Clinical Data for the Use of Cannabis-Based Treatments: A Comprehensive Review of the Literature.

OBJECTIVE: To compile and synthesize the available literature describing medical cannabis use across various disease states. DATA SOURCES: PubMed, EBSCO, and Google Scholar searches were conducted using MeSH and/or keywords. STUDY SELECTION AND DATA EXTRACTION: Studies were included if they described the use of cannabis-based products and medications in the treatment of a predefined list of disease states in humans and were published in English. The extraction period had no historical limit and spanned through April 2019. DATA SYNTHESIS: Evidence was compiled and summarized for the following medical conditions: Alzheimer disease, amyotrophic lateral sclerosis, autism, cancer and cancer-associated adverse effects, seizure disorders, human immunodeficiency virus, inflammatory bowel disease, multiple sclerosis (MS), nausea, pain, posttraumatic stress disorder, and hospice care. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Based on identified data, the most robust evidence suggests that medical cannabis may be effective in the treatment of chemotherapy-induced nausea and vomiting, seizure disorders, MS-related spasticity, and pain (excluding diabetic neuropathy). Overall, the evidence is inconsistent and generally limited by poor quality. The large variation in cannabis-based products evaluated in studies limits the ability to make direct comparisons. Regardless of the product, a gradual dose titration was utilized in most studies. Cannabis-based therapies were typically well tolerated, with the most common adverse effects being dizziness, somnolence, dry mouth, nausea, and euphoria. CONCLUSIONS: As more states authorize medical cannabis use, there is an increasing need for high-quality clinical evidence describing its efficacy and safety. This review is intended to serve as a reference for clinicians, so that the risks and realistic benefits of medical cannabis are better understood.

Add-On Therapies in Cardiovascular Disease: Reviewing ICER's Report and the Potential Effect on Payers.

DISCLOSURES: No outside funding supported this commentary. The authors have nothing to disclose.

Trends in Prevalence of Non-Valvular Atrial Fibrillation and Anticoagulation Therapy in a Japanese Region　- Analysis Using the National Health Insurance Database.

BACKGROUND: Direct oral anticoagulants (DOACs) are effective in reducing thromboembolism events in patients with non-valvular atrial fibrillation (NVAF). However, little is known about trends in NVAF prevalence and DOAC prescriptions in daily clinical practice. This study investigated the current status and trends in NVAF prevalence and DOAC prescriptions in a region of Japan.Methods and Results:Annual data for the 4 years from May 2014 to May 2017 in the Tsugaru region of Aomori Prefecture, Japan, were obtained for analysis from the Japanese National Health Insurance database ("Kokuho" database [KDB]). The prevalence of NVAF in subjects aged 40-74 years increased gradually over the 4-year study period (1,094/57,452 [1.90%] in 2014, 1,055/56,018 [1.88%] in 2015, 1,072/54,256 [1.98%] in 2016, and 1,154/52,341 [2.20%] in 2017). The proportion of NVAF patients prescribed warfarin decreased (42%, 33%, 24%, and 21% in 2014, 2015, 2016, and 2017, respectively), the proportion of those prescribed DOACs increased (30%, 42%, 50%, and 57%, respectively), and the proportion not prescribed an oral anticoagulant (OAC) decreased (28%, 25%, 26%, and 22%, respectively). However, 17% of patients with a CHADS2score ≥2 were not prescribed an OAC in 2017. CONCLUSIONS: By using the KDB we found that the prevalence of NVAF has increased gradually from 2014 to 2017. In the Tsugaru region in Japan, DOACs prescriptions increased and warfarin prescriptions decreased over the 4-year period.

Vitamin D Practice Patterns in National Collegiate Athletic Association Division I Collegiate Athletics Programs.

