RESUMEN
BACKGROUND: Medication review is a core aspect of medicine optimisation, yet existing models of review vary substantially in structure and content and are not necessarily easy to implement in clinical practice. This study aimed to use evidence from the existing literature to identify key medication review components and use this to inform the design of an improved review model. METHODS: A systematic review was conducted (PROSPERO: CRD42018109788) to identify randomised control trials of stand-alone medication review in adults (18+ years). The review updated that by Huiskes et al. (BMC Fam Pract. 18:5, 2017), using the same search strategy implemented in MEDLINE and Embase. Studies were assessed using the Cochrane risk of bias tool. Key review components were identified, alongside relevant clinical and health service outcomes. A working group (patients, doctors and pharmacists) developed the model through an iterative consensus process (appraisal of documents plus group discussions), working from the systematic review findings, brief evidence summaries for core review components and examples of previous models, to agree on the main purpose of the review model, overarching model structure, review components and supporting material. RESULTS: We identified 28 unique studies, with moderate bias overall. Consistent medication review components included reconciliation (26 studies), safety assessment (22), suboptimal treatment (19), patient knowledge/preferences (18), adherence (14), over-the-counter therapy (13) and drug monitoring (10). There was limited evidence from studies for improvement in key clinical outcomes. The review structure was underpinned by patient values and preferences, with parallel information gathering and evaluation stages, feeding into the final decision-making and implementation. Most key components identified in the literature were included. The final model was considered to benefit from a patient-centred, holistic approach, which captured both patient-orientated and medication-focused problems, and aligned with traditional consultation methods thus facilitating implementation in practice. CONCLUSIONS: The Bristol Medication Review Model provides a framework for standardised delivery of structured reviews. The model has the potential for use by all healthcare professionals with relevant clinical experience and is designed to offer flexibility of implementation not limited to a particular healthcare setting.
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Personal de Salud , Farmacéuticos , HumanosRESUMEN
Eczema is a common long-term condition, but inadequate support and information can lead to poor adherence and treatment failure. We have reviewed the international literature of interventions designed to promote self-management in adults and children with eczema. MEDLINE, MEDLINE in process, Embase, CINAHL and the Global Resource for EczemA Trials database were searched from their inception to August 2016, for randomized controlled trials. Two authors independently applied eligibility criteria, assessed risk of bias for all included studies and extracted data. Twenty studies (3028 participants) conducted in 11 different countries were included. The majority (n = 18) were based in secondary care and most (n = 16) targeted children with eczema. Reporting of studies, including descriptions of the interventions and the outcomes themselves, was generally poor. Thirteen studies were face-to-face educational interventions, five were delivered online and two were studies of written action plans. Follow-up in most studies (n = 12) was short term (up to 12 weeks). Only six trials specified a single primary outcome. There was limited evidence of effectiveness. Only three studies collected and reported outcomes related to cost and just one study undertook any formal cost-effectiveness analysis. In summary, we have identified a general absence of well-conducted and well-reported randomized controlled trials with a strong theoretical basis. Therefore, there is still uncertainty about how best to support self-management of eczema in a clinically effective and cost-effective way. Recommendations on design and conduct of future trials are presented.
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Eccema/terapia , Automanejo/métodos , Adulto , Niño , Análisis Costo-Beneficio , Eccema/economía , Humanos , Internet , Educación del Paciente como Asunto/economía , Educación del Paciente como Asunto/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto , Automanejo/educación , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this systematic review of randomised controlled trials (RCTs) and controlled trials (non-RCTs, NRCTs) is to investigate the effectiveness and related costs of case management (CM) for patients with heart failure (HF) predominantly based in the community in reducing unplanned readmissions and length of stay (LOS). SETTING: CM initiated either while as an inpatient, or on discharge from acute care hospitals, or in the community and then continuing on in the community. PARTICIPANTS: Adults with a diagnosis of HF and resident in Organisation for Economic Co-operation and Development countries. INTERVENTION: CM based on nurse coordinated multicomponent care which is applicable to the primary care-based health systems. PRIMARY AND SECONDARY OUTCOMES: Primary outcomes of interest were unplanned (re)admissions, LOS and any related cost data. Secondary outcomes were primary healthcare resources. RESULTS: 22 studies were included: 17 RCTs and 5 NRCTs. 17 studies described hospital-initiated CM (n=4794) and 5 described community-initiated CM of HF (n=3832). Hospital-initiated CM reduced readmissions (rate ratio 0.74 (95% CI 0.60 to 0.92), p=0.008) and LOS (mean difference -1.28â days (95% CI -2.04 to -0.52), p=0.001) in favour of CM compared with usual care. 9 trials described cost data of which 6 reported no difference between CM and usual care. There were 4 studies of community-initiated CM versus usual care (2 RCTs and 2 NRCTs) with only the 2 NRCTs showing a reduction in admissions. CONCLUSIONS: Hospital-initiated CM can be successful in reducing unplanned hospital readmissions for HF and length of hospital stay for people with HF. 9 trials described cost data; no clear difference emerged between CM and usual care. There was limited evidence for community-initiated CM which suggested it does not reduce admission.
