José Murcia-Zaragoza

Hospital General Universitario de Alicante, Alicante, Valencia, Spain

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Publications (12)10.78 Total impact

  • [show abstract] [hide abstract]
    ABSTRACT: To analyze the prescription profile and the factors associated with multiple medications (polypharmacy) and non-adherence in patients with advanced chronic diseases. Longitudinal cross-sectional study including 41 Spanish hospitals (PALIAR project). Polypharmacy was defined as a prescribed treatment with five or more drugs, and excessive polypharmacy when the number was ten or more. The adherence was evaluated using a questionnaire completed by the patients or their caregivers. Description of drug prescription profile and analysis was performed on the risk factors associated with multiple medications and non-adherence. The study included 1847 patients, and 1778 (96.2%) completed the questionnaire. Mean age was 78.74±10 years. Antihypertensives (82.6%), gastroprotectives (73.8%), anti-platelets/anticoagulants (70.3%), and psychotropic drugs (51.8%) were the most frequently prescribed drugs. Prevalence of polypharmacy/excessive polypharmacy was 86.2%/31.3%, with a mean of 8±3.5 drugs per patient. Errors in treatment compliance were detected in 48.2% of patients, but 38.5% and 9.6% referred to an occasional or almost daily failure, respectively. Factors associated with non-adherence were: to be a patient with multiple diseases, cognitive impairment, three or more 3 hospital admissions in the last three months, and having polypharmacy. Factors associated with polypharmacy were: to be a patient with multiple diseases, an ECOG score <3, age <85 years, and 3 or more hospital admissions. Factors associated with excessive polypharmacy were: to be a patient with multiple diseases and previous frequent hospital admissions. The prevalence of polypharmacy in patients with advanced chronic diseases is high, and mistakes in treatment compliance are frequent. Further studies with better defined objectives and more specific therapeutic limits are needed.
    Revista Española de Geriatría y Gerontología 03/2014;
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    ABSTRACT: Context Efforts in developing useful tools to properly identify the end-of-life trajectory of patients with advanced medical diseases have been made, but the calibration and/or discriminative power of these tools has not been optimal. Objectives Our objective was to develop a new, reliable prognostic tool to identify the probability of death within six months in patients with chronic medical diseases. Methods This was a multicenter, prospective, observational study in 41 Spanish hospitals, which included 1778 patients with one or more of the following: advanced conditions such as heart failure, respiratory failure, chronic renal failure, chronic liver disease, and/or chronic neurological disease. All patients were followed over six months. Each factor independently associated with death in the derivation cohort (884 patients from eastern areas of Spain) was assigned a prognostic weight, and the score was calculated by summing up the factors. The score's accuracy in the validation cohort (894 patients from western areas of Spain) was assessed by analyzing its calibration and discriminative power; we also calculated sensitivity, specificity, and positive and negative predictive values. Results Mortality in the derivation/validation cohorts was 37.6%/37.7%, respectively. We identified six independent predictors of mortality (≥85 years, three points; New York Heart Association Class IV/Stage 4 dyspnea on the modified Medical Research Council, 3.5 points; anorexia, 3.5 points; presence of pressure ulcer(s), three points; Eastern Cooperative Oncology Group Performance Status of three or more, four points; and albuminemia ≤2.5 g/dL, four points). Mortality in the derivation/validation cohorts according to risk group was 20%/21.5% for patients with zero points; 33%/30.5% for those with 3–3.5 points; 46.3%/43% for those with four to seven points; and 67%/61% for those who reached 7.5 or more points, respectively. The calibration was good (Hosmer-Lemeshow test, P = 0.39), as was the discriminative power (area under the receiver operating characteristic curve of 0.69 [0.66–0.72]). The sensitivity (85%), specificity (86%), positive and negative predictive values (64% and 80%, respectively) at 180 days were high. Conclusion The PALIAR score is a precise and reliable tool for identifying the end-of-life trajectory in patients with advanced medical diseases.
