of resistance of many Gram-positive bacterial strains that cause complicated skin and soft tissue infections, as well as sepsis and bacteremia, has necessitated the search for new drugs that will improve treatment strategies. Daptomycin is a cyclic lipopeptide antibacterial that was launched for the treatment of complicated skin and soft tissue infections caused by Gram-positive organisms. The drug's mechanism of action is different from that of any other antibiotic. It binds to bacterial membranes and causes a rapid depolarization of membrane potential. This loss of membrane potential causes inhibition of protein, DNA and RNA synthesis, which results in bacterial cell death. The in vitro spectrum of activity of daptomycin encompasses most clinically relevant aerobic Gram-positive pathogenic bacteria. Compared to other antibiotics with a similar antibacterial spectrum, daptomycin does not cause nephrotoxicity. Taking these and other characteristics into consideration, daptomycin appears to be a good alternative to other drugs used in the treatment of complicated skin and soft tissue infections and in Gram-positive bacteremial infections.

[Pharmaceutical care self-assessment process for hospitalized patients through the Valor program]

OBJECTIVE

To assess the quality of pharmaceutical care for inpatients using qualitative criteria as established in the Valor program.

METHOD

Evaluation study through 43 explicit structural, process, and outcome criteria within the Valor program, in which pharmacists in the Unit Dose Functional Unit may assess themselves along a compliance scale from 0 to 100%. This Unit provides daily individualized pharmaceutical care to 550 patients in an adult general and surgery hospital. Mean scores per pharmacist and item are estimated for the 2003-2005 period.

RESULTS

Mean compliance assessments for all 14 interannual "structural items" were 53, 57, and 64%; those for all 13 "process items" were 52, 51, and 46%; and those for all 15 "outcome items" were 18, 28, and 26%. A variability of 20% was documented for structure and process evaluations, and of 50% for outcome assessments.

CONCLUSIONS

Every autoevaluation raises to the equipment the necessity to establish improvements and to enhance communication, and the application of standardized procedures in the pharmaceutical care process.

Estudio de utilización y descripción de costes de eritropoyetina en pacientes hematológicos

OBJECTIVE

To assess the effectiveness of erythropoietin use in hematologic patients; to analyze the extent to which recommendations are applied as provided by Spanish prescribing information, American Society of Clinical Oncology (ASCO) and American Society of Hematology (ASH) guidelines, as well as specific recommendations for myelodysplastic syndromes (MDSs), and to perform a descriptive analysis of costs.

METHOD

A descriptive retrospective study. Patient selection was performed by Unidad de Atención Farmacéutica a Pacientes Externos (UFPE: Pharmaceutical Outpatient Care Unit) during a 3-month period of time. Follow-up was performed to month 9 after selection.

RESULTS

Thirty-six patients (37% males) were included. In the group of patients with multiple myeloma and lymphomas, effectiveness was 57%; while in the MDS group it was 45-64% (depending on criteria used to measure erythroid response). Of all 24 patients (MDSs excluded) only 4 (17%) met indication criteria--adjustment to erythroid response at 4 and 8 weeks, and dosage titration when needed. Continued treatment with erythropoietin in all non-responders amounted to 59-69% of total expense for non-responders.

CONCLUSIONS

There is a high percentage of therapy failures and inconsistency between erythropoietin use recommendations and clinical practice. This circumstance, as well as the high financial impact it entails, makes it essential that monitoring and follow-up strategies are implemented to contribute to an optimal usage of erythropoiesis stimulating factors.

Efecto de la administración concomitante de indometacina o ibuprofeno en la farmacocinética de amikacina en neonatos prematuros

OBJECTIVE

To evaluate whether the concomitant administration of ibuprofen or indomethacin plus amikacin may alter the latter drug s pharmacokinetic parameters, and hence amikacin plasma levels.

METHOD

Retrospective cohort study performed by reviewing the medical records of premature children with persistent ductus arteriosus receiving amikacin and ibuprofen, or amikacin and indomethacin. They were divided up into three groups: group 1: treatment with amikacin went before indomethacin or ibuprofen; group 2: simultaneously treated with amikacin and indomethacin; group 3: simultaneously treated with amikacin and ibuprofen. Pharmacokinetic parameters, distribution volume, and amikacin clearance were measured using the PKS program (a non-linear regression method). Half life was determined from previous parameters.

RESULTS

Twenty-eight patients were included. No statistically significant differences were found among pharmacokinetic parameters corresponding to each study group.

CONCLUSIONS

Further studies are needed with a greater number of patients and currently recommended doses to assess the influence of indomethacin and ibuprofen in the pharmacokinetics of amikacin in premature children with persistent ductus arteriosus.

