4. Discussion
cognitive dependence, dementia, end-stage organ failure, paralysis, heart or lung disease, organ failure, dementia-like
DRUG INTERACTIONS, DISEASE, DISEASES, PCP
The two illness trajectories had a clearly different pattern of comorbidities at EOL, as well as in their functional and cognitive dependence. This is in accordance with the previous report by Lynn and Adamson [Our results also demonstrate that patients with organ failure trajectories display greater polypharmacy, numbers of drug–drug interactions, and pharmacotherapeutic complexity. This means that this population is especially vulnerable to drug-related problems. These findings agree in part with those reported by Todd et al. [To our knowledge, this is the first study to analyze the effect of a pharmacotherapeutic intervention on different illness trajectories at EOL, observing significant differences in the intensity of the effect in each of them. For patients with a dementia-like trajectory, the PCP model was effective in reducing the mean number of chronic medications, inappropriate or futile medications at EOL according to the STOPPFrail criteria, pharmacotherapeutic complexity, and the cost associated with medical prescriptions. However, the effect on organ failure trajectories was more modest and not significant. This lower effect in patients with end-stage organ failure may be related to difficulties involved in formulating a short- to medium-term prognosis and identifying the terminal phase of such diseases, concluding in the so-called prognostic paralysis [The analysis performed according to the degree of frailty of patients at EOL reported a high proportion of patients with an advanced stage (Frail-VIG > 0.5; 53%), characterized by high comorbidity, and up to 83.7% of people had a diagnosis of any degree of dementia. Notably, in previous studies, patients with advanced frailty presented a mortality rate at one–two years of practically 100% [In addition, the comparative analysis of the baseline pharmacotherapeutic characteristics between different degrees of frailty highlighted a higher DBI in those with advanced frailty. This may be related to a situation closer to the EOL, which requires these patients to use more drugs with anticholinergic and sedative characteristics [In people with a dementia-like trajectory, the PCP model has improved pharmacotherapeutic indicators, leading to a decrease in the monthly cost of medications. From the perspective of health economics, pharmaceutical spending may represent only a small part of the total healthcare spending—15% in the case of Spain [However, the effect on the cost of pharmacotherapy for people with an organ failure trajectory was not significant. Importantly, people with a history of primarily advanced heart or lung disease are those who are associated with a higher health care cost in the last 12 months of life, due to 80% being readmitted to hospital [This study has some limitations. First, the objectives were based on surrogate variables such as pharmacotherapeutic indicators and not on health outcomes that could facilitate the interpretation of the results’ clinical significance. Second, the economic analysis considered only the savings on direct costs associated with pharmacological prescriptions. Future studies should also consider savings on indirect costs, such as decreased medical consultations or hospital readmissions caused by therapy optimization.However, this work also has notable strengths. Establishing the PCP model in a hospital’s geriatric convalescence unit has allowed systematizing the early identification of EOL in people with trajectories of non-oncological diseases, guaranteeing universal coverage of palliative care. It has also allowed an understanding of the effectiveness of the PCP model on the different disease trajectories and frailty statuses.