Estimating the Theoretical Cost Implications of Funding New Drugs Considered Not to Be Cost-Effective.

This study aims to estimate the theoretical excess expenditure that would be incurred by the Irish state-payer, should drugs be reimbursed at their original asking ("list") price rather than at a price at which the drug is considered cost-effective. In Ireland, all new drugs are evaluated by the National Centre for Pharmacoeconomics. For this study, drugs that were submitted by pharmaceutical companies from 2012 to 2017 and considered not cost-effective at list price were reviewed. A total of 43 such drugs met our inclusion criteria, and their pharmacoeconomic evaluations were further assessed. The price at which the drug could be considered cost-effective (cost-effective price) at the upper cost-effectiveness threshold used in Ireland (€ 45 000/quality adjusted life-year) was estimated for 18 drugs with an available cost-effectiveness model. Then, for each drug, the list price and cost-effective price (both per unit) were both individually applied to 1 year of national real-world drug utilization data. This allowed the estimation of the expected expenditures under the assumptions of list price paid and cost-effective price paid. The resulting theoretical excess expenditure, the expenditure at list price minus the expenditure at the cost-effective price, was estimated to be €108.2 million. This estimate is theoretical because of the confidentiality of actual drug prices. The estimation is calculated using the list price and likely overestimates the actual excess expenditure, which would reduce to zero if cost-effective prices are agreed. Nevertheless, this estimate illustrates the importance of a process to assess the value of new drugs so that potential excess drug expenditure is identified.

Factors associated with the appropriate use of ultra-broad spectrum antibiotics, meropenem, for suspected healthcare-associated pneumonia.

ABSTRACT: Pneumonia is a common disease-causing hospitalization. When a healthcare-associated infection is suspected, antibiotics that provide coverage for multi-drug resistant (MDR) or extended-spectrum beta-lactamase (ESBL) bacteria are frequently prescribed. Limited data is available for guidance on using meropenem as a first-line empiric antimicrobial in hospitalized patients with risk factors for MDR/ESBL bacterial infections.This was a single-center, retrospective study designed and conducted to identify factors associated with positive cultures for MDR/ESBL pathogens in hospitalized patients with suspected healthcare-associated pneumonia.Of the 246 patients, 103 patients (41%) received meropenem. Among patients prescribed meropenem, MDR/ESBL pathogens were detected in only 20 patients (13%). Patients admitted from a skilled nursing facility/long-term acute care (SNF/LTAC) or with a history of a positive culture for MDR/ESBL pathogens were significantly associated with positive cultures of MDR/ESBL pathogens during the hospitalization (odds ratio [95% confidence intervals], 31.40 [5.20-189.6] in SNF/LTAC and 18.50 [2.98-115.1] in history of culture-positive MDR/ESBL pathogen). There was no significant difference in mortality between the 3 antibiotic groups.Admission from a SNF/LTAC or having a history of cultures positive for MDR/ESBL pathogens were significantly associated with a positive culture for MDR/ESBL pathogens during the subsequent admission. We did not detect significant association between meropenem use as a first-line drug and morbidity and mortality for patients admitted to the hospital with suspected healthcare-associated pneumonia, and further prospective studies with larger sample size are needed to confirm our findings.

Medicine reviews: do they reduce benzodiazepine use in older Australians?

