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Proyecto PROFUND., [ES] Objetivos: Analizar la sensibilidad (S), la especificidad (E) y los valores predictivos positivo (VPP) y negativo (VPN) de cada dimensión del índice de Barthel (IB) con respecto al cuestionario completo en pacientes pluripatológicos (PPP). Métodos: Estudio transversal multicéntrico. Se consideraron dos puntos de corte del IB (≥ 90 puntos para el cribado de fragilidad y < 60 puntos para el diagnóstico de dependencia severa). Para cada dimensión y combinaciones de dos dimensiones se calcularon la S, la E, el VPP y el VPN con respecto al IB completo. Resultados: El IB medio de los 1.632 PPP incluidos (edad media de 77,9 ± 9,8 años, 53% varones) fue 69 ± 31 (< 90 en el 58,7% y < 60 en el 31,4% de pacientes). La dimensión «alimentación» obtuvo los mayores VPN para tener un IB ≥ 60 y ≥ 90 puntos (87% y 99,6%, respectivamente). Las dimensiones «deambular» y «subir y bajar escaleras» obtuvieron el mayor VPP para tener un IB ≥ 60 y ≥ 90 (99,2/99,5% y 81/92%, respectivamente; la combinación de ambas preguntas aumentó el VPP al 95 y al 99,6%, respectivamente. Conclusiones: Los PPP de ámbito hospitalario presentan con elevada frecuencia deterioro funcional. La dimensión referente a alimentarse obtuvo el mayor VPN, por lo que se puede utilizar para el diagnóstico de dependencia severa, mientras que la combinación de deambular y subir y bajar escaleras obtuvo el mayor VPP, pudiendo utilizarse para plantear el cribado de fragilidad de los PPP., [EN] Objectives: To analyse the sensitivity, specificity and positive predictive (PPV) and negative predictive (NPV) values of each measure of the Barthel index (BI) compared with the full questionnaire for polypathological patients (PPPs). Methods: Multicentre cross-sectional study. We considered 2 cut-off points for the BI (≥ 90 points for screening frailty and < 60 points for diagnosing severe dependence). For each measure and combination of 2 measures, we calculated the sensitivity, specificity, PPV and NPV with respect to the full BI. Results: The mean BI of the 1,632 included PPPs (mean age, 77.9 ± 9.8 years; 53% men) was 69 ± 31 (< 90 for 58.7% and < 60 for 31.4% of the patients). The “feeding” measure achieved the highest NPV, for a BI ≥ 60 and ≥ 90 points (87% and 99.6%, respectively). The “walking” and “going up and down stairs” measures achieved the highest PPV, for a BI ≥ 60 and ≥ 90 (99.2%/99.5% and 81%/92%, respectively. The combination of the 2 measures increased the PPV to 95% and 99.6%, respectively. Conclusions: PPPs in hospital settings have a high rate of functional impairment. The measure for feeding achieved the highest NPV and can therefore be employed for diagnosing severe dependence. The combination of the measures for walking and going up and down stairs achieved the highest PPV and can therefore be employed to propose frailty screening for PPPs.

