FundaÃÃo de Amparo à Pesquisa do Estado do Cearà / INTRODUÃÃO: A prescriÃÃo mÃdica à o principal determinante do uso de medicamentos e contribui para a efetividade da atenÃÃo à saÃde, agravos relacionados aos medicamentos e para os gastos pÃblicos em saÃde. A avaliaÃÃo da qualidade da prescriÃÃo tem sido compreendida como uma estratÃgia para sua melhoria. OBJETIVO: Desenvolver e testar indicadores de qualidade da prescriÃÃo (IQP) mÃdica em atenÃÃo primÃria de saÃde (APS) no municÃpio de Fortaleza-CE. METODOLOGIA: RevisÃo da literatura em bases de dados indexadas. SeleÃÃo, adaptaÃÃo e listagem dos IQP; convite aos prescritores da APS e distribuiÃÃo de material para leitura crÃtica; oficina de consenso com prescritores pela TÃcnica do Consenso Informal (TCI); aplicaÃÃo dos indicadores pactuados a uma amostra das prescriÃÃes em APS em Fortaleza no perÃodo de janeiro a fevereiro de 2008. Foram identificados na literatura 99 IQP, dos quais 43 foram excluÃdos obedecendo aos critÃrios de inclusÃo e exclusÃo. Os demais foram adaptados à realidade investigada e aos objetivos do estudo obtendo-se 59 indicadores que foram classificados em dois grupos: Indicadores dos processos gerais da prescriÃÃo (10) e Indicadores orientados ao medicamento (49). Um texto explicativo acompanhado da listagem dos IQP foi distribuÃdo aos prescritores com 7 dias de antecedÃncia e trazido para discussÃo em grupo, seguida de plenÃria de consenso, moderada pelas pesquisadoras. RESULTADOS: Participaram do consenso 17 prescritores (9 mulheres), idade mÃdia de 38 anos. Destes, 35,29% graduaram-se entre 1999 e 2007. Seis eram preceptores (3 mestres) e 11 residentes em medicina da famÃlia (6 especialistas). A mÃdia de atuaÃÃo no serviÃo pÃblico era de 10 anos. Durante a plenÃria, o grupo consenso decidiu aceitar todos os IQP prÃ-selecionados e acrescentaram mais seis. Os indicadores dos aspectos gerais da prescriÃÃo foram mais simples de calcular e interpretar, enquanto os indicadores orientados ao medicamento apresentaram maiores dificuldades devido à ausÃncia de requisitos tÃcnicos na prescriÃÃo que dificultaram a aplicaÃÃo. Todavia apÃs aplicaÃÃo dos IQP foi possÃvel conhecer o perfil da prescriÃÃo mÃdica de Fortaleza. Os indicadores foram aplicados a uma amostra das prescriÃÃes (N=624, sendo 30 por unidade de saÃde), envolvendo 1582 itens de medicamentos prescritos e uma mÃdia de 2,52 medicamentos por prescriÃÃo. 87% dos medicamentos prescritos pertenciam a lista padronizada do municÃpio, sendo o paracetamol o mais freqÃente. A prescriÃÃo por denominaÃÃo genÃrica aconteceu em 90,6% dos casos. 2,1% das prescriÃÃes possuÃam injetÃveis ou psicotrÃpicos e 8,3% das prescriÃÃes eram injustificÃveis. Em mÃdia o gasto por prescriÃÃo foi de R$ 2,40. A prevalÃncia dos grupos terapÃuticos analisados foi: 22,8% - anti-hipertensivos, 8,81% - antiagregante plaquetÃrio, 6,57% antidiabÃticos, 8,17% - anti-secretores, 27,08% - analgÃsicos, 22,25% - antibiÃticos. CONCLUSÃO: AtravÃs da TCI foi possÃvel elaborar um sistema de indicadores capazes de avaliar a prescriÃÃo mÃdica em APS. Esses IQP darÃo suporte ao profissional farmacÃutico para realizar avaliaÃÃes periÃdicas e planejarem intervenÃÃes necessÃrias, no sentido de aperfeiÃoar cada vez mais a prescriÃÃo tendo em vista o benefÃcio dos pacientes. / INTRODUCTION: The medical prescription is the main determinant of the use of medicines and contributes to the effectiveness of the health care, offences related to medicines and for the public costs in health. The evaluation of the quality of the prescription has been considered as a strategy to achieve its improvement. OBJECTIVE: Develop and test indicators of quality of the medical prescription (IQP) in primary health care (PHA) in the municipal district of Fortaleza-CE. METHODOLOGY: Revision of the literature in bases of indexed data. Selection, adaptation and listing of IQP; invitation sent to the doctors of PHA and material distribution for critical reading; consensus workshop with doctors using technique of the informal consensus (TIC); application of agreed indicators to a sample of the prescriptions in PAH in Fortaleza in the period of January to February 2008. 