OBJECTIVES: Medicine reviews are an opportunity to identify and address inappropriate prescribing. The aim of this study was to explore changes in benzodiazepine use among older Australians following a medicine review. STUDY TYPE: Retrospective observational cohort study using linked administrative data. METHODS: We used Medicare Benefits Schedule and Pharmaceutical Benefits Scheme claims from a random 10% sample of Medicare beneficiaries. We identified people aged 65 years or older who received a medicine review in 2013-14 and were using benzodiazepines at the time of review. We identified a propensity score matched comparison cohort of those using benzodiazepines who did not receive a review. Two outcome measures were used: any benzodiazepine use and changes to the quantity of benzodiazepines dispensed (diazepam equivalents) from baseline to 90 and 180 days following a medicine review. RESULTS: We identified 4002 people using benzodiazepines on the day of their medicine review, of whom approximately one-third discontinued benzodiazepines within 90 days (29.7%) and 180 days (36.4%;) after the review. We observed a similar discontinuation rate in the comparison group (32.6%, p = 0.006; and 38.0%, p = 0.12, respectively). In people who were dispensed lower quantities of benzodiazepines (less than 250 mg of diazepam equivalents in the 90 days before the medicine review), we found that 50.3% ceased using benzodiazepines or used lower quantities (measured as diazepam equivalents) following the medicine review (28.7% and 19.7% respectively). We also observed a reduction in the quantities used in people where initial exposure was high (3.4% ceased; 59.4% decreased). We observed a similar change in volume within the matched comparison group. CONCLUSIONS: Medicine reviews are not associated with any additional reduction in benzodiazepine use among older adults, up to 180 days after review, beyond what was observed in the general population.

Attitudes towards and use of cannabis in New Zealand patients with inflammatory bowel disease: an exploratory study.

AIMS: We aimed to assess the use of and attitudes towards cannabis use (medicinal and recreational) by people with IBD in New Zealand. METHODS: People with IBD were invited to complete an anonymous online questionnaire. Participants were recruited via postal mail using a hospital database of patients with IBD (developed by the Gas-troenterology Department at Dunedin Public Hospital) and via online recruitment (advertised on the Crohn's and Colitis New Zealand website, Facebook page and e-mail list). Inclusion criteria were ages 18+ and self-reported confirmed IBD diagnosis. RESULTS: In total, 378 participants completed the questionnaire, with 334 eligible responses. Partici-pants were predominantly New Zealand European (84%) and female (71%). Sixty-one percent of re-spondents had CD and 34% UC. Overall, 51% of respondents reported having ever used cannabis. Of those, 63% reported use as recreational and 31% for reduction of IBD symptoms. Users were more likely to be younger (on average by 6.4 years), with on-going symptoms, unemployed or self-employed and current or ex-smokers. There were no differences by disease status or severity. Symp-toms most reported as improved by cannabis use were abdominal pain/cramping, nausea/vomiting and loss of appetite. Fifty-four percent of participants reported that if cannabis were legal, they would request it for medicinal use to help manage their symptoms. CONCLUSIONS: Overall, our research aligns with previous observational research that reports im-provements in symptoms of IBD with cannabis use. Studies of a higher evidence level (eg, RCTs) would be needed to guide prescribing. In the meantime, this research provides useful background to clini-cians about patients' views and experiences.

Characterization of individuals with osteoarthritis in the United States and their use of prescription and over-the-counter supplements.