CONTEXT: Vitamin D status has been associated with performance, health, and well-being in athletic populations. The measurement of vitamin D status via 25-hydroxyvitamin D [25(OH)D] testing has increased in the general population, as has vitamin D supplement use. It is unclear if similar patterns exist in collegiate athletics programs. OBJECTIVE: To describe the clinical care related to the prevention, evaluation, and treatment of vitamin D deficiency and insufficiency used by sports medicine providers with National Collegiate Athletic Association (NCAA) Division I programs. DESIGN: Cross-sectional study. SETTING: Population-based online survey. PATIENTS OR OTHER PARTICIPANTS: All NCAA Division I head athletic trainers. MAIN OUTCOME MEASURE(S): Information related to 25(OH)D testing, vitamin D supplementation, vitamin D-related protocols and procedures, and characteristics of athletic programs and participants. RESULTS: We received 249 responses (72% response rate). Use of 25(OH)D testing was described by 68% of participants, with the most common indicators being health status/history (78%) and injury status/history (74%). One-fifth of participants stated that vitamin D testing was conducted as screening (without a specific cause or indication). Target blood vitamin D concentrations were highly variable. A range of 8 to 1660 annual vitamin D blood tests was reported at a cost of <$50 (8%), $51 to $100 (51%), $101 to $150 (20%), and >$150 (10%). Forty-two percent of programs covered the cost of vitamin D supplements. More than half of the participants indicated that vitamin D blood testing and supplements were not a good use of program funds. In comparison with Football Championship Subdivision programs, Football Bowl Subdivision programs were more likely to conduct vitamin D testing and pay for vitamin D supplements, and their providers were more likely to believe that testing and supplements were a good use of program funds. CONCLUSIONS: A great deal of variability was present in vitamin D-related clinical practices among NCAA Division I athletics programs, which reflects existing contradictions and uncertainty in research, recommendations, and guidelines. Knowledge of current practice patterns is important in evaluating and establishing best practices, policies, and procedures for sports medicine and sports nutrition professionals in the collegiate setting.

Real-World Treatment Patterns Among Patients Initiating Small Molecule Kinase Inhibitor Therapies for Thyroid Cancer in the United States.

INTRODUCTION: Little is known about real-world use of small molecule kinase inhibitors (SMKI) for advanced thyroid cancer in the United States. This study examined prescribing patterns of SMKI agents recommended by the National Comprehensive Cancer Center (NCCN). METHODS: This retrospective study used a national health insurance database to identify patients diagnosed with thyroid cancer during 1/1/2006-6/30/2016 and with prescription claims for NCCN-recommended SMKI during 1/1/2010-5/31/2016 whose first claim date was the index date. Inclusion also required continuous enrollment in a health plan for 3 months pre-index (baseline) and ≥ 1 month post-index (follow-up) with no claims for SMKI during baseline. Lines of therapy (LOT) were defined by the date of SMKI claims and days of drug supply. Median time to SMKI discontinuation in each LOT was estimated by Kaplan-Meier method. RESULTS: The study included 217 patients. During follow-up (mean duration 499.0 days), 35.5% of patients (n = 77) received a second or later LOT; among patients with ≥ 12 months follow-up after first LOT (LOT1) initiation, 53.1% (n = 60) received a second or later LOT. Median treatment duration was 5.0 months for LOT1 and 5.1 months for LOT2. Over the entire follow-up period (2010-2016), sorafenib was the most common regimen in LOT1 (36.9% of patients) and LOT2 (24.7%) followed by sunitinib and levantinib (13.4% each) in LOT1 and sunitinib (19.5%) in LOT2. Starting in 2015, the year lenvatinib was approved for differentiated thyroid cancer, lenvatinib was the most common first-line regimen among patients initiating LOT1 in 2015 (43.4%) and 2016 (66.7%). CONCLUSION: Sorafenib was the most common first-line agent during 2010-2014 but was supplanted by lenvatinib starting in 2015. Approximately 36-53% of patients received a second-line treatment. Median treatment duration results suggested potential benefit of SMKI in second-line therapy. SMKI treatment after first-line failure may be considered for appropriately selected patients. FUNDING: Eisai, Inc. (Woodcliff Lake, NJ).

Clinical pharmacist led hospital-wide direct oral anticoagulant stewardship program.