99 IQP were identified in the literature, of which 43 were excluded according to the criteria of inclusion and exclusion. The others were adapted to the reality investigated and the objectives of the study resulting in 59 indicators that were classified into two groups: indicators of processes of the general prescription (10) and targeted drug indicators (49). An explanatory text added of a list of IQP was distributed to prescribers 7 days in advance and brought to discussion groups, followed of full consensus, moderated by the researchers. RESULTS: Seventeen prescribers had participated of the consensus (9 women), average age 38 years. Among these, 35.29% graduated between 1999 and 2007. Six of them were preceptors (3 masters) and 11 residents in family medicine (6 experts). The average performance in the public service was 10 years. During the session, the consensus group decided to accept all IQP pre-selected and added six more. The indicators of the general aspects of the prescription was simple to calculate and interpret, while indicators targeted drug showed greater difficulties due to lack of technical requirements in the prescription that hampered the implementation. However after applying the IQP was possible to know the profile of the medical prescription in Fortaleza. The indicators were applied to a sample of prescriptions (N = 624, being 30 per health unit), involving 1,582 items of prescribed drugs and an average of 2.52 drugs per prescription. 87% of prescribed drugs were the standard list of the municipality, the paracetamol as being the most frequent drug. The prescription by generic denomination occurred in 90.6% of cases. 2.1% of prescriptions had injected drugs or psychotropics and 8.3% of prescriptions were unjustifiable. On average the cost per prescription was R $ 2.40. The prevalence of treatment groups was analyzed: 22.8% - antihypertensives, 8.81% - platelet aggregation inhibitor, 6.57% - antidiabetics, 8.17% - antiulcer, 27.08% - analgesics, 22.25 % - antibiotics. CONCLUSION: Through the TCI it was possible to devise a system of indicators able to evaluate the prescription in APS. These IQP will support the professional pharmacist to conduct periodic assessments and to plan necessary interventions, in order to improve prescribe aiming at the benefit of patients.

Atualmente, uns dos assuntos mais discutidos na medicina quando se trata de erros é a prescrição médica. Estes erros podem causar grandes danos à saúde dos pacientes, e um dos grandes causadores destes erros é a prescrição feita de forma manual, ou seja, de forma escrita manuscrita pelos médicos. Outro problema decorrente é o fato que nos modelos existentes não contemplam todas as informações necessárias para a correta prescrição. A prescrição médica é um documento que deve conter dados do paciente e de seu tratamento, como medicamentos, doses, periodicidade e, entre outras informações. Como na maioria das vezes quem realiza a infusão dos medicamentos nos pacientes não são os mesmos médicos que os prescreveram, a escrita manuscrita pode dificultar a leitura e o entendimento para quem for realizar o procedimento no paciente. Assim, os problemas proporcionados pela prescrição médica manuscrita como a falta de informações, escrita ilegível, rasuras e informações incompletas, podem ocasionar interpretações errôneas por parte dos profissionais de saúde que os leem, provocando sérios prejuízos diretos aos pacientes. Como atualmente é inevitável à introdução da tecnologia da informação (T.I.) na medicina, houve a iniciativa de criar um questionário eletrônico com perguntas sobre quais informações devem contemplar uma prescrição eletrônica, a fim de não haver falta e nem excesso de informações no modelo de prescrição eletrônica evitando possíveis problemas. Foi criado um questionário contendo 24 questões de múltiplas escolhas, com respostas do tipo SIM ou NÃO. Os questionários foram enviados aos associados da Sociedade Brasileira de Oncologia Clínica. Foram 215 questionários respondidos, sendo que das 24 questões 17 tiveram 80% ou mais de respostas sim, onde significa que estas informações devem fazer parte do modelo de prescrição, que foi desenvolvido a partir destas informações. / Nowadays, one of the most discussed subjects in medicine when it comes to errors, is medical prescription. These errors can cause great harm to patients, and one of the great causes of these errors is the prescription made manually, that is, in handwritten by doctors. Another problem is the fact that in the existing models it is not include all the information necessary for the correct prescription. The