PURPOSE: Osteoarthritis (OA) is a frequently occurring, chronic condition; however, few studies describe the clinical characteristics of individuals with OA and the treatments they use to manage their symptoms. We conducted a study to characterize the OA population in the US and describe the nonsurgical management used by this population based on consumer research data collected through an online survey. METHODS: Data from the 2017 US National Health and Wellness Survey (NHWS) for adults aged ≥35 years were used to evaluate the relationship between OA and certain study participant characteristics and to identify the most commonly used treatment options. NHWS data were collected through a survey of individuals drawn from the internet panel maintained by Lightspeed Research (Bridgewater, New Jersey) and its panel partners. Weighted estimates were generated using data from the 2016 Current Population Survey (Annual Demographics File) of the US Census Bureau. Comparisons between the general and OA populations were made based on body mass index (BMI), exercise frequency, and comorbid diagnoses of hypertension or diabetes. Among the OA population, the use of dietary supplements, prescription or over-the-counter (OTC) treatments with chondroitin with or without glucosamine (Ch ± Gl), prescription treatment by time since OA diagnosis, and utilization of a physical therapist were also recorded. RESULTS: The prevalence of OA in the overall population was 17.6 % and was higher for individuals with a BMI ≥ 25 (21.9 %), patients diagnosed with hypertension or diabetes (36.2 %), and those who did not exercise regularly (19.0 %). Adults without OA were more likely to exercise regularly (12 days per month or more) than adults diagnosed with OA. Ch ± Gl (6.0 %) was the most commonly used OTC dietary supplement in the OA population, followed by omega-3 fatty acids (2.8 %), vitamin D (1.9 %), calcium (1.1 %), and multivitamins (0.7 %). Individuals using Ch ± Gl were more likely to use OTC only products (75.4 % vs 37.3 %) or prescription medications, namely non-steroidal anti-inflammatory drugs (NSAIDs) and/or opioids, and OTC products (24.6 % vs 13.0 %) compared with individuals not using Ch ± Gl, while individuals not using Ch ± Gl were more likely to be untreated (30.3 % vs 0) or to use prescription medications only (19.4 % vs 0). Nearly 32 % of individuals with OA reported using prescription treatments, and the likelihood of using a prescription treatment increased with number of years since OA diagnosis (<3 years: 27.5 %; ≥21 years: 32.5 %). The pharmaceutical products used by this population primarily consisted of nonsteroidal anti-inflammatory drugs, acetaminophen and opioids. Approximately 13 % of patients with OA had visited a physical therapist in the past 6 months. CONCLUSIONS: The prevalence of OA was higher in those with a high BMI, and comorbid diabetes or hypertension. Individuals with OA using Ch ± Gl primarily reported use of OTC products only or used them in combination with prescription products. The likelihood of using prescription products increased with the length of OA history. These data provide valuable new information about demographics, clinical characteristics, and commonly used prescription and OTC treatments and dietary supplements in the OA population.

Comparative associations between anticholinergic burden and emergency department visits for anticholinergic adverse events in older Korean adults: a nested case-control study using national claims data for validation of a novel country-specific scale.

BACKGROUND: Considering the limited generalizability of previous anticholinergic burden scales, the Korean Anticholinergic Burden Scale (KABS) as a scale specific to the Korean population was developed. We aimed to validate the KABS by detecting the associations between high anticholinergic burden, measured with the KABS, and emergency department (ED) visits compared to the pre-existing validated scales in older Korean adults. METHODS: A nested case-control study was conducted using national claims data. The cases included the first anticholinergic ED visits between July 1 and December 31, 2016. Anticholinergic ED visits were defined as ED visits with a primary diagnosis of constipation, delirium, dizziness, fall, fracture, or urinary retention. Propensity score-matched controls were identified. Average daily AB scores during 30 days before the index date were measured. Multivariate logistic regression analyses were performed. RESULTS: In total, 461,034 were included. The highest proportion of those with high AB was identified with KABS (5.0%). Compared with those who had a KABS score of 0, older adults with a score ≥ 3 were at higher risk for overall anticholinergic ED visits (aOR, 1.62, 95% CI, 1.53-1.72), as well as visits for falls/fractures (aOR: 1.54, 95% CI: 1.40-1.69), dizziness (aOR: 1.44, 95% CI: 1.30-1.59), delirium (aOR: 2.96, 95% CI: 2.28-3.83), constipation (aOR: 1.84, 95% CI: 1.68-2.02), and urinary retention (aOR: 2.13, 95% CI: 1.79-2.55). High AB by KABS showed a stronger association with overall anticholinergic ED visits and visits due to delirium and urinary retention than those by other scales. CONCLUSIONS: In conclusion, KABS is superior to pre-existing scales in identifying patients with high AB and predicting high AB-related ED visits in older Korean adults.

Children with Heterozygous Familial Hypercholesterolemia in the United States: Data from the Cascade Screening for Awareness and Detection-FH Registry.