INTRODUCTION: In the past decade, direct-acting oral anticoagulants (DOAC) have been introduced to medical practice for several indications, with a wide range of dosing regimens. As both over- and under-dosing might lead to life-threatening events, development of methods promoting safe and effective utilization of these agents is imperative. The Hadassah Clinical Pharmacy team initiated a hospital-wide program, for monitoring and promoting safe and effective prescription of DOAC during hospitalization. This study describes the types of drug related problems addressed and the program's performance in terms of consultation rates and physician acceptance. METHODS: Electronic medical records throughout the hospital were screened for DOAC orders. All DOAC orders were assessed by a clinical pharmacist for potentially-inappropriate prescribing. When potentially-inappropriate prescribing or a drug-related problem was identified, the clinical pharmacist provided consultation on management options. In specific cases, additional guidance was provided by coagulation and pharmacology specialists. Data on patient characteristics, clinical pharmacist consultations, and physician response was retrospectively retrieved for the first six months of 2017. Characteristics of patients with and without consultations were compared, consultations were categorized by the recommended management of the drug related problem, and physician acceptance rates were evaluated by category. RESULTS: During the evaluated period, 585 patients with DOAC orders were identified. Patients were evenly distributed by gender, and age averaged 78 years. Most patients received apixaban (75%) followed by rivaroxaban (14%) and dabigatran (11%), and most (63%) received "reduced dose" regimens. Clinical pharmacists provided 258 consultations for 210 patients, regarding anticoagulation management, such that more than one in three patients on DOAC had potentially inappropriate prescribing or drug related problems. Consultations included alerts regarding potentially inappropriate DOAC doses and recommendations to increase (29%) or decrease (5%) the dose, potentially inappropriate concomitant antiplatelet agents (20%), need for DOAC level monitoring (23%), and alerts regarding other drug related problems (23%). More than 70% of recommendations were accepted by the attending physician. CONCLUSION: Due to the complexity of DOAC management, potentially-inappropriate prescribing and drug related problems are common. Multidisciplinary collaborative projects including review and consultation by clinical pharmacists are an effective method of improving management of patients on DOAC. TRIAL REGISTRATION: Retrospectively registered at clinicaltrials.gov, NCT03527615 .

Clinical and economic impacts of clinical pharmacists' interventions in Iran: a systematic review.

OBJECTIVES: There are many studies about Iranian clinical pharmacists' interventions and their impacts on medication safety and cost. The aim of this study is to collect data and critically evaluate the clinical and economic effects of Iranian clinical pharmacist interventions and activities. To our best of knowledge, this research is the first review of publications about Iranian clinical pharmacists' interventions and activities. EVIDENCE ACQUISITION: Six online databases, including PubMed, Scopus, Medline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systemic Reviews, and Google Scholar were searched using the terms '"Iranian", "clinical pharmacist", 'adverse drug reactions", "medication errors", "drug interaction", "drug utilization evaluation", "cost", and "interventions" for English studies conducted in Iran and described clinical pharmacist-initiated interventions, published before December 2018. The search and extraction process followed PRISMA guidelines. Observational or retrospective studies, clinical trials, congress abstracts, and case reports or case series were excluded. The search strategy after full-text review identified 39 articles matching the eligibility criteria. RESULTS: Thirty-nine articles were recruited. They included establishing pharmaceutical care in out-patient clinics and drug information centers (n = 4); prevention, detection, and management of adverse drug reactions(n = 4), designing protocols and improving drug utilization pattern(n = 16), prevention, detection, and management of medication errors (n = 11), and all clinical pharmacist services(n = 4). Most clinical pharmacist interventions and activities were regarding designing protocols, improving drug utilization pattern, as well as detection, prevention, and management of medication errors. About three-fourth (74.35%) of included studies were from either ambulatory care or in-patient settings in Tehran. The median (interquartile range) duration of intervention as well as follow-up phases was 9 (5) months. CONCLUSION: Data of our review support the beneficial role of clinical pharmacists in the improvement of quality, safety, and efficiency of patients' pharmaceutical care in Iran. Graphical abstract Clinical pharmacists' interventions in Iran.

Trends in Utilization of Statin Therapy and Contraindicated Statin Use in HIV--Infected Adults Treated With Antiretroviral Therapy From 2007 Through 2015.

Background HIV is associated with an increased risk for atherosclerotic cardiovascular disease, which may result in many people living with HIV taking a statin. Some statins are contraindicated with certain antiretroviral therapies ( ART ) and other medications commonly used by HIV -infected patients. Methods and Results We analyzed trends in the use of statins, including contraindicated statins, between 2007 and 2015 among HIV -infected patients aged ≥19 years taking ART who had employer-sponsored or Medicare supplemental health insurance in the Marketscan database (n=186 420). Statin use was identified using pharmacy claims. Contraindicated statin use was defined by a pharmacy claim for HIV protease inhibitors, cobicistat, hepatitis C protease inhibitors, anti-infectives, calcium channel blockers, amiodarone, gemfibrozil, or nefazodone followed by a fill for a contraindicated statin type and dosage within 90 days. The percentage of beneficiaries with HIV taking a statin remained unchanged between 2007 (24.6%) and 2015 (24.7%). Among those taking a statin, the percentage taking a contraindicated statin declined from 16.3% in 2007 to 9.0% in 2014 and then increased to 9.8% in 2015. The proportion of contraindicated statin fills attributable to HIV protease inhibitors declined from 63.9% in 2007 to 51.0% in 2015, while those attributable to cobicistat increased from 0% before 2012 to 20.6% in 2015. Conclusions Changes in ART regimens resulted in a decline in contraindicated statin use from 2007 to 2014, but this favorable trend was attenuated in 2015 because of increased use of cobicistat-containing ART regimens.