Introduction Previous studies of antihypertensive treatment of older patients have focused on blood pressure control, cardiovascular risk or adherence, whereas data on inappropriate antihypertensive prescriptions to older patients are scarce. Objectives The aim of the study was to assess inappropriate antihypertensive prescriptions to older patients. Methods An observational, prospective multicentric study was conducted to assess potentially inappropriate prescription of antihypertensive drugs, in patients aged 75 years and older with arterial hypertension (HTN), in the month prior to hospital admission, using four instruments: Beers, Screening Tool of Older Person's Prescriptions (STOPP), Screening Tool to Alert Doctors to the Right Treatment (START) and Assessing Care of Vulnerable Elders 3 (ACOVE-3). Primary care and hospital electronic records were reviewed for HTN diagnoses, antihypertensive treatment and blood pressure readings. Results Of 672 patients, 532 (median age 85 years, 56% female) had HTN. 21.6% received antihypertensive monotherapy, 4.7% received no hypertensive treatment, and the remainder received a combination of antihypertensive therapies. The most frequently prescribed antihypertensive drugs were diuretics (53.5%), angiotensin-converting enzyme inhibitors (ACEIs) (41%), calcium antagonists (32.2%), angiotensin receptor blockers (29.7%) and beta-blockers (29.7%). Potentially inappropriate prescription was observed in 51.3% of patients (27.8% overprescription and 35% underprescription). The most frequent inappropriately prescribed drugs were calcium antagonists (overprescribed), ACEIs and beta-blockers (underprescribed). ACEI and beta-blocker underprescriptions were independently associated with heart failure admissions [ beta-blockers odds ratio (OR) 0.53, 95% confidence interval (CI) 0.39-0.71, p < 0.001; ACEIs OR 0.50, 95% CI 0.36-0.70, p < 0.001]. Conclusion Potentially inappropriate prescription was detected in more than half of patients receiving antihypertensive treatment. Underprescription was more frequent than overprescription. ACEIs and beta-blockers were frequently underprescribed and were associated with heart failure admissions.

Background/objectives The PROFUND index stratifies accurately the 12-month mortality risk of polypathological patients (PPs), but its fitness over a longer follow-up period remains unknown. We aimed to explore the calibration and discrimination power of PROFUND index over 4-years, in order to assess its follow-up interval generalizability. Design Multicenter prospective cohort-study. Setting 33 Spanish hospitals. Participants PPs included after hospital discharge, outpatient clinics, or home hospitalization. Measurements Mortality over a 4-year follow-up period. Methods PROFUND index calibration was assessed by risk-quartiles predicted/observed mortality (Hosmer–Lemeshow goodness-of-fit test), and its discrimination power by ROC curves. Results A total of 768 patients were included (630 [82%] of them completed the 4-year follow-up). Global mortality rate was 63.5%. When assessing individual patient scores, mortality was 52% in the lowest risk group (0–2 points in PROFUND score); 73.5% in the low-intermediate risk group (3–6 points), 85% in the intermediate-high group (7–10 points); and 92% in the highest risk group (≥11 points). Accuracy testing of the PROFUND index showed good calibration ( P =.8 in the Hosmer–Lemeshow goodness-of-fit test), and also a good discrimination power (AUC=0.71 [0.67–0.77] in ROC curve). Conclusions The PROFUND index maintained its accuracy in predicting mortality of polypathological patients over a 4-year follow-up period. This index may be of potential usefulness in deciding the most appropriate health-care interventions in populations with multimorbidity.

The purpose of this study is to describe the characteristics of older patients treated with psychotropic medicines and the associated factors and to assess their inappropriate use. An observational, prospective study was carried out in 672 elderly patients admitted to seven hospitals for a year. A comparison of sociodemographic characteristics, geriatric variables, multimorbidity and the number of prescribed medicines taken in the preceding month before hospitalization between patients treated with psychotropics and those not treated was performed. To assess factors associated with psychotropics, multivariate logistic regression analyses were performed. Inappropriate use was assessed using the Beers and the STOPP criteria. A total of 57.5 % patients (median [Q1-Q3] age 81.7 [78.2-86.1], 65.7 % female) were treated with psychotropics (44.2 % anxiolytics, 22.6 % antidepressants and 10.8 % antipsychotics). Independent factors associated with the use of psychotropics were female gender (OR = 2.3; CI 95 %,1.6-3.5), some degree of disability on admission (slight [OR = 2.2; 1.2-4.2], moderate [OR = 3.2, 1.6-6.6], severe [OR = 3.4; 1.4-8] and very severe [OR = 5.1; 2.0-12.8]) and polypharmacy (5-9 medicines [OR = 3.0; 1.3-6.9] and a parts per thousand yen10 medicines [OR = 6.0; 2.7-13.6]). The associated factors varied depending on the different types of psychotropics. In patients treated with psychotropics, the percentage of those with at least one Beers (61.6 %) or at least one STOPP (71.4 %) criteria was significantly higher in comparison with those not treated with psychotropics (30.7 and 47.7 %, respectively, p < 0.001). Psychotropics are widely used in the elderly population and often their use is inappropriate. Female gender, a poor functional status and polypharmacy, are the characteristics linked to their use. Interventional strategies should be focused on patients with these characteristics.