OBJECTIVE: To describe enrollment characteristics of youth in the Cascade Screening for Awareness and Detection of FH Registry. STUDY DESIGN: This is a cross-sectional analysis of 493 participants aged <18 years with heterozygous familial hypercholesterolemia recruited from US lipid clinics (n = 20) between April 1, 2014, and January 12, 2018. At enrollment, some were new patients and some were already in care. Clinical characteristics are described, including lipid levels and lipid-lowering treatments. RESULTS: Mean age at diagnosis was 9.4 (4.0) years; 47% female, 68% white and 12% Hispanic. Average (SD) highest Low-density lipoprotein cholesterol (LDL-C) was 238 (61) mg/dL before treatment. Lipid-lowering therapy was used by 64% of participants; 56% were treated with statin. LDL-C declined 84 mg/dL (33%) among those treated with lipid-lowering therapy; statins produced the greatest decline, 100 mg/dL (39% reduction). At enrollment, 39% had reached an LDL-C goal, either <130 mg/dL or ≥50% decrease from pre-treatment; 20% of those on lipid-lowering therapy reached both goals. CONCLUSIONS: Among youth enrolled in the Cascade Screening for Awareness and Detection of FH Registry, diagnosis occurred relatively late, only 77% of children eligible for lipid-lowering therapy were receiving treatment, and only 39% of those treated met their LDL-C goal. Opportunities exist for earlier diagnosis, broader use of lipid-lowering therapy, and greater reduction of LDL-C levels.

[Strategies to reduce antibiotic use with the help of complementary and integrative medicine]. / Stratégies de réduction de l'usage d'antibiotiques à l'aide de la médecine complémentaire et intégrative.

Limiting antibiotic use is urgent due to increasing antibiotic resistance and the long-term implications of a disturbed microbiome. Data on antibiotic use of physicians integrating conventional and complementary medicine show that a significant reduction of antibiotic use in primary care is possible. In the setting of non-complicated infections in out-patient medicine, open dialogue with the patient, recognizing the importance of fever and reducing antipyretic use are general measures that can help reduce patients' concerns, and increase their trust in a well-functioning immune system and a treatment approach without antibiotics. Accumulating evidence suggests that complementary medicine strategies are useful in the management of common infections without antibiotics.

Vu l'augmentation de la résistance aux antibiotiques et les conséquences qu'implique, à long terme, un microbiote perturbé, il est urgent de limiter leur consommation. Les données obtenues chez les médecins intégrant médecines conventionnelle et complémentaire montrent un recours aux antibiotiques diminué dans les soins primaires. Une communication adaptée, la compréhension de l'importance de la fièvre et la diminution de la prise d'antipyrétiques sont autant d'étapes clés pouvant aider les patients à surmonter leurs craintes, à renforcer leur confiance en leur système immunitaire et en un traitement sans antibiotiques en cas d'infections simples. Un nombre croissant d'études démontre ainsi que les outils de la médecine complémentaire peuvent contribuer à la gestion des infections courantes sans antibiotiques.

Patterns and determinants of prescribed drug use among pregnant women in Adigrat general hospital, northern Ethiopia: a cross-sectional study.

BACKGROUND: A vigilant prescription of drugs during pregnancy can potentially safeguard the growing fetus from the deleterious effect of the drug while attempting to manage the mother's health problems. There is a paucity of information about the drug utilization pattern in the area of investigation. Hence, this study was implemented to investigate the pattern of drug utilization and its associated factors among pregnant women in Adigrat general hospital, Northern Ethiopia. METHODS: An institution-based cross-sectional study was conducted among randomly selected 314 pregnant women who attended obstetrics-gynecology and antenatal care units of the hospital. Relevant data were retrieved from the pregnant women's medical records and registration logbook. The drugs prescribed were categorized based on the United States Food and Drug Administration (US-FDA) fetal harm classification system. Data analysis was done using SPSS version 20 statistical software. Multivariate logistic regression was employed to analyze the association of the explanatory variables with the medication use, and p < 0.05 was declared statistically significant. RESULTS: The overall prescribed drug use in this study was found to be 87.7%. A considerable percentage of the study participants (41.4%) were prescribed with supplemental drugs (iron folate being the most prescribed drug) followed by antibiotics (23.4%) and analgesics (9.2%). According to the US-FDA drug's risk classification, 42.5, 37, 13, and 7% of the drugs prescribed were from categories A, B, C, and D or X respectively. Prescribed drug use was more likely among pregnant women who completed primary [AOR = 5.34, 95% CI (1.53-18.6)] and secondary education [AOR = 4.1, 95% CI (1.16-14)], who had a history of chronic illness [AOR = 7.9, 95% CI (3.14-19.94)] and among multigravida women [AOR = 2.9, 95% CI (1.57 5.45)]. CONCLUSIONS: The finding of this study revealed that a substantial proportion of pregnant women received drugs with potential harm to the mother and fetus. Reasonably, notifying health practitioners to rely on up-to-date treatment guidelines strictly is highly demanded. Moreover, counseling and educating pregnant women on the safe and appropriate use of medications during pregnancy are crucial to mitigate the burden that the mother and the growing fetus could face.