medical prescription is a document that should contain data about the patient and their treatment, such as medications, doses, periodicity among other information. As most of the time those who infuse the drugs are not the same doctors who prescribed them, handwriting may make it difficult to read and understand for those who perform the procedure. Thus, the problems provided by medical prescription such as lack of information, illegible writing, erasures and incomplete information, can lead to misinterpretations by health professionals who read them, causing serious harm to patients. As it is currently unavoidable the introduction of informatics technology (IT) in medicine, there was the initiative to create an electronic questionnaire with questions about what information should contemplate an electronic prescription. In order to avoid lack or excess of information in the prescription model, avoiding possible problems, a questionnaire containing 24 multiple choice (YES or NO) questions was created. The questionnaires were sent to the members of the Brazilian Society of Clinical Oncology. There were 215 questionnaires answered, and of the 24 questions, 17 had 80% or more answers, which means that this information should be part of the prescription model.

Class of 2013 Abstract / Specific Aims: The aim of this study was to compare memory retention between two methods (the teach-back method and the standard method) of educating subjects about mock prescription medications during a simulated counseling session. Methods: Men and women ages 18 to 89 years located on the University of Arizona main campus were recruited to participate. Blinded subjects were randomly placed into either the teach-back method or standard counseling method group. The standard method involved telling the subject eight counseling points about two separate fictitious medications while the subject handled mock prescription bottles. The teach-back method added to the standard method by asking three open-ended questions to recall what was taught and correct any misunderstandings. Memory retention was assessed within 5 minutes by a blinded investigator who asked 6 questions concerning the first hypothetical drug. The total score of correct answers between subjects in the two groups were compared using the Mann-Whitney U test. Also, demographic characteristics (age, sex, education, current prescription use) were compared. Main Results: A total of 62 subjects were enrolled in the study. Subjects in the teach-back method remembered one more counseling point on average compared to those in the standard method (median 6 vs 5, mode 6 vs 5, teach-back and standard respectively; Mann-Whitney U test: Z= -3.08, p=0.0021). Conclusion: The teach-back method is a quick and easy counseling method health care providers can use in their daily practice to improve memory retention by patients who receive new medications.

Class of 2017 Abstract / Objectives: To evaluate the perceptions of the pharmacy staff on prescription errors, efficiency, and difficulty of use before and after implementation of a new pharmacy computer system. Subjects: Employees of El Rio Community Health Center outpatient pharmacies located at the Congress, Northwest, and El Pueblo Clinics. Methods: This study was of a retrospective pre-post design. A 5-question survey on error rates and workflow efficiency was distributed to pharmacists and technicians 6 months after a new computer system had been implemented. Participants of the study included employees of El Rio Community Health Center outpatient pharmacies who were employed with El Rio during the time of transition between the old and new computer systems. Results: Questionnaire responses were completed by 10 (41.7%) technicians and 6 (66.7%) pharmacists at three El Rio Clinics. There was an increase in perceived efficiency between the new (Liberty) (n=17, 94.4%) and old (QS1) (n=11, 61.1%) computer systems (p<0.05). There were no significant differences in perceived difficulty of use, most common types of errors, error rates, and time to fix detected errors. Conclusions: While there were no significant differences between Liberty and QS1 in perceived difficulty of use, most common types of errors, error rates, and time to correct detected errors, there was a significant difference in the perceived efficiency, which may have beneficial implications.