[EN] Background and objective: The objective of the study was to evaluate the effects of a multidisciplinary intervention on the outcomes of polypathological patients (PP). Methods: A multicenter quasi-experimental pre-post study with a 12-month follow up was performed. In-hospital, at discharge and outpatient clinics patients who met criteria of PP between March 2012 and October 2013 were included. The multidisciplinary approach was defined by 11 interventions performed by general practitioners, internal medicine physicians, team care nurses and hospital pharmacists. The primary outcome was reduction in the number of hospital admissions and days of hospitalization. Secondary outcomes included mortality and the effects of 11 interventions on mortality. Results: 420 patients were included. Mean patient age was 77.3 (SD: 8.90) and average number of PP defining categories was 2.99 (SD: 1.00). Number of hospital admissions and days of hospitalization decreased significantly after intervention: 1.52 (SD: 1.35) versus 0.82 (SD: 1.29), p < 0.001, and 13.77 (SD: 15.20) versus 7.21 (SD: 12.90), p < 0.001 respectively. 12-month mortality was 37.7%. PP who failed to receive a structured medical visit from the internal medicine physician and educational workshops from the team care nurses had a higher risk of exitus in the next 12 months, HR: 1.68; 95% CI: 1.15–2.46, p = 0.007 and HR: 2.86; 95% CI: 1.92–4.27, p < 0.001, respectively. Conclusions: This multidisciplinary intervention reduced the risk of PP hospital admission and days of hospitalization. Educational workshop programs for PP and their caregivers and structured IM medical visits were associated with improvements of survival., [ES] Introducción y objetivo: El objetivo del estudio fue evaluar los resultados en salud tras la implantación de una intervención multidisciplinar a pacientes pluripatológicos (PP). Metodología: Se realizó un estudio multicéntrico antes-después cuasi-experimental, con seguimiento a 12 meses. Se incluyeron pacientes que cumplían los criterios de PP entre marzo de 2012 y octubre de 2013, tanto en el ámbito hospitalario como en atención primaria. El enfoque multidisciplinar fue definido por 11 intervenciones realizadas por médicos de familia, médicos internistas, enfermeras y farmacéuticos hospitalarios. El resultado fundamental fue la reducción en el número de ingresos hospitalarios y días de hospitalización al año de seguimiento. Los resultados secundarios incluyeron la mortalidad y los efectos de las intervenciones sobre la misma. Resultados: Se incluyeron 420 pacientes. La edad media de los pacientes fue de 77,3 (DE: 8,90) y la media de categorías definitorias de PP fue de 2,99 (DE: 1,00). El número de ingresos hospitalarios y los días de hospitalización disminuyeron significativamente después de la intervención: 1,52 (DE: 1,35) versus 0,82 (DE: 1,29), p < 0,001 y 13,77 (DE: 15,20) versus 7,21 (DE: 12,90), p < 0,001, respectivamente. La mortalidad a los 12 meses fue del 37,7%. Los PP que no recibieron la visita médica estructurada del médico internista tras la inclusión y los talleres educativos de las enfermeras tuvieron un mayor riesgo de exitus en los 12 meses de seguimiento, HR: 1,68; IC del 95%: 1,15-2,46, p = 0,007 y HR: 2,86; IC del 95%: 1,92-4,27, p < 0,001, respectivamente. Conclusiones: Esta intervención multidisciplinaria reduce el riesgo de ingreso y los días de ingreso hospitalario en PP. Los programas de talleres educativos para PP y sus cuidadores, y las visitas médicas estructuradas por parte de medicina interna se asociaron con una mayor supervivencia.