Decreasing major surgical rates for Crohn's disease in an emerging economy over two decades: Is it due to biologic therapy?

BACKGROUND: Alteration in the natural history of Crohn's disease (CD) since the advent of biologic therapy remains to be proven. Our aim was to look at the intestinal surgical rates and the association with biologic therapy over the last two decades. METHODS: This was a retrospective study in which all CD patients seen in two tertiary referral hospitals in Malaysia were recruited. Patients were stratified into two cohorts; cohort 1 was patients diagnosed from year 1991 to 2000 and cohort 2 was patients diagnosed from year 2001 to 2010. These time cohorts were selected based on initial availability of biologic agents in Malaysia in year 2000. Details of demography, disease location, medications and cumulative surgical rates over 7 years were recorded. RESULTS: A total of 207 patients were recruited: 70 from cohort 1 and 137 from cohort 2. Differences seen in terms of disease location, phenotype, and use of immunomodulatory therapy between the two cohorts were not significant. Patients who were ever exposed to biologics were significantly different between the two cohorts, approximately two times higher at 35.8% (n = 49) in cohort 2, and 18.6% (n = 13) in cohort 1, p = 0.011. There was a significant reduction in the 7-year cumulative intestinal surgical rates between cohort 1 and cohort 2, from 21.4% (n = 15) to 10.2% (n = 14), p = 0.028. However, there was no statistically significant difference in biologic exposure between those who underwent surgery and those who did not. CONCLUSIONS: There has been a significant reduction in intestinal surgical rates for Crohn's disease over the last two decades but does not appear to be associated with the increased use of biologics.

Real-World Experience With Apremilast in the Treatment of Adults With Moderate to Severe Plaque Psoriasis in Québec: A Claims-Based Analysis of Drug Utilization and Healthcare Resource Utilization.

BACKGROUND: In Québec, targeted biologic therapies for moderate to severe plaque psoriasis are restricted to patients who have not responded to phototherapy or conventional systemic treatment, primarily due to high drug costs. Apremilast, an oral treatment for plaque psoriasis, was added to the Québec provincial health insurance plan (Régie de l'assurance maladie du Québec; RAMQ) formulary in 2015, making this the only province in Canada with public drug plan reimbursement for apremilast. OBJECTIVES: The aim of this study is to describe patients' characteristics, treatment patterns, healthcare resource utilization (HCRU), and associated costs and to measure real-world budget impact of using apremilast before biologics in plaque psoriasis. METHODS: This study was performed using RAMQ drug claims and medical services data. Patients diagnosed with psoriasis between January 2015 and December 2017 were identified. Medical services and prescription claims were categorized as all-cause and psoriasis-related. Using RAMQ database estimates, a 3-year budget impact analysis was developed comparing treatment cost with and without the addition of apremilast to the formulary. RESULTS: In all, 540 patients were identified (apremilast: n = 92; biologics: n = 448). Comorbidity burden and treatment persistence and adherence were comparable between apremilast and biologic users. The year following the index date, all-cause HCRU was lower for apremilast versus biologic users (CAN$19 763 vs CAN$28 025; P < .01), mainly driven by drug cost. Using apremilast before biologics resulted in an estimated RAMQ net savings of CAN$49 290 (2015), CAN$746 856 (2016), and CAN$1 216 512 (2017), and a total savings of CAN$2 012 658 since apremilast's addition to the formulary. CONCLUSION: Adding apremilast to the drug formulary of other Canadian provinces could result in significant healthcare savings.