Patient involvement is essential in identifying drug-related problems.

AIMS: The aim of this study is to evaluate how critical patient involvement is in pharmacist-led clinical medication reviews and in identifying the most significant clinical drug-related problems (DRPs). METHODS: Pharmacist-led clinical medication reviews were conducted with 161 consenting patients aged ≥75 years with at least seven prescribed medicines, living independently at home in Finland. A pharmacist, a nurse and a physician evaluated the clinical significance of the DRPs identified during the patient interview at an interprofessional case conference. It was evaluated whether the most significant clinical DRPs could also have been identified through reviewing the medication list only or the medication list and certain patient details. RESULTS: Altogether, the 111 most significant clinical DRPs were evaluated. Only 6% could have been identified through reviewing the medication list only, and 16% through reviewing the medication list and certain patient details. Hence, 84% of the most significant clinical DRPs could only have been identified with patient involvement. The most common DRPs were: poor therapy control (25%); nonoptimal drug (22%); intentional nonadherence (12%); and additional drug needed (11%). patient involvement was critical when identifying DRPs related to additional drug needed, unintentional nonadherence, use of over-the-counter medicines or dietary supplements, or contradictions in counselling. CONCLUSION: Patient involvement is essential when identifying clinical DRPs. Indeed, poor therapy control, nonoptimal drug use, intentional or unintentional nonadherence might otherwise be missed.

Comparison of the effectiveness of brand-name and generic antipsychotic drugs for treating patients with schizophrenia in Taiwan.

The purpose of this nationwide population-based study is to compare the long-term effectiveness of brand-name antipsychotics with generic antipsychotics for treating schizophrenia. We identified patients with schizophrenia who were prescribed antipsychotics from a random sample of one million records from Taiwan's National Health Insurance database, observed between January 1, 2000 and December 31, 2012. Only those with no prior use of antipsychotics for at least 180days were included. We selected patients who were prescribed brand-name risperidone (N=404), generic risperidone (N=145), brand-name sulpiride (N=334), or generic sulpiride (N=991). The effectiveness of the treatments researched in this study consisted of average daily doses, rates of treatment discontinuation, augmentation therapy, and psychiatric hospitalization. We found that compared to patients treated with generic risperidone, those treated with brand-name risperidone required lower daily doses (2.14mg vs. 2.61mg). However, the two groups demonstrated similar rates of treatment discontinuation, augmentation, and psychiatric hospitalization. On the other hand, in comparison with patients prescribed generic sulpiride, those treated with brand-name sulpiride not only required lower daily doses (302.72mg vs. 340.71mg) but also had lower psychiatric admission rates (adjusted hazard ratio: 0.24, 95% confidence interval: 0.10-0.56). In conclusion, for both risperidone and sulpiride, higher daily doses of the respective generic drugs were prescribed than with brand-name drugs in clinical settings. Furthermore, the brand-name sulpiride is more effective at preventing patients from hospitalization than generic sulpiride. These findings can serve as an important reference for clinical practices and healthcare economics for treating schizophrenic patients.

Trends in oral anticoagulant use in Qatar: a 5-year experience.