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Manejo de Caso/organización & administración , Servicios de Salud Comunitaria/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Insuficiencia Cardíaca/terapia , Hospitalización/estadística & datos numéricos , Manejo de Caso/economía , Ensayos Clínicos como Asunto , Servicios de Salud Comunitaria/economía , Costos de la Atención en Salud , Insuficiencia Cardíaca/economía , HumanosRESUMEN
Prostate cancer is the second most common cancer in men worldwide, accounting for an estimated 1.1 million new cases diagnosed in 2012 (www.globocan.iarc.fr). Currently, there is a lack of specific guidance on supportive care for men with prostate cancer. This article describes a qualitative systematic review and synthesis examining men's experience of and need for supportive care. Seven databases were searched; 20 journal articles were identified and critically appraised. A thematic synthesis was conducted in which descriptive themes were drawn out of the data. These were peer support, support from partner, online support, cancer specialist nurse support, self-care, communication with health professionals, unmet needs (emotional support, information needs, support for treatment-induced side effects of incontinence and erectile dysfunction) and men's suggestions for improved delivery of supportive care. This was followed by the development of overarching analytic themes which were: uncertainty, reframing, and the timing of receiving treatment, information and support. Our results show that the most valued form of support men experienced following diagnosis was one-to-one peer support and support from partners. This review highlights the need for improved access to cancer specialist nurses throughout the care pathway, individually tailored supportive care and psychosexual support for treatment side effects.
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Evaluación de Necesidades , Neoplasias de la Próstata/terapia , Apoyo Social , Comunicación , Necesidades y Demandas de Servicios de Salud , Humanos , Masculino , Relaciones Profesional-Paciente , Neoplasias de la Próstata/psicologíaRESUMEN
There is an increasing amount of research into the health benefits of berry flavonoids. Moreover, the consumption of flavonoid-rich food is on the increase; with women in particular showing a interest in eating a diet which may benefit their long-term health. The aim of this review was to examine the evidence for the benefits of berry flavonoids for cardiovascular health, cancer and cognition in the menopausal woman. Due to the limited amount of clinical data on this subject both in vitro and animal as well as human studies have been included. These data appear to support epidemiological studies that suggest cardiovascular benefits, cancer prevention and cognitive improvement from berry flavonoid consumption. However to date, it is not possible to be definitive about the specific berry type, preparation or regime which confers maximum benefits, or to give specific advice to menopausal women. Limited data from a combination of pre-clinical and clinical studies suggest that the addition of berry flavonoids to the diet has moderate effects on cardiovascular function in subjects at risk and potential preventative effects in oesophageal cancer. Evidence for cognitive benefits is limited to animal data but shows promise.
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Antioxidantes/farmacología , Enfermedades Cardiovasculares/prevención & control , Trastornos del Conocimiento/prevención & control , Flavonoides/farmacología , Frutas/química , Neoplasias/prevención & control , Animales , Femenino , Humanos , Menopausia , Extractos Vegetales/farmacologíaRESUMEN
Grape flavonoids are members of a larger group of plant compounds called polyphenols. Epidemiological evidence relating to the traditional Mediterranean diet, which is high in polyphenols, derived from vegetables and red wine, suggests that dietary polyphenols are of benefit to health and reduce the incidence of cardiovascular disease. Overall, the evidence is promising for the benefit of grape flavonoids in the form of red wine, red grape juice and related preparations for cardiovascular risk factors. There are data to suggest a reduction in platelet activation, inflammation and low-density lipoprotein oxidation, and improvement of endothelial function with grape flavonoids. The evidence for grape flavonoids and renal function, cognition and cancer is less clear. However, it is important to note that much of this research has been carried out in animal and cell models; relatively little work has been done in humans and specifically on the health of menopausal women. There are no general safety concerns with ingestion of grape products. Obviously, consumption of red wine should be within recommended limits and it should be noted that grape juice has high sugar content. Grape flavonoids are also available as a supplement. In conclusion, it is likely that grape flavonoids do benefit the menopausal women. Further research is needed on the mode and dosage of application to maximize these benefits.