The roles of stakeholder experience and organizational learning in declining mass drug administration coverage for lymphatic filariasis in Port-au-Prince, Haiti: A case study.

The World Health Organization (WHO) defines an effective round of mass drug administration (MDA) for lymphatic filariasis (LF) as one that reaches at least 65% of the target population. In its first round of MDA in 2011-2012, the National Program to Eliminate LF in Haiti achieved a 79% epidemiological coverage in urban Port-au-Prince. In 2013, coverage dropped below the WHO threshold and has declined year-over-year to a low of 41% in 2017. We conducted a retrospective qualitative case study to identify key factors behind the decline in coverage in Port-au-Prince and ways to address them. Our findings suggest that the main contributors to the decline in MDA coverage appear to be the absence of effective documentation of practices, reporting, analysis, and program quality improvement-i.e., learning mechanisms-within the program's MDA design and implementation strategy. In addition to their contribution to the program's failure to meet its coverage targets, these deficits have resulted in a high cost for the MDA campaign in both lost momentum and depleted morale. Through a proposed operating logic model, we explore how the pathway from program inputs to outcomes is influenced by a wide array of mediating factors, which shape potential participants' experience of MDA and, in turn, influence their reasoning and decisions to take, or not take, the pills. Our model suggests that the decisions and behavior of individuals are a reflection of their overall experience of the program itself, mediated through a host of contextual factors, and not simply the expression of a fixed choice or preference. This holistic approach offers a novel and potentially valuable framing for the planning and evaluation of MDA strategies for LF and other diseases, and may be applicable in a variety of global health programs.

Treatment Pathways Leading to Biologic Therapies for Ulcerative Colitis and Crohn's Disease in the United States.

OBJECTIVES: Biologic therapies have been available for inflammatory bowel disease for >20 years, but patient outcomes have not changed appreciably over this time period. To better understand medication utilization for this disease, we evaluated a novel technique for visualizing treatment pathways, including initial treatment, switching, and combination therapies. METHODS: This retrospective, observational study used administrative claims data from the Truven Health MarketScan Commercial and Medicare Database. Adult patients with ≥2 consecutive health claims and newly diagnosed with ulcerative colitis (UC) or Crohn's disease (CD) were evaluated. Treatment pathways were visualized using Sankey diagrams representing the number of patients receiving treatment and duration of each treatment. RESULTS: In all, 28,119 patients with UC and 16,260 patients with CD were identified. The most common initial treatment for UC was 5-aminosalicylic acid monotherapy (61% of the patients), followed by corticosteroid monotherapy (25%); <1% of patients were initially treated with biologics. The most common initial treatment for CD was corticosteroid monotherapy (42%), followed by 5-aminosalicylic acid monotherapy (35%); <5% of the patients were initially treated with biologics. Significantly fewer patients followed biologic vs nonbiologic treatment pathways (UC: 6% vs 94%, CD: 19% vs 81%, both P < 0.05). DISCUSSION: Significantly fewer patients with inflammatory bowel disease followed treatment pathways that included biologic therapies compared with nonbiologic therapies, and very few patients were ever initiated on biologic therapy. Although we have made significant progress in treatment, our most effective medications are only being used in a small proportion of patients, suggesting barriers prevent optimized patient management.

Effects of transcutaneous electrical nerve stimulation on physical symptoms in advanced cancer patients receiving palliative care.