Background: Worldwide, prices for cancer drugs have been under downward pressure where several governments have mandated price cuts of branded and generic products. A better alternative to mandated price cuts would be the estimation of a launch price based on drug performance, cost effectiveness and a country’s ability to pay. In this study, the development of a global pricing index for new drugs that encompasses all of these attributes in patients with metastatic colorectal cancer (mCRC) is described. Methods: A pharmacoeconomic model was developed to simulate clinical outcomes in mCRC patients receiving chemotherapy with the addition of a “new drug” that improves survival by 1.4, 3 and 6 months. Cost and health state utility data were obtained from cancer centers and oncology nurses (total n=112) in Canada (n=24), Spain (n=24), India (n=24), South Africa (n=16) and Malaysia (n=24). A price per dose was estimated for each survival increment using a target value threshold of three times the per capita gross domestic product (GDP) for each country, as recommended by the World Health Organisation (WHO). Multivariable analysis was then used to develop the pricing index, which considers survival benefit, per capita GDP and income dispersion as measured by the Gini coefficient as predictor variables. Results: Higher survival benefits were associated with elevated drug prices, especially in wealthier countries such as Canada and Spain. For a nation like Argentina with a per capita GDP of $15,000 and a Gini coefficient of 51, it is estimated that for a drug which provides a 4 month survival benefit in mCRC, the value based price would be $US 630 per dose. In contrast, the same drug in a wealthier country like Norway could command a price of $US 2,775 and still be considered cost effective according to the WHO criteria. Conclusions: A global pricing index was presented that can be used to estimate a value based price in different countries for new drugs in mCRC. The application of this index to estimate a price based on cost effectiveness would be a good starting point for opening dialogue between the key stakeholders and a better alternative to governments’ mandated price cuts.

Class of 2017 Abstract / Objectives: To first educate undergraduates involved in social sororities about prescription stimulant medications and to evaluate the effectiveness of an educational intervention in influencing the attitudes and beliefs regarding prescription stimulant medication use of undergraduates involved in a social sorority. Methods: The intervention, an educational session, was presented to undergraduates involved in social sororities. Questionnaire that included demographic data of gender, age, ethnicity, race, undergraduate year, grade point average, type of member, history of an attention-deficit/hyperactivity disorder (ADHD) diagnosis, and previous or current non-medical use of prescription stimulants were collected. The participants’ beliefs on nine statements regarding prescription stimulants were queried pre- and post-intervention using a four-point Likert scale ranging from strongly disagree to strongly agree. To analyze change in attitudes and beliefs, Mann-Whitney test was used. Results: One hundred sixty-three sorority members participated in the study. The average age of participants was 19 years with the majority of respondents identifying as an active sorority member (81%) and in their first year of undergraduate study (69%). There was a statistically significant change in beliefs regarding the safety (p < 0.01) and health risks (p = 0.02) associated with prescription stimulants. There was no significant difference in topics relating to addiction, legality, emotional and academic outcomes from the use of prescription stimulants. Conclusions: The education session was effective in changing participants’ beliefs on safety and health risks of nonmedical use of prescription stimulants.

Les effets indésirables liés aux médicaments (EIM) sont des dommages liés au traitement médicamenteux plutôt qu’aux conditions sous-jacentes du patient. Ils mettent les patients en danger, et la plupart d’entre eux sont évitables. La détection des EIM repose habituellement sur les reports spontanés d’EIM et sur la revue de dossiers. L’objectif du présent travail est d’identifier automatiquement les cas d’EIM en utilisant des méthodes de Data Mining (fouille statistique de données). Le DataMining est un ensemble de méthodes statistiques particulièrement adaptées à la découverte de règles dans de grandes bases de données.Matériel Un modèle de données commun est tout d’abord défini, dans le but de décrire les données qui peuvent être extraites des dossiers patient électroniques. Plus de 90 000séjours hospitaliers complets sont extraits de 5 hôpitaux français et danois. Ces enregistrements incluent les diagnostics, les résultats de biologie, les médicaments administrés, des informations démographiques et administratives, et enfin du texte libre (courriers, comptes-rendus). Lorsque les médicaments ne peuvent être extraits d’un CPOE (système de prescription connectée), ils sont extraits des courriers pa rSemantic Mining (fouille de texte). De plus, la société Vidal fournit un ensemble exhaustif de RCP (Résumés des Caractéristiques du Produit).Méthode On tente de tracer dans les données tous les événements indésirables décrits dans les RCP. Puis en utilisant les méthodes de Data Mining, en particulier les arbres de décision et les règles d’association, on identifie les circonstances qui favorisent l’apparition d’EIM. Plusieurs règles de détection des EIM sont ainsi obtenues, elles sont ensuite filtrées et validées par un comité d’experts. Enfin, les règles sont décrites sous forme de fichiers XML et stockées dans une base. Elles sont exécutées afin de calculer certaines statistiques et de détecter les cas d’EIM.Résultats236 règles de détection des EIM sont ainsi