[Leflunomide: assessing teratogenic risk during the first trimester of pregnancy]

OBJECTIVE

To assess the teratogenic risk associated with leflunomide during the first quarter of pregnancy, and to establish guidelines to minimize said risk.

METHOD

Literature search using tertiary, secondary, and primary sources related to teratogenicity, including databases (MEDLINE and EMBASE) and specific webs. The information required for assessment, as well as for the establishment of criteria was collected.

RESULTS

Leflunomide demonstrated an increased risk of fetal death and teratogenic effects in animals. No major or minor malformation cases have been reported in humans regarding leflunomide, which is classified within category X of fetal risk. A wash-out regimen may possibly reduce the risk for fetal harm.

CONCLUSIONS

Conception scheduling or early pregnancy detection is required for better clinical counselling and the avoidance of unnecessary risk.

Diseño de un módulo para la prevención de reacciones de hipersensibilidad en un sistema de prescripción electrónica asistida

OBJECTIVE

To develop a module for the prevention of drug-related allergies to be integrated within the assisted electronic prescription software PRISMA.

METHOD

On module design potential sources of medication errors regarding drug allergies were first analyzed, and ideal module characteristics were defined. Then a review of the literature was performed to define "group allergies", and last of all master archives were created, with their required relations being established.

RESULTS

A module for the prevention of drug-related allergies in the setting of an assisted electronic prescription software was designed. By interrelating tables listing active ingredients, excipients, chemical structures/functional groups, and "group allergies" prescriptions may be interactively checked, and useful information is provided to the prescribing practitioner--as well as the whole multidisciplinary team--to help him make his/her decisions.

[Analyzing the evolution of a Pharmacy Department using a relative value unit system]

INTRODUCTION

This study proposes the use of relative value units (RVU) as a clinical management tool to evaluate departmental services.

OBJECTIVES

To measure productivity from 2000 to 2002 by estimating RVU. To determine RVU cost in constant Euros and evaluate system efficiency during this period of time.

METHODS

Retrospective, observational study of a pharmacy department s production. RVU assigned to each activity have been obtained from a standardized document drawn up by the Sociedad Española de Farmacia Hospitalaria. Cost of each RVU was determined based on total cost assigned to the pharmacy department and the total number of RVUs produced.

RESULTS

Drug dispensation activities account for 76% of the total production, followed by elaboration activities (21%).

CONCLUSIONS

Productivity in our department has increased 46.48% in this period of time, while efficiency has increased by 23.8%.

[Therapeutic interchange of drugs not included in the hospitaĺs pharmacotherapeutic guide: a quality program]

BACKGROUND

Standardised substitution of those drugs not included in the hospitaĺs formulary constitutes one of several methods used to improve therapeutic efficiency, due to reduction of variability in pharmaceutical practice and prevention of potential medication errors.

OBJECTIVES

To evaluate quality of drug substitution procedures in those drugs not included in the hospital's formulary.

METHODS

Assessment study in a surgical hospital with 314 beds, using structural, process and outcome criteria from 1998 to 2002.

RESULTS

Compliance degree for structure, process and outcome criteria were 100, 89 and 35%, respectively, while the established standards were 100%. Prevalence values for patients with substituted medication, increased from 2.9 (95%CI, 2.4-3.6) in 1998 to 11.1% (95%CI, 10.2-12.1) in 2002. Non-substituted drugs annual cost decreased from 20,199 in 1998 to 12,356 Euro in 2002. Drug substitution made by the pharmacist had an acceptance degree of 82.5%. No interchange errors were found in 126 replaced drugs.

CONCLUSIONS

The development of quality programs to improve drug prescription adherence to the hospitaĺs formulary, specially those that promote therapeutic interchange under the Pharmacy Committee guidance, are helpful strategies to make a proficient management of patients pharmacotherapy.

[Cost-benefit analysis of a semi-automated process in the preparation of unit-doses by the Pharmacy Department]

OBJECTIVE

To determine in monetary terms the effect of implementing a semi-automated procedure for preparation of drugs for unit dose distribution.

METHODS

The current net value was estimated for three different flows involved in the evaluation of semi-automated drug storage and retrieval systems used in the unit dose distribution area in a hospital: capital investment, staff costs and structural costs related to physical space occupied.

RESULTS

Implantation of the new work procedure produced an annual saving of 32,390 euro in staff costs and 5,645 euro in structural costs. Global cash flow has been estimated in -96,565 euro for a five year amortization period, with a benefit/cost ratio of 2.19.

