Multimorbidity and the associated use of multiple medicines (polypharmacy), is common in the older population. Despite this, there is no consensus definition for polypharmacy. A systematic review was conducted to identify and summarise polypharmacy definitions in existing literature. The reporting of this systematic review conforms to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist. MEDLINE (Ovid), EMBASE and Cochrane were systematically searched, as well as grey literature, to identify articles which defined the term polypharmacy (without any limits on the types of definitions) and were in English, published between 1st January 2000 and 30th May 2016. Definitions were categorised as i. numerical only (using the number of medications to define polypharmacy), ii. numerical with an associated duration of therapy or healthcare setting (such as during hospital stay) or iii. Descriptive (using a brief description to define polypharmacy). A total of 1156 articles were identified and 110 articles met the inclusion criteria. Articles not only defined polypharmacy but associated terms such as minor and major polypharmacy. As a result, a total of 138 definitions of polypharmacy and associated terms were obtained. There were 111 numerical only definitions (80.4% of all definitions), 15 numerical definitions which incorporated a duration of therapy or healthcare setting (10.9%) and 12 descriptive definitions (8.7%). The most commonly reported definition of polypharmacy was the numerical definition of five or more medications daily (n = 51, 46.4% of articles), with definitions ranging from two or more to 11 or more medicines. Only 6.4% of articles classified the distinction between appropriate and inappropriate polypharmacy, using descriptive definitions to make this distinction. Polypharmacy definitions were variable. Numerical definitions of polypharmacy did not account for specific comorbidities present and make it difficult to assess safety and appropriateness of therapy in the clinical setting.

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What is polypharmacy? A systematic review of definitions

Evaluating the quality of medical care.

The accurate measurement of blood pressure (BP) is essential for the diagnosis and management of hypertension. This article provides an updated American Heart Association scientific statement on BP measurement in humans. In the office setting, many oscillometric devices have been validated that allow accurate BP measurement while reducing human errors associated with the auscultatory approach. Fully automated oscillometric devices capable of taking multiple readings even without an observer being present may provide a more accurate measurement of BP than auscultation. Studies have shown substantial differences in BP when measured outside versus in the office setting. Ambulatory BP monitoring is considered the reference standard for out-of-office BP assessment, with home BP monitoring being an alternative when ambulatory BP monitoring is not available or tolerated. Compared with their counterparts with sustained normotension (ie, nonhypertensive BP levels in and outside the office setting), it is unclear whether adults with white-coat hypertension (ie, hypertensive BP levels in the office but not outside the office) have increased cardiovascular disease risk, whereas those with masked hypertension (ie, hypertensive BP levels outside the office but not in the office) are at substantially increased risk. In addition, high nighttime BP on ambulatory BP monitoring is associated with increased cardiovascular disease risk. Both oscillometric and auscultatory methods are considered acceptable for measuring BP in children and adolescents. Regardless of the method used to measure BP, initial and ongoing training of technicians and healthcare providers and the use of validated and calibrated devices are critical for obtaining accurate BP measurements.

Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association.

Background
Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing.

Objectives
This review sought to determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

Search methods
In November 2013, for this first update, a range of literature databases including MEDLINE and EMBASE were searched, and handsearching of reference lists was performed. Search terms included 'polypharmacy', 'medication appropriateness' and 'inappropriate prescribing'.

Selection criteria
A range of study designs were eligible. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people 65 years of age and older in which a validated measure of appropriateness was used (e.g. Beers criteria, Medication Appropriateness Index (MAI)).

Data collection and analysis
Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. Study-specific estimates were pooled, and a random-effects model was used to yield summary estimates of effect and 95% confidence intervals (CIs). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall quality of evidence for each pooled outcome.

Main results
Two studies were added to this review to bring the total number of included studies to 12. One intervention consisted of computerised decision support; 11 complex, multi-faceted pharmaceutical approaches to interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals, such as prescribers and pharmacists. Appropriateness of prescribing was measured using validated tools, including the MAI score post intervention (eight studies), Beers criteria (four studies), STOPP criteria (two studies) and START criteria (one study). Interventions included in this review resulted in a reduction in inappropriate medication usage. Based on the GRADE approach, the overall quality of evidence for all pooled outcomes ranged from very low to low. A greater reduction in MAI scores between baseline and follow-up was seen in the intervention group when compared with the control group (four studies; mean difference -6.78, 95% CI -12.34 to -1.22). Postintervention pooled data showed a lower summated MAI score (five studies; mean difference -3.88, 95% CI -5.40 to -2.35) and fewer Beers drugs per participant (two studies; mean difference -0.1, 95% CI -0.28 to 0.09) in the intervention group compared with the control group. Evidence of the effects of interventions on hospital admissions (five studies) and of medication-related problems (six studies) was conflicting.

Authors' conclusions
It is unclear whether interventions to improve appropriate polypharmacy, such as pharmaceutical care, resulted in clinically significant improvement; however, they appear beneficial in terms of reducing inappropriate prescribing.