    Journal of Pain and Symptom Management. 01/2014; 47(3):551–565.
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    ABSTRACT: Objectives To analyze the prescription profile and the factors associated with multiple medications (polypharmacy) and non-adherence in patients with advanced chronic diseases. Method Longitudinal cross-sectional study including 41 Spanish hospitals (PALIAR project). Polypharmacy was defined as a prescribed treatment with five or more drugs, and excessive polypharmacy when the number was ten or more. The adherence was evaluated using a questionnaire completed by the patients or their caregivers. Description of drug prescription profile and analysis was performed on the risk factors associated with multiple medications and non-adherence. Results The study included 1847 patients, and 1778 (96.2%) completed the questionnaire. Mean age was 78.74±10 years. Antihypertensives (82.6%), gastroprotectives (73.8%), anti-platelets/anticoagulants (70.3%), and psychotropic drugs (51.8%) were the most frequently prescribed drugs. Prevalence of polypharmacy/excessive polypharmacy was 86.2%/31.3%, with a mean of 8±3.5 drugs per patient. Errors in treatment compliance were detected in 48.2% of patients, but 38.5% and 9.6% referred to an occasional or almost daily failure, respectively. Factors associated with non-adherence were: to be a patient with multiple diseases, cognitive impairment, three or more 3 hospital admissions in the last three months, and having polypharmacy. Factors associated with polypharmacy were: to be a patient with multiple diseases, an ECOG score <3, age <85 years, and 3 or more hospital admissions. Factors associated with excessive polypharmacy were: to be a patient with multiple diseases and previous frequent hospital admissions. Conclusions The prevalence of polypharmacy in patients with advanced chronic diseases is high, and mistakes in treatment compliance are frequent. Further studies with better defined objectives and more specific therapeutic limits are needed.
    Revista Española de Geriatría y Gerontología 01/2014;
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    ABSTRACT: Background and objectives To determine the use of oral anticoagulants in polypathological patients with atrial fibrillation and its influence on mortality and loss of functionality.Patients and methodsPatients with polypathological patient criteria and atrial fibrillation were included in an observational, prospective and multicenter study. Data on demographic, clinical, functional and sociofamilial characteristics, CHADS2 score, levels of hemoglobin, albumin and creatinine, use of oral anticoagulants and survival and functional status at one year were collected.ResultsFive hundred and thirty-two (32.6%) of 1,632 polypathological patients had atrial fibrillation. The stroke risk was high in 505 (94.9%), moderate in 24 (4.5%) and low in 3 (0.6%) patients. Oral anticoagulants were used in 61% of patients with CHADS2 score ≥ 2 and in 37.5% with CHADS2 score = 1. Oral anticoagulants were less used in older patients, with more functional and cognitive impairment. Heart failure was associated with more use of oral anticoagulants. There was no difference by the presence of hypertension, diabetes, anemia, renal insufficiency or stroke. In multivariate analysis the use of oral anticoagulants was independently associated with lower age, lower cognitive impairment, absence of hepatic disease and with higher stroke risk. The prescription of oral anticoagulants was independently associated with more survival at one year with no influence on functional status.Conclusions Oral anticoagulants are underused in polypathological patients with atrial fibrillation despite being associated with more survival.
    Medicina Clínica. 02/2013; 140(3):97–103.
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    ABSTRACT: 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.
    European Journal of Internal Medicine 01/2013; · 2.05 Impact Factor