découvertes. Elles permettent de détecter27 types d’événements indésirables différents. Plusieurs statistiques sont calculées automatiquement pour chaque règle dans chaque service, comme la confiance ou le risque relatif. Ces règles impliquent des conditions innovantes : par exemple certaines règles décrivent les conséquences de l’arrêt d’un médicament. De plus, deux outils Web sont développés et mis à la disposition des praticiens via Internet : les Scorecards permettent de présenter des informations statistiques e tépidémiologiques sur les EIM propres à chaque service, tandis que l’Expert Explorer permet aux médecins d’examiner en détail les cas probables d’EIM de leur service.Enfin, une évaluation préliminaire de l’impact clinique des EIM est menée, ainsi que l’évaluation de la précision de détection des EIM. / Adverse Drug Events (ADE) are injuries due to medication management rather than the underlying condition of the patient. They endanger the patients and most of them could be avoided. The detection of ADEs usually relies on spontaneous reporting ormedical chart reviews. The objective of the present work is to automatically detectcases of ADEs by means of Data Mining, which are a set of statistical methodsparticularly suitable for the discovery of rules in large datasets.MaterialA common data model is first defined to describe the available data extracted from the EHRs (electronic health records). More than 90,000 complete hospital stays areextracted from 5 French and Danish hospitals. Those complete records includediagnoses, lab results, drug administrations, administrative and demographic data aswell as free-text reports. When the drugs are not available from any CPOE(Computerized Prescription Order Entry), they are extracted from the free-text reports by means of semantic mining. In addition, an exhaustive set of SPCs (Summaries of Product Characteristics) is provided by the Vidal Company.MethodsWe attempt to trace all the outcomes that are described in the SPCs in the dataset. By means of data mining, especially Decision Trees and Association Rules, the patternsof conditions that participate in the occurrence of ADEs are identified. Many ADEdetection rules are generated; they are filtered and validated by an expert committee. Finally, the rules are described by means of XML files in a central rules repository, and are executed again for statistics computation and ADE detection.Results236 ADE-detection rules have been discovered. Those rules enable to detect 27different kinds of outcomes. Several statistics are automatically computed for eachrule in every medical department, such as the confidence or the relative risk. Thoserules involve innovative conditions: for instance some of them describe theconsequences of drug discontinuations.In addition, two web tools are designed and are available through the web for thephysicians of the departments: the Scorecards enable to display statistical andepidemiological information about ADEs in a given department and the ExpertExplorer enables the physicians to review the potential ADE cases of theirdepartment.Finally, a preliminary evaluation of the clinical impact of the potential ADEs isperformed as well as a preliminary evaluation of the accuracy of the ADE detection.

Class of 2006 Abstract / Objectives: To evaluate the public’s awareness regarding the professional role pharmacists have in a community pharmacy setting. Methods: The study design was a small-scale, cross-sectional survey conducted in two community pharmacy sites. Subjects included patients picking up prescription medications requiring pharmacist consultation. Volunteer participation and completion of the PQ, constituted eligible enrollment into the study. The pharmacy questionnaire (PQ) consisted of 11 statements. Subjects were to read and signify along an ordinal scale whether they strongly disagreed to strongly agree with each statement. A total of 134 surveys were completed and returned for analysis from the two pharmacy sites. Analysis of the PQ looked at responses within and between group demographics, such as gender, age, frequency and reason for visitation to pharmacy. The impact of the independent variables on patient responses to the questionnaire and the differences in patient responses between the two collection periods was analyzed using independent t-tests or a one-way ANOVA. Results: The average response scores were positive for all Statements, ranging from ‘Somewhat Agree’ to ‘Agree.’ The two lowest rated statements were concerning the refusal to fill an unsafe prescription, and checking for prescription 3x for accuracy. The three highest rated Statements were ensuring patient understanding of proper medication use, answering questions about side effects, and pharmacist knowledge and expertise. Women answering questions more positively than men, particularly with ensuring patient understanding of proper medication use (p <0.01) and answering questions about side effects (p <0.05). The pharmacists’ knowledge and expertise was significantly higher rated in women than in men (p <0.01) and older women answered more positively than younger women (p <0.05). The statement about Refusing to fill an unsafe prescriptions had subjects 26 to 35 years old answering more negatively when compared to the 46 to 55 and >65 year old groups (p <0.05). As age increased, subjects responded more positively to the pharmacist verifying dosages, and men disagreed to a greater degree than women (p <0.01). Increases in the frequency of pharmacy visits had a visual trend of more positive responses, but only the verification of dosages was nearly significant (p <0.05). By whom the questionnaire was completed by (self or non-self) had no bearing on the response. Conclusions: Regardless of age, gender, or setting, patients tended to be reasonably familiar with the role community pharmacists take part in as a member of the health care profession.