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Interventions to improve the appropriate use of polypharmacy for older people

Background Severe asthma is characterized by difficulty to achieve disease control despite high-intensity treatment. However, prevalence figures of severe asthma are lacking, whereas longstanding estimates vary between 5% and 10% of all asthmatic patients. Knowing the exact prevalence of severe refractory asthma as opposed to difficult-to-control asthma is important for clinical decision making, drug development, and reimbursement policies by health authorities. Objective We sought to estimate the prevalence of severe refractory asthma as defined by the Innovative Medicine Initiative consensus. Methods Adult patients with a prescription for high-intensity treatment (high-dose inhaled corticosteroids and long-acting β2-agonists or medium- to high-dose inhaled corticosteroids combined with oral corticosteroids and long-acting β2-agonists) were extracted from 65 Dutch pharmacy databases, representing 3% of the population (500,500 inhabitants). Questionnaires were sent to 5,002 patients, of which 2,312 were analyzed. The diagnosis of asthma and degree of asthma control were derived from questionnaires to identify patients with difficult-to-control asthma. Inhalation technique was assessed in a random sample of 60 adherent patients (prescription filling, ≥80%). Patients with difficult-to-control asthma, adherence to treatment, and a correct inhalation technique were qualified as having severe refractory asthma. Results were mirrored to the Dutch population. Results Of asthmatic adults, 3.6% (95% CI, 3.0% to 4.1%) qualified for a diagnosis of severe refractory asthma, representing 10.4 patients per 10,000 inhabitants. Conclusion The prevalence of severe refractory asthma might be lower than estimated by expert opinion. This implies that currently recognized severe asthma subphenotypes could meet the criteria of rare diseases.

The prevalence of severe refractory asthma

En Colombia, la Revista VITAE de la Facultad de Quimica Farmaceutica de la Universidad de Antioquia es una de las 23 publicaciones cientificas clasificadas en la maxima categoria (A1) del Indice Bibliografico Nacional (Publindex). Por su parte, internacionalmente, desde el 2009, VITAE se encuentra incluida en los sistemas de indexacion Redalyc, ISI-Thompson y SCOPUS, reconocidos como los sistemas de mayor visibilidad. En este sentido, en la version del 2010 del Journal Citation Report, se le asigna un factor de impacto de 0.205; valor que la situa en el puesto 5 entre las 14 revistas reportadas para Colombia.

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Investigar y publicar en atención farmacéutica: una labor por fortalecer

Cost-Utility Analysis of A Medication Review With Follow-Up for Older People With Polypharmacy in Community Pharmacies in Spain: Consigue Program

Professional pharmaceutical services may impact on patient’s health behaviour as well as influence on patients’ perceptions of the pharmacist image. The Health Belief Model predicts health-related behaviours using patients’ beliefs. However, health beliefs (HBs) could transcend beyond predicting health behaviour and may have an impact on the patients’ perceptions of the pharmacist image. This study objective was to develop and test a model that relates patients’ HBs to patient’s perception of the image of the pharmacist, and to assess if the provision of pharmacy services (Intervention group-IG) influences this perception compared to usual care (Control group). A qualitative study was undertaken and a questionnaire was created for the development of the model. The content, dimensions, validity and reliability of the questionnaire were pre-tested qualitatively and in a pilot mail survey. The reliability and validity of the proposed model were tested using Confirmatory Factor Analysis (CFA). Structu...

Modelling elderly patients’ perception of the community pharmacist image when providing professional services*

Objective: To assess the effect of a protocol-based pharmacist intervention on blood pressure control and medication adherence among treated hypertensive patients who are users of community pharmacies. Methods: A quasi experimental study design with control group has been designed to compare the effect of pharmaceutical intervention (intervention group) versus the standard healthcare procedure (control group) on blood pressure and medication adherence among hypertensive patients receiving drug therapy in community pharmacies. The patients will be allocated evenly between the two groups (ncontrol = nintervention), with a 6-month follow-up. The pharmaceutical intervention program will comprise three main parts: 1) patient education / information on issues relating to hypertension and medication adherence; 2) self-monitoring of blood pressure; and 3) interaction with the physician through personalized reports when the mean blood pressure values recorded at home exceed the treatment goal according to the clinical condition of the patient. In order to evaluate the effect of the pharmaceutical intervention upon medication adherence and blood pressure, blood pressure recordings will be made in the pharmacy, while percent medication adherence will be established based on pill count in both groups at the start and end of the study. Discussion: To our knowledge, this is the first study in the community pharmacy setting in Spain to evaluate the effectiveness of pharmaceutical intervention in combination with home blood pressure monitoring on blood pressure control. In addition, the pharmaceutical intervention has been designed for inclusion as standard practice in the context of Pharmaceutical Care.

Daniel Sabater-Hernández

Papers

Investigar y publicar en atención farmacéutica: una labor por fortalecer

Cost-Utility Analysis of A Medication Review With Follow-Up for Older People With Polypharmacy in Community Pharmacies in Spain: Consigue Program

Modelling elderly patients’ perception of the community pharmacist image when providing professional services*

adherence and blood pressure control in treated hypertensive patients: Rationale, design and methods of the AFenPA pilot study.

Letter of response to correspondence regarding article "Defining professional pharmacy services in community pharmacy".