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    ABSTRACT: Background and objectives To determine the use of oral anticoagulants in polypathological patients with atrial fibrillation and its influence on mortality and loss of functionality. PATIENTS AND METHODS: Patients with polypathological patient criteria and atrial fibrillation were included in an observational, prospective and multicenter study. Data on demographic, clinical, functional and sociofamilial characteristics, CHADS2 score, levels of hemoglobin, albumin and creatinine, use of oral anticoagulants and survival and functional status at one year were collected. RESULTS: Five hundred and thirty-two (32.6%) of 1,632 polypathological patients had atrial fibrillation. The stroke risk was high in 505 (94.9%), moderate in 24 (4.5%) and low in 3 (0.6%) patients. Oral anticoagulants were used in 61% of patients with CHADS2 score≥2 and in 37.5% with CHADS2 score=1. Oral anticoagulants were less used in older patients, with more functional and cognitive impairment. Heart failure was associated with more use of oral anticoagulants. There was no difference by the presence of hypertension, diabetes, anemia, renal insufficiency or stroke. In multivariate analysis the use of oral anticoagulants was independently associated with lower age, lower cognitive impairment, absence of hepatic disease and with higher stroke risk. The prescription of oral anticoagulants was independently associated with more survival at one year with no influence on functional status. CONCLUSIONS: Oral anticoagulants are underused in polypathological patients with atrial fibrillation despite being associated with more survival.
    Medicina Clínica 11/2012; · 1.40 Impact Factor
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    ABSTRACT: Frail and polypathological patients (PP) are often undertreated with evidence-based cardiovascular drugs, as their benefits are uncertain in this population. To determine the effects of treatment with renin-angiotensin system blockers/inhibitors (ACEI/ARB), statins and/or beta-blockers on survival rates and functional decline in PP with evidence-based clinical indications for treatment with any of these drug families. Prospective observational multicentre cohort study with a 12-month follow-up period. We selected PP with any condition of the following: chronic heart failure, coronary heart disease, chronic renal disease, cerebrovascular disease, peripheral artery disease, diabetes mellitus with any visceral involvement, hypertension, and dyslipidaemia. Clinical, functional (Barthel index), socio-familial risk data and drug prescriptions were measured at baseline. Multivariate Cox proportional hazards and logistic regression models were used to identify variables independently associated with survival and functional decline. The analysis included 1260 PP. The mean age was 79±9.5 years. The mortality rate was 34.5%. Statin (aHR 0.671; P=0.001), beta-blocker plus statin (aHR 0.645; P=0.007), ACEI/ARB plus statin (aHR 0.680; P=0.002), or combined ACEI/ARB plus statin plus beta-blocker (aHR 0.541; P=0.000) prescriptions were associated with longer survival times. Additionally, PP whose Barthel index was ≥60 showed a lower risk of disability progression if treated with statins (aOR=0.476; P=0.000), or their combinations, mainly with ACEI/ARB plus beta-blockers (aOR 0.563; P=0.031). The prescription of statins, alone or in combination with other drugs, may impact the survival and functional decline in polypathological patients. Further prospective blinded randomised assays are needed to confirm these observations.
    European Journal of Internal Medicine 03/2012; 23(2):179-84. · 2.05 Impact Factor
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    ABSTRACT: Around one third to one half of patients with hip fractures require red-cell pack transfusion. The increasing incidence of hip fracture has also raised the need for this scarce resource. Additionally, red-cell pack transfusions are not without complications which may involve excessive morbidity and mortality. This makes it necessary to develop blood-saving strategies. Our objective was to assess safety, efficacy, and cost-effictveness of combined treatment of i.v. ferric carboxymaltose and erythropoietin (EPOFE arm) versus i.v. ferric carboxymaltose (FE arm) versus a placebo (PLACEBO arm) in reducing the percentage of patients who receive blood transfusions, as well as mortality in the perioperative period of hip fracture intervention. Multicentric, phase III, randomized, controlled, double blinded, parallel groups clinical trial. Patients > 65 years admitted to hospital with a hip fracture will be eligible to participate. Patients will be treated with either a single dosage of i.v. ferric carboxymaltose of 1 g and subcutaneous erythropoietin (40.000 IU), or i.v. ferric carboxymaltose and subcutaneous placebo, or i.v. placebo and subcutaneous placebo. Follow-up will be performed until 60 days after discharge, assessing transfusion needs, morbidity, mortality, safety, costs, and health-related quality of life. Intention to treat, as well as per protocol, and incremental cost-effectiveness analysis will be performed. The number of recruited patients per arm is set at 102, a total of 306 patients. We think that this trial will contribute to the knowledge about the safety and efficacy of ferric carboxymaltose with/without erythropoietin in preventing red-cell pack transfusions in patients with hip fracture. CLINICALTRIALS.GOV IDENTIFIER: NCT01154491.