In Qatar, dabigatran was introduced in 2011 followed by rivaroxaban in 2014. In this study, we aim to explore the trends in oral anticoagulant use in Qatar over the past 5 years and to what extent did DOACs replace warfarin. We also explored the extent of switching between different anticoagulants (from warfarin to DOACs and vice versa). We collected all anticoagulant prescriptions dispensed as in- or out-patient from 2011 to 2015 in all Hamad Medical Corporation (HMC) hospitals. Overall number of patients using warfarin, dabigatran and rivaroxaban over the last 5 years collectively was calculated. Per each calendar year, we calculated the number of all 3 OAC used (warfarin, dabigatran and rivaroxaban), frequency of use of each one of the OAC prescribed and compared the change in proportion of DOACs to warfarin prescriptions over the years. Overall, 6961 patients were using OAC over the past 5 years among which 5849 (84%) used warfarin, 496 (7.1%) used dabigatran and 616 (8.8%) used rivaroxaban. Oral anticoagulants use increased gradually from 2091 in 2011 to 3688 in 2015. Number of patients receiving DOACs increased significantly compared to warfarin [11 (0.5%) in 2011 vs. 849 (23%) in 2015 (p < 0.0001)]. Since its introduction in 2014, number of rivaroxaban users increased significantly compared to dabigatran [212 (40.9%) in 2014 vs. 544 (64.1%) in 2015]. DOACs have been gradually replacing warfarin in Qatar and the trend of their use is similar to that reported in other countries. Warfarin remains the most commonly used oral anticoagulant.

[Anti-Diabetic Medication During the First Four Years of Treatment. A Study Based on Claims Data]. / Antidiabetische Medikation in den ersten vier Therapiejahren. Eine Studie auf Basis von Krankenkassendaten.

Background Ever since the UKPDS study reassessed the usefulness of the substance metformin in 1998, it has been the first-line medication in anti-diabetic treatment. In addition, new classes and agents released on the market have given rise to new treatment options. The present study investigates prescription practice at the onset of treatment and in the years thereafter and measures it against German diabetes guidelines. Database and Methods Database: Statutory health insurance sample AOK/KV Hesse; Ages: 40 and over (N = 142514). STUDY POPULATION: New users of anti-diabetic medication in 2008 (no medication during the preceding 730 days) (n = 1882). Investigation of anti-diabetic medication for four years after initial prescription with regard to substance spectrum, combination treatments, changes in treatment. Log-binomial model: factors influences onset of treatment with metformin versus sulfonylureas (age, sex, duration of illness, comorbidity). Results In 2008 67.9 % of patients began treatment exclusively with metformin, 17.8 % exclusively with sulfonylureas, and 6.7 % exclusively with insulin. Patients diagnosed as obese were significantly more likely to receive metformin. Elderly (80 years and over) or who had been diagnosed with diabetes at least three years prior or patients with renal or cerebrovascular illnesses were significantly less likely to receive metformin. Over the course of treatment, the number of patients receiving multiple medications increased from 5 % to 30 %. (The most frequent combinations were metformin/DPP4 inhibitor, metformin/sulfonylureas, and metformin/insulin.) Conclusion The findings show that German patient care guidelines on diabetes are reflected in prescription practice. Renal diseases are taken into account as potential contraindications for metformin treatment. In the wake of the expansion of approval for metformin in 2015 - reducing the creatinine clearance level to which application is possible - this first-line medication will be available for an ever larger circle of patients in the future.

Racial and Ethnic Differences in Antihypertensive Medication Use and Blood Pressure Control Among US Adults With Hypertension: The National Health and Nutrition Examination Survey, 2003 to 2012.

BACKGROUND: A key to reduce and eradicate racial disparities in hypertension outcomes is to understand their causes. We aimed at evaluating racial differences in antihypertensive drug utilization patterns and blood pressure control by insurance status, age, sex, and presence of comorbidities. METHODS AND RESULTS: A total of 8796 hypertensive individuals ≥18 years of age were identified from the National Health and Nutrition Examination Survey (2003-2012) in a repeated cross-sectional study. During the study period, all 3 racial groups (whites, blacks, and Hispanics) experienced substantial increase in hypertension treatment and control. The overall treatment rates were 73.9% (95% confidence interval [CI], 71.6%-76.2%), 70.8% (95% CI, 68.6%-73.0%), and 60.7% (95% CI, 57.0%-64.3%) and hypertension control rates were 42.9% (95% CI, 40.5%-45.2%), 36.9% (95% CI, 34.7%-39.2%), and 31.2% (95% CI, 28.6%-33.9%) for whites, blacks, and Hispanics, respectively. When stratified by insurance status, blacks (odds ratio, 0.74 [95% CI, 0.64-0.86] for insured and 0.59 [95% CI, 0.36-0.94] for uninsured) and Hispanics (odds ratio, 0.74 [95% CI, 0.60-0.91] for insured and 0.58 [95% CI, 0.36-0.94] for uninsured) persistently had lower rates of hypertension control compared with whites. Racial disparities also persisted in subgroups stratified by age (≥60 and <60 years of age) and presence of comorbidities but worsened among patients <60 years of age. CONCLUSIONS: Black and Hispanic patients had poorer hypertension control compared with whites, and these differences were more pronounced in younger and uninsured patients. Although black patients received more intensive antihypertensive therapy, Hispanics were undertreated. Future studies should further explore all aspects of these disparities to improve cardiovascular outcomes.