Objectives To report the health outcomes of a multidisciplinary care program for patients over 65 years with hip fracture. Patients and methods We have developed a care coordination model for the comprehensive care of hip fracture patients. It establishes what, who, when, how and where orthopedists, internists, family physicians, emergency, intensive care, physiotherapists, anesthetists, nurses and workers social intervene. All elderly patients over 65 years admitted with the diagnosis of hip fracture (years 2006–2010) were retrospectively evaluated. Results One thousand episodes of hip fracture, corresponding to 956 patients, were included. Mean age was 82 years and mean stay 6.7 days. This was reduced by 1.14 days during the 5 years of the program. A total of 85.1% were operated on before 72 yours, and 91.2% during the program. Incidence of surgical site infection was 1.5%. In-hospital mortality was 4.5% (24.2% at 12 months). Readmissions at one year was 14.9%. Independence for basic activity of daily living was achieved by 40% of the patients. Conclusions This multidisciplinary care program for hip fracture patients is associated with positive health outcomes, with a high percentage of patients treated early (more than 90%), reduced mean stay (less than 7 days), incidence of surgical site infections, readmissions and inpatient mortality and at one year, as well as adequate functional recovery.

Fever in the elderly as compared with young adults has a clinical expression, prevalence, and diagnosis that require a specific type of evaluation. The significance of fever in the elderly gains importance with the increase of the population's age and it must be considered an alarm signal in these patients. Etiologically, the primary cause of prolonged fever with unspecific origin in this population, is arteritis of giant cells, followed by (according to epidemiological environment) tuberculosis and hematological neoplasias. There is no consensus on diagnostic approaches, but it is essential to take great care in the process due to risk associated with invasive tests and low tolerance to them.

Aims To assess inappropriate prescribing in older people with diabetes mellitus during the month prior to a hospitalization, using tools on potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs) and comparing inappropriate prescribing in patients with without diabetes. Methods In an observational, prospective multicentric study, we assessed inappropriate prescribing in 672 patients aged 75 years and older during hospital admission. The Beers, Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right Treatment (START) criteria and Assessing Care of Vulnerable Elders (ACOVE-3) medicine quality indicators were used. We analysed demographic and clinical factors associated with inappropriate prescribing. Results Of 672 patients, 249 (mean age 82.4 years, 62.9% female) had a diagnosis of diabetes mellitus. The mean number of prescribing drugs per patient with diabetes was 12.6 (4.5) vs. 9.4 (4.3) in patients without diabetes (P < 0.001). Of those patients with diabetes, 74.2% used 10 or more medications; 54.5% of patients with diabetes had at least one Beers-listed PIM, 68.1% had at least one STOPP-listed PIM, 64.6% had at least one START-listed PPO and 62.8% had at least one ACOVE-3-listed PPO. Except for the Beers criteria, these prevalences were significantly higher in patients with diabetes than in those without. After excluding diabetes-related items from these tools, only STOPP-listed PIMs remained significantly higher among patients with diabetes (P = 0.04). Conclusions Polypharmacy is common among older patients with diabetes mellitus. Inappropriate prescribing is higher in older patients with diabetes, even when diabetes-related treatment is excluded from the inappropriate prescribing evaluation.

Natriuretic peptides are extremely useful in the diagnosis and prognosis of patients with heart failure. However, it is not clear whether their values are stable. We carried out a prospective study of 30 consecutive ambulatory patients (mean age, 62.6 [12.2] years) with stable systolic heart failure, as determined by the 6minute walk test, who were in New York Heart Association class II or III and who had a left ventricular ejection fraction