CONCLUSION

Replacement of traditional unit dose cart filling systems by a semi automated procedure presents a positive benefit/cost ratio and initial investment is paid off in 44 months.

[Cost-benefit analysis of the implementation of automated drug-dispensing systems in Critical Care and Emergency Units]

OBJECTIVE

To determine monetary impact when traditional drug floor stocks are replaced by Automated Drug Dispensing Systems (ADDS) in the Medical Intensive Care Unit, Surgical Intensive Care Unit and the Emergency Room.

METHODS

We analysed four different flows considered to be determinant when implementing ADDS in a hospital environment: capital investment, staff costs, inventory costs and costs related to drug use policies.

RESULTS

Costs were estimated by calculation of the current net value. Its analysis shows that those expenses derived from initial investment are compensated by the three remaining flows, with costs related to drug use policies showing the most substantial savings. Five years after initial investment, global cash-flows have been estimated at 300.525 euros.

CONCLUSION

Replacement of traditional floor stocks by ADDS in the Medical Intensive Care Unit, Surgery Intensive Care Unit and the Emergency Room produces a positive benefit/cost ratio (1.95).

[Approximation of a proposal of therapeutic criteria for parenteral nutrition]

The care of patients with parenteral nutrition is made up of the care provided by the different members of a multidisciplinary team. This cooperative participation is translated into the establishment and the application of a therapeutic protocol as a frame for the use of parenteral nutrition. It is usual for these protocols to include the normalization of the formulations of parenteral nutrition units, as well as containing logistical processes such as prescription, preparation, dispensation, and administration. Also, the classical review studies on the use of parenteral nutrition aim to know the degree of compliance with the protocols and/or the variability in the application of this therapy. However, this model aims to re-direct itself towards the improvement of the effectiveness and the therapeutic quality obtained in patients treated with parenteral nutrition. The objective of the present study is to present explicit criteria to be included in the parenteral nutrition protocols and the constitute action guidelines for the identification of problems and taking decisions in the resolution and prevention of the same. Also, they are elements for the evaluation of the applied processes and of therapeutic results obtained in patients fed intra-venously.

[Profile of primary care physicians in a health area: a cluster analysis]

OBJECTIVES

To discover characteristics of primary care doctors. To find homogeneous groups of doctors.

DESIGN

A basically descriptive crossover observational study.

SETTING

Primary care doctors from a health area.

PARTICIPANTS

The following variables were recorded on the 99 doctors who worked in Castellon Area 03 during 1992: age, gender, fixed or temporary post, rural or urban area, MIR training, primary care model, patient load, sole employment, drugs expenditure, number of pensioners and total number of patients registered.

MEASUREMENTS AND MAIN RESULTS

We found a first group of older doctors, working mainly in the old model, for whom PC was not their sole employment; another younger group without MIR training and with an average patient load; the third group was women in temporary posts with a somewhat higher drugs expenditure; the fourth was doctors working in rural areas with a very low patient load; the fifth, final and youngest group was family doctors, with an average patient load, low expenditure and a high number of patients registered. We observed highly significant differences between groups.

CONCLUSIONS

Doctors' age and gender divide them into different groupings; family doctors form one group. Multivariable, descriptive methods proved useful in finding, describing and classifying doctors and centres, etc., and could be of use in resource and action planning.

[Factors determining costs of drug prescriptions in primary health care]

OBJECTIVE

To describe and explain the annual pharmaceutical expenditure generated by the professionals in a Health Area.

DESIGN

An observational crossover study.

SETTING

Primary Care. Doctors in a Health Area.

PARTICIPANTS

99 general practitioners who worked during 1992 in Area 3, Castellón.

INTERVENTIONS

We used as a variable reply the pharmaceutical expenditure of each doctor during 1992, the expenditure per inhabitant and the expenditure per inhabitant standardised for the percentage of passives. We gathered as explanatory variables of the same: age, gender, whether the post was provisional or permanent, rural or urban area, MIR (resident) training or not, the model of Primary Care, frequency of attendance, whether the doctors worked there exclusively, the number of pensioners and the number of patients at work registered.

MEASUREMENTS AND RESULTS

In the bivariant analysis we found a significant association of expenditure with being provisional in the post, the old model of primary care, an urban area, greater age of the doctor, greater frequency of attendance, non-exclusivity and the number of patients registered. These associations varied in line with the variable reply used. In the different models of multiple linear regression obtained, the influence of the number, non-exclusivity, gender and work-place characteristics predominated.

CONCLUSIONS

Greater pharmaceutical expenditure appears to be related to the number of patients registered, the absence of exclusivity, doctors being women and the features of the town where they work.