Orientador: Guilherme Antonio Moreira de Barros / Resumo: Introdução: A dor é uma experiência pessoal, subjetiva, que envolve aspectos sensitivos e culturais que podem ser alterados pelas variáveis socioculturais e psíquicas do indivíduo, do meio e, apesar de classificações diversas, geralmente relacionada ao sofrimento. No Brasil estudos indicam que, embora cerca de 50% dos pacientes portadores de dor estejam medicados, a maior parte deles está descontente com os resultados do tratamento. Em situação de dor aguda traumática, apenas 7% dos pacientes tem suas dores totalmente aliviadas e, em pacientes em vigência de dor de intensidade moderada a grande, somente 25% receberam opioides como parte de seu tratamento, apesar de recomendação da OMS de uso destes analgésicos, como descrito na escada analgésica. Objetivo: Compreender as razões da baixa prescrição dos opioides no tratamento da dor no Brasil, com ênfase aos entraves sociais, legais e burocráticos existentes. Métodos: Trata-se de um estudo epidemiológico, prospectivo, analítico observacional e transversal, aprovado pela Comissão de Ética em Pesquisa, e realizado a partir de questionário investigativo disponibilizado em plataforma online, com perguntas fechadas e abordagem quantitativa. Foram convidados a participarem do estudo, por meio de mensagens eletrônicas a médicos atuantes em território Nacional. Aqueles que concordaram em participar assinaram, eletronicamente, o Termo de Consentimento Livre e Esclarecido (TCLE) online. Para análise estatística foram realizados os teste... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: Pain is a personal, subjective experience, involving sensitive and cultural aspects that can be altered by the socio-cultural and psychological variables of the individual, the environment and, despite different classifications, it is frequently related to suffering. In Brazil studies indicate that, although about 50% of pain patients are medicated, most of them are unhappy with the treatment outcomes. In situations of acute traumatic pain, only 7% of patients have their pain totally relieved and, in patients with moderate to severe pain, only 25% received opioids as part of their treatment, despite of the WHO recommendation to use these analgesics, as described on the analgesic ladder. Objective: To understand the reasons for the low prescription of opioids in the treatment of pain in Brazil, with emphasis on the existing social, legal and bureaucratic barriers. Method: This is a prospective, observational and cross-sectional epidemiological study, approved by the Research Ethics Committee, and carried out using an investigative questionnaire available on an online platform, with closed questions and a quantitative approach. Participants were invited to participate in the study, through electronic messages to medical doctors working in the national territory. Those who agreed to participate signed, electronically, the Free and Informed Consent Term (ICF) online. For statistical analysis, chi-square tests were performed followed by Z tests and Student's t tests.... (Complete abstract click electronic access below) / Doutor

Prescription stimulant abuse is a recent drug abuse trend that is becoming a major problem across the United States. Previous research has mainly examined the amount of individuals that are abusing prescription stimulants and has ignored using sociological theory to explain why individuals are abusing these drugs. To address this gap in the literature, this thesis applies the theory of social capital to explain how an adolescents’ family structure can affect the likelihood they will abuse prescription stimulants. Examining survey data from the 2008 The National Survey on Drug Use and Health, it was found that adolescents from single parent households, with minimal parental involvement, are more likely to report abusing prescription stimulants. These findings highlight the influence of family structure and parental involvement in an adolescent’s life, as well as the need for additional research in this area to fully understand prescription stimulant abuse.