Purpose: This study aims to assess inappropriate prescribing (IP) to elderly patients during the month prior to hospitalization and to compare different IP criteria. Methods: An observational, prospective and multicentric study was carried out in the internal medicine services of seven Spanish hospitals. Patients aged 75 years and olderwere randomly selected after hospital admission for a year. To assess potentially inappropriate medicines (PIMs), the Beers and STOPP criteria were used and to assess potentially prescribing omissions (PPOs), the START criteria and ACOVE-3 medicine quality indicators were used. An analysis to assess factors associated with IP was performed. Results: 672 patients [median age (Q1-Q3) 82 (79-86) years, 55.9% female] were included. Median prescribed medicines in the month prior to hospitalization were 10(Q1-Q3 7-13). The prevalence of IP was 87.6%, and 54.3% of patients had PIMs and PPOs concurrently. A higher prevalence rate of PIMs was predicted using the STOPP criteria than with the Beers criteria (p < 0.001) and a higher prevalence of PPOs using the ACOVE-3 criteria than using the START criteria (p < 0.001) was observed. Polypharmacy (>= 10 medicines) was the strongest predictor of IP [OR = 11.34 95% confidence interval (CI) 4.96-25.94], PIMs [OR = 14.16, 95% CI 6.44-31.12], Beers-listed PIMs [OR = 8.19, 95% CI 3.01-22.28] and STOPP-listed PIMs [OR = 8.21, 95% CI 3.47-19.44]. PIMs was the strongest predictor of PPOs [OR = 2.79, 95% CI 1.81-4.28]. Conclusions: A high prevalence of polypharmacy and PIMs and PPOs were reported. More than half the patients had simultaneous PIMs and PPOs. The related factors to PIMs and PPOs were different. (c) 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Purpose: There are limited tools to assess potential prescribing omissions (PPOs) or underprescribing in the elderly. The ACOVE project defines comprehensive quality care indicators for older people and some of these indicators focused on appropriate use of medicines. The aim of the present study was to assess the inter-rater reliability between observers using the ACOVE 3 prescribing indicated medications indicators and compare it with the inter-rater reliability obtained for the Screening Tool of Older Person's Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria. Methods: In the context of an observational and multicentric study of a cohort of 672 patients 75 years and older who were hospitalized in Internal Medicine services of seven Spanish hospitals, an inter-rater reliability study using the ACOVE selected indicators and the STOPP/START criteria was carried out between April 2011 and March 2012. Three patients were randomly selected in each participating hospital, one for each four months of study. Results: A total of 21 patients (mean (SD) age of 84.3 (5.6) years, 57.1% female) were included in the inter-rater reliability study. For the STOPP, START and ACOVE criteria, the median kappa coefficient for the seven hospital analyses was 0.97, 0.92 and 0.95, respectively. Out of 123 total indicators in only 7 (5.7%) was the kappa coefficient value below 0.75. Only for 2 (5.6%) of the 37 studies selected ACOVE quality indicators was the kappa coefficient value less than 0.75. Conclusions: A high inter-rater reliability was obtained for the selected underprescribing quality indicators of ACOVE 3. These quality indicators may be considered a useful tool in detecting underprescribing to the elderly patients. (C) 2014 Elsevier Ireland Ltd. All rights reserved.

Background A comprehensive evaluation of polypathological patients (PP) should always include a functional evaluation. For this purpose, a modified version of the Barthel Index (BI) is the most applied questionnaire, and it consists of a 10-variable scale. The aim of this study was to develop a screening and confirmation tool to diagnose high disability with the fewest number of dimensions of the BI as possible. Method This present cross-sectional observational multicentre study included PP attended in 36 Spanish hospitals that were divided into two geographical areas (Western and Eastern). The Western area was considered to be the derivation subgroup of PP, and the Eastern area was the validation subgroup. Complete disability for each item (value of 0) was assessed for the diagnosis of severe disability. Diagnostic validity indices (sensitivity, specificity, negative and positive predictive values [NPV and PPV, respectively], and negative and positive likelihood ratios [NLR and PLR, respectively]) were determined for the derivation subgroup. The dimensions with the best diagnostic validity indices were then used to evaluate the validation subgroup. Results The analysis included 1521 PP, 753 PP from the Western area and 768 PP from the Eastern area. Needing complete help for bathing showed the highest NPV and lowest NLR in the derivation/validation subgroups (NPV 96.87/95.54, NLR 0.07/0.13). Being disabled for feeding alone showed high PPV and PLR values (PPV 97.97/95.65, PLR 109.25/49.62), as did disability for transfers (PPV 98.48/97.96, PLR 143.36/107.68). In addition, complete disability for feeding and transfers had the best PPV and PLR in both subgroups (PPV 100/100, PLR X/0). Conclusions A two-dimension mini-Barthel Index may represent a reliable diagnostic test for severe disability in PP.