Transcutaneous electrical nerve stimulation (TENS) is primarily used for pain, but might be useful for various other physical symptoms, including nausea, fatigue, dyspnea, and constipation. However, few studies have used TENS for treating the physical symptoms of patients with advanced cancer. In this crossover trial, we assess the effects of TENS on pain and other physical symptoms in 20 in-patients with advanced cancer receiving palliative care. For 5-day phases between wash out periods of 5 days, patients received TENS or non-TENS. TENS was delivered at four points: the center of the back for mainly nausea and dyspnea, on the back at the same dermatomal level as the origin of the pain (100 Hz), and on both ankle joints for constipation (10 Hz). The intensity of pain and the total opioid dose used during phases were recorded. Physical symptoms were evaluated using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 15 Palliative Care (QLQ-C15-PAL). Hematological and biochemical data were recorded before and after the TENS phase. The average pain and total number of opioid rescue doses were significantly reduced by TENS. TENS tended to improve nausea and appetite loss, but not constipation. There were no effects on hematological and biochemical parameters. Use of TENS could safely improve pain, nausea, and appetite loss in patients with advanced cancer. Although it cannot be used as a substitute for opioids and other pharmaceutical treatment, it may be useful to support palliative care.

A successful program preventing nonventilator hospital-acquired pneumonia in a large hospital system.

OBJECTIVE: To develop and evaluate a program to presvent hospital-acquired pneumonia (HAP). DESIGN: Prospective, observational, surveillance program to identify HAP before and after 7 interventions. An order set automatically triggered in programmatically identified high-risk patients. SETTING: All 21 hospitals of an integrated healthcare system with 4.4 million members. PATIENTS: All hospitalized patients. INTERVENTIONS: Interventions for high-risk patients included mobilization, upright feeding, swallowing evaluation, sedation restrictions, elevated head of bed, oral care and tube care. RESULTS: HAP rates decreased between 2012 and 2018: from 5.92 to 1.79 per 1,000 admissions (P = .0031) and from 24.57 to 6.49 per 100,000 members (P = .0014). HAP mortality decreased from 1.05 to 0.34 per 1,000 admissions and from 4.37 to 1.24 per 100,000 members. Concomitant antibiotic utilization demonstrated reductions of broad-spectrum antibiotics. Antibiotic therapy per 100,000 members was measured as follows: carbapenem days (694 to 463; P = .0020), aminoglycoside days (154 to 61; P = .0165), vancomycin days (2,087 to 1,783; P = .002), and quinolone days (2,162 to 1,287; P < .0001). Only cephalosporin use increased, driven by ceftriaxone days (264 to 460; P = .0009). Benzodiazepine use decreased between 2014 to 2016: 10.4% to 8.8% of inpatient days. Mortality for patients with HAP was 18% in 2012% and 19% in 2016 (P = .439). CONCLUSION: HAP rates, mortality, and broad-spectrum antibiotic use were all reduced significantly following these interventions, despite the absence of strong supportive literature for guidance. Most interventions augmented basic nursing care. None had risks of adverse consequences. These results support the need to examine practices to improve care despite limited literature and the need to further study these difficult areas of care.

Adherence to iron-folic acid supplement and associated factors among antenatal care attending pregnant mothers in governmental health institutions of Adwa town, Tigray, Ethiopia: Cross-sectional study.

BACKGROUND: Iron-folic acid supplementation during pregnancy is among the very effective interventions to prevent iron deficiency anemia, low birth weight, and prematurity. There is a need of having recent studies on adherence to the supplement that consider the very recent interventions targeted to scale up the use of iron-folic acid (IFA) supplement. Therefore we sought to assess adherence to IFA supplement and its associated factors among antenatal care attending pregnant mothers in governmental health institutions of Adwa town. METHODS: Institution-based cross-sectional study was conducted among 629 antenatal care attending pregnant mothers. Systematic random sampling method was used to select the study subjects. Data were collected through face-to-face interview and chart-review. Bivariable and multivariable binary logistic regression was computed. Variables with P-value <0.05 were considered statistically significant at 95% confidence interval (CI). RESULT: Only 40.9% (95%CI: 37.0%- 44.7%) of participants were adherent (took four or more tablets per week). Women in the age group of 25-29 years [AOR: 2.22(1.21-4.07)] had increased odds of adherence as compared to those in the age group ≥ 35 years. Women who received nutrition counseling [AOR: 4.12(2.12-8.03)] and partner support [AOR: 2.23 (1.42-3.49)] had increased odds of adherence as compared to those who didn't receive nutrition counseling and partner support respectively. Similarly, women who had satisfactory knowledge on IFA supplement (AOR: 2.16(1.37-3.40)) had increased odds of adherence as compared to those who didn't have satisfactory knowledge on IFA supplement. CONCLUSION: Adherence to the supplement was low. Efforts shall be done to improve awareness of pregnant mothers about IFA supplement through targeted nutrition counseling that includes the engagement of a partner.