Rasch analysis of the Antimicrobial Self-Assessment Toolkit for National Health Service (NHS) Trusts (ASAT v17).

OBJECTIVES: The Antimicrobial Self-Assessment Toolkit for National Health Service (NHS) Trusts (ASAT) was developed to evaluate hospital-based antimicrobial stewardship programmes. Iterative validity investigations of the ASAT were used to produce a 91-item ASAT v17 utilizing qualitative methodology. Rasch analysis was used to generate question (item) behaviour estimates and to investigate the validity of ASAT v17. METHODS: In 2012, the partial credit model (PCM) was used to analyse ASAT responses from 33 NHS Trusts within England. WINSTEPS® outputs such as fit statistics and respondent/item maps were examined to determine unidimensionality, item discrimination and item hierarchy. Ordinary least squares regression modelling was used to determine the predictive validity using NHS Trust ability estimates generated from the PCM and corresponding Clostridium difficile rates. RESULTS: Each domain contained items that were misfitting the PCM (with INFIT MNSQ <0.7 or >1.3), except Domain 3. Subsequent iterative item removal had a negligible effect on the fit indices within most ASAT domains. Scale analysis demonstrated that most items were productive for measurement (n = 81). Respondent/item maps showed ceiling effects (n = 3) and floor effects (n = 1) within ASAT domains. Ordinary least squares regression modelling identified that there was limited predictive validity due to the small positive correlation between the predictor and outcome variables for participating hospitals (ρ = 0.146; P = 0.418). CONCLUSIONS: Rasch analysis was an effective measurement technique for evaluating the validity of ASAT v17 by providing evidence that each sub-scale and the overall scale demonstrated unidimensionality (construct validity). Improved item targeting may be required to improve item discrimination within the toolkit.

Potential drug-drug interactions and adverse drug reactions in dermatological inpatients.

OBJECTIVES: To present information on the frequency of drug-drug interactions and adverse drug reactions, and to provide assistance on how to minimize these major problems in the pharmacological treatment of dermatological inpatients. PATIENTS AND METHODS: The medications given to 1,099 dermatological inpatients were retrospectively analyzed for drug-drug interactions and adverse drug reactions using web-based drug interaction software (Diagnosia® Check). RESULTS: We report an overall frequency of relevant drug-drug interactions of 51.7 %, with an average of 3.2 interactions per affected inpatient. Drug combinations that should have been avoided were found in 5.7 % of the study population. Total drug count was the most important risk factor. Drug groups involved in the majority of interactions were analgesics, cardiovascular and antithrombotic agents, as well as antidepressants. The risk of developing adverse drug reactions was rated as "high" in 53.1 % of inpatients. The top five adverse reactions in this patient group were bleeding, constipation, anticholinergic effects, sedation, and orthostatic effects. CONCLUSIONS: Potential drug-drug interactions as well as adverse drug reactions are alarmingly common in dermatological inpatients. Every other patient is at risk of experiencing such interactions or adverse reactions, and every twentieth patient receives a drug combination that should not be administered. Increased alertness is a must in order to identify patients at risk.

Factors affecting the delivery of community pharmacist-led medication reviews: evidence from the MedsCheck annual service in Ontario.

BACKGROUND: Medication reviews have become part of pharmacy practice across developed countries. This study aimed to identify factors affecting the likelihood of eligible Ontario seniors receiving a pharmacy-led medication review called MedsCheck annual (MCA). METHODS: We designed a cohort study using a random sample of pharmacy claims for MCA-eligible Ontario seniors using linked administrative data from April 2012 to March 2013. Guided by a conceptual framework, we constructed a generalized-estimating-equations model to estimate the effect of patient, pharmacy and community factors on the likelihood of receiving MCA. RESULTS: Of the 2,878,958 eligible claim-dates, 65,605 included an MCA. Compared to eligible individuals who did not receive an MCA, recipients were more likely to have a prior MCA (OR = 3.03), receive a new medication on the claim-date (OR = 1.78), be hypertensive (OR = 1.18) or have a recent hospitalization (OR = 1.07). MCA recipients had fewer medications (e.g., OR = 0.44 for ≥12 medications versus 0-4 medications), and were less likely to receive an MCA in a rural (OR = 0.74) or high-volume pharmacy (OR = 0.65). CONCLUSIONS: The most important determinant of receiving an MCA was having had a prior MCA. Overall, MCA recipients were healthier, younger, urban-dwelling, and taking fewer medications than non-recipients. Policies regarding current and future medication review programs may need to evolve to ensure that those at greatest need receive timely and comprehensive medication reviews.