There is a concern about the accuracy of the available prognostic indexes when applying them to the emergent population of polypathological patients (PP).To develop a 1-year mortality predictive index on PP, we developed a multicenter prospective cohort-study recruiting 1.632 PP after hospital discharge, outpatient clinics, or home hospitalization, from 33 hospitals. Potential risk factors were obtained in the 1.525 PP who completed follow-up. Each factor independently associated with mortality in the derivation cohort (757 PP from western hospitals) was assigned a weight, and risk scores were calculated by adding the points of each factor. Accuracy was assessed in the validation cohort (768 PP from eastern hospitals) by risk quartiles calibration, and discrimination power, by ROC curves. Finally, accuracy of the index was compared with that of the Charlson index.Mortality in the derivation/validation cohorts was 35%/39.5%, respectively. Nine independent mortality predictors were identified to create the index (age ≥85 years, 3 points; No caregiver or caregiver other than spouse, 2 points; active neoplasia, 6 points; dementia, 3 points; III-IV functional class on NYHA and/or MRC, 3 points; delirium during last hospital admission, 3 points; hemoglobinemia10 g/dl, 3 points; Barthel index60 points, 4 points; ≥4 hospital admissions in last 12 months, 3 points). Mortality in the derivation/validation cohorts was 12.1%/14.6% for patients with 0-2 points; 21.5%/31.5% for those with 3-6 points; 45%/50% for those with 7-10 points; and 68%/61.3% for those with ≥11 points, respectively. Calibration was good in derivation/validation cohorts, and discrimination power by area under the curve was 0.77/0.7. Calibration of the Charlson index was good, but discrimination power was suboptimal (area under the curve, 0.59).This prognostic index provides an accurate and transportable method of stratifying 1-year death risk in PP.

Little is known about the main features of the emergent population of PP. Our objective was to determine the clinical, care and social characteristics of a multi-institutional population of PP, by means of a crosssectional study including a reference population of hospital-based PP from 36 hospitals. The main clinical, functional, mental and social features and their associated factors were assessed: 1632 PP (53% males, mean age 77.9 9.8 years) were included. An informal caregiver was required by 52% (78% of caregivers were close female relatives). The mean inclusion criteria (Cat): were 2.7 0.8 (49.5% presented 3 Cat). The most frequent inclusion Cat were heart (77.5%), lung (45.6%), neurological (38.2%), and kidney diseases (32.2%), whereas the mean of other comorbidities was 4.5 2.7 per PP. The mean Charlson comorbidity index (CCI) was 4; 47.6%, and 52.4% presented dyspnea 3 on the NYHA, and on the MRC, respectively; nearly 19% required home oxygen therapy, 19% had suffered >1 fall in previous year, and 11% suffered an active neoplasia. The mean hospital admissions in last 12/3 months, and chronically prescribed drugs were 2/1, and 8 3, respectively. More than 70% presented obesity, while 60% had hypoalbuminemia. The basal/inclusion Barthel index (BI) score was 69 31/58 34 (BI score < 60 was present in 31.5%/44%, respectively); and the mean Pfeiffer score was 2.94 3.2 (43% answered with 3 errors). More than half of the subjects were at risk or already had established social problems. This emergent population is considerably homogeneous, highly complex, clinically vulnerable, functionally impaired, dependent on caregivers and socially fragile. They need to receive more attention in clinical research and more support in health interventions based on comprehensive attention and continuity of care.