    BMC Musculoskeletal Disorders 02/2012; 13:27. · 1.88 Impact Factor
  • International Journal of Gerontology - INT J GERONTOL. 01/2012;
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    ABSTRACT: 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; hemoglobinemia <10 g/dl, 3 points; Barthel index <60 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.
    European Journal of Internal Medicine 06/2011; 22(3):311-7. · 2.05 Impact Factor
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    ABSTRACT: 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 cross-sectional 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.
    Archives of gerontology and geriatrics 01/2011; 53(3):284-91. · 1.36 Impact Factor
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    ABSTRACT: IntroductionIt is a challenge to reliably identify the end-of-life trajectory in patients with advanced-stage chronic medical conditions. This makes advanced supportive care planning and transition from survival to comfort objectives more difficult in these emergent patient populations.
    Revista Española de Geriatría y Gerontología. 01/2010; 45(4).
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    ABSTRACT: It is a challenge to reliably identify the end-of-life trajectory in patients with advanced-stage chronic medical conditions. This makes advanced supportive care planning and transition from survival to comfort objectives more difficult in these emergent patient populations. To evaluate the sensitivity (Se), specificity (Sp), positive predictive values (PPV) and negative (NPV), and validity index (IV) of NHO criteria for terminal medical conditions, PPI and ECOG in patients with advanced heart, lung, liver, kidney and/or neurological diseases, and to build and validate an accurate index to determine this border-line. A multicentre prospective cohort study, with inclusion of patients with the predefined advanced medical diseases. Demographic, clinical, care, stratification and staging of disease(s), functional, analytical, NHO criteria, ECOG, PPS and PPI data collection; The end-point (death) will be assessed 180 days after inclusion. Analysis of Se, Sp, PPV, NPV, and IV of the NHO criteria, ECOG scale and PPI at 30, 60, 90, 120, 150 and 180 days. Derivation of PALIAR Index, after multivariate analysis and appropriate weighting of risk factors (beta of risk factor/lowest beta of the model), and validation in the validation cohort, and in the historical PROFUND cohort. The project is still ongoing, with 50 investigators from 33 hospitals throughout Spain, who have already included 1138 patients (92.5% during hospital admissions, 51.4% of them are male, with a mean age of 78.5 years). Mean inclusion chronic diseases were 1.4 per patient (44.5% of patients suffered chronic neurological diseases, 38.6% with heart failure, 34.2% with lung diseases, 12% with liver diseases, and 6.5% with renal diseases). Around 69% fulfilled the criteria of polypathological patients (mean Charlson index 3.4), and were prescribed around 8 drugs chronically. Mean Barthel index was 40 points, and 77% of them were dependent on a caregiver. Around 46% were ECOG-PS stage III or IV, and mean PPS score was 45 points. The availability of an accurate and powerful tool that could enable us to identify the end-of-life trajectory of these patients could allow us to establish specific intervention strategies for these populations. Therefore, and with these preliminary data, we believe that the PALIAR PROJECT will answer with rigour the questions and objectives of the study.
    Revista Española de Geriatría y Gerontología 01/2010; 45(4):203-12.

Publication Stats

16 Citations
17 Downloads
381 Views
10.78 Total Impact Points

Institutions

  • 2013
    • Hospital General Universitario de Alicante
      • Departamento de Medicina Interna
      Alicante, Valencia, Spain
  • 2012
    • hospital Royo Villanova
      Caesaraugusta, Aragon, Spain
  • 2010–2012
    • Hospital Universitario Virgen del Rocío
      • Servicio de Medicina Interna
      Hispalis, Andalusia, Spain