Consumption of medicines used for gastric acid-related disorders in Australia and South Korea: a cross-country comparison.

PURPOSE: The study's aim was to compare the use of proton pump inhibitors (PPIs), histamine 2-receptor antagonists (H2RAs) and mucoprotective medicines (MPs) used for gastric acid-related disorders (GARD) in Australia and South Korea (Korea) from 2004 to 2017. METHODS: Prescription data for PPIs, H2RAs and MPs for Australian outpatients were extracted from the Australian Statistics on Medicines annual reports, with dose-specific and expenditure data obtained from Medicare. Similar data were obtained from Korean National Health Insurance Service claims data. We analysed the volume and expenditure of medicines use annually using the defined daily dose per 1,000 population per day. We calculated which medicines accounted for 90% of use and estimated the proportions of use for low- and high-dose PPIs. RESULTS: While total utilisation for GARD medicines increased over time in both countries, patterns of use differed. Overall, use was somewhat higher in Australia but increased more rapidly in Korea. PPIs were used more extensively in Australia, while more MPs and H2RAs were used in Korea. Expenditure and use of low-dose PPIs is escalating in Korea. CONCLUSION: There were substantial differences in the use of GARD medicines in Australia and Korea over 14 years. Both countries face similar challenges to promote rational medicines use and contain medical care costs. The discrepant prescribing patterns can be attributed to differences in healthcare systems, pharmaceutical policies and demographics. This study provides a baseline to influence more rational use of these medicines. It provides insight into medicines policies for other countries that face similar challenges.

Medicinal Cannabis in Orthopaedic Practice.

Cannabis has gained widespread public advocacy since its legalization in several states with recent evidence suggesting that its self-reported use has increased in patients undergoing a primary total joint arthroplasty. The endocannabinoid system has been proposed to play a role in decreasing the inflammatory cascade and enhancing pain management. For these reasons, interest has emerged in the orthopaedic community as a potential treatment or adjunct to treatment in many musculoskeletal conditions. However, the evidence to date is scant and precludes recommendations for its widespread use. Given the current paucity of evidence in the orthopaedic cohort, future research is warranted in this area to determine the efficacy and safety before endorsements can be made by orthopaedic surgeons.

Very Low Frequency of Drug Therapy of Alcohol Dependence in Germany - Analysis of Data of A Statutory Health Insurance.

Acamprosate and naltrexone are medications of proven efficacy in the treatment of alcohol dependence. In order to investigate the prescription of these drugs in outpatient routine treatment in Germany (frequency of prescription, duration, medical specialty of prescribing physician), data of a large statutory health insurance were analyzed. Persons were included who were discharged from inpatient treatment with an alcohol-related disorder among their diagnoses during a one year observation period and with no diagnosed additional substance-related disorder (apart from nicotine- and cannabis-related disorders). Thus 12.958 patients were identified (mainly male, 77.9%; at average 51.4 years [+/-12.7] of age). 44.3% of these patients were treated in a psychiatric hospital, the remaining patients in hospitals of other specialties (e. g. 9.2% in departments of surgery). During an observation period of 6 months after discharge, acamprosate or naltrexone were prescribed at least once to 98 persons (0.76% of 12.958 patients; acamprosate n=80, 0.62%; naltrexone n=18, 0.14%). 16 (0.12%) patients were prescribed acamprosate or naltrexone for more than 3 months. Half of the prescriptions were issued by general practitioners. Possible reasons for this under-prescription are lack of knowledge about the drug treatment of alcohol dependence outside of addiction psychiatry, neglect of biological aspects (including medication) regarding etiology and treatment of substance-related disorders, and stigma of patients with substance-related disorders.