Psychopharmacological Prescriptions in Children and Adolescents in Germany.

BACKGROUND: In view of the well-known increase in prescriptions of stimulants for children and adolescents over the last 20 years, it is important to study trends in the prevalence and incidence of the use of other psychotropic drugs by this age group as well, to enable an early response to potential problems in the current care situation. METHODS: We used nationwide data from German statutory health insurance funds (Allgemeine Ortskrankenkasse [AOK], all insurees; Techniker Kranken - kasse [TK], a 50% randomized sample) concerning all insurees aged 0-17 years (5.0 million people in 2012) to study trends in the prevalence and incidence of psychotropic medication use as well as initially prescribing medical specialties over the period 2004-2012, both for the overall group of psychotropic drugs and for selected subgroups of drugs. RESULTS: From 2004 to 2012, the prevalence of psychotropic drug prescriptions (not including herbal and homeopathic substances) for children and adolescents rose from 19.6 to 27.1 per 1000 individuals. Marked rises were seen for stimulants (10.5 to 19.1 per 1000) and antipsychotic drugs (2.3 to 3.1 per 1000), while the prevalence of antidepressant prescriptions remained constant at about 2 per 1000. The rates of new prescriptions from 2006 to 2012 were generally constant or decreasing; for the overall group of (non-herbal, nonhomeopathic) psychotropic drugs, the rate of new prescriptions fell from 9.9 to 8.7 per 1000. There was a trend toward the issuance of new prescriptions by medical specialists, rather than by family physicians and pediatricians. CONCLUSION: The observed increased prevalence of psychotropic drug use among children and adolescents appears to be due not to an increased rate of initial prescriptions for these drugs, but rather to a rise in the number of patients who, once having received such drugs, were given further prescriptions for them in the years that followed.

Potentially inappropriate medications in a sample of Portuguese nursing home residents: Does the choice of screening tools matter?

UNLABELLED: Background Potentially inappropriate medications (PIMs) are often found in high proportion among the elderly population. The STOPP criteria have been suggested to detect more PIMs in European elderly than the Beers criteria. Objective This study aimed to determine the prevalence of PIMs and potential prescribing omissions (PPOs) in a sample of Portuguese nursing homes residents. Setting Four elderly facilities in mainland Portugal Method A descriptive cross-sectional study was used. Elderly polypharmacy patients were included in the study and their medication (registered in patient clinical records) analysed using the Beers (2012 original version and 2008 version adapted to Portugal), STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria. Data were analysed using univariate and bivariate descriptive statistics, considering a confidence interval of 95 %. MAIN OUTCOME MEASURES: Prevalence of PIMs and PPOs. Results The sample included 161 individuals, with a mean age of 84.7 years (SD = 6.35), 68.9 % being female. A total of 807 PIMs and 90 PPOs were identified through the application of the three set of criteria. The prevalence of PIMs using the most recent version of the Beers criteria was 85.1 and 42.1 % for independent and dependent of diagnosis, respectively. The Portuguese adaptation of this same tool indicated a lower prevalence of PIMs, 60.3 and 16.7 %, respectively. The prevalence of PIMs using the STOPP criteria was 75.4 %, whilst the prevalence of PPOs, using START, was 42.9 %. There were significant differences in the mean number of PIMs detected depending on the tool used. (p < 0.001). Conclusions The application of the studied criteria in an elderly sample enabled the identification of a notable amount of PIMs and PPOs, indicating there is room for improving the quality of care. The variation in prevalence indicates careful choice of the tool is a prerequisite for engaging in medication review. Using START/STOPP criteria enabled a more holistic approach to the quality of prescribing in the elderly, highlighting low levels of cardiovascular risk prevention and abuse of psychotropic drugs, aside with system failures largely preventable by electronic prescribing and alert generation.