Potentially inappropriate prescribing in two populations with differing socio-economic profiles: a cross-sectional database study using the PROMPT criteria.

PURPOSE: The purpose of this study is to establish the prevalence of potentially inappropriate prescribing (PIP) in middle-aged adults (45-64 years) in two populations with differing socio-economic profiles, and to investigate factors associated with PIP, using the PROMPT (PRescribing Optimally in Middle-aged People's Treatments) criteria. METHODS: A retrospective cross-sectional study was conducted using 2012 data from the Enhanced Prescribing Database (EPD), covering the full population in Northern Ireland and the Health Services Executive Primary Care Reimbursement Service (HSE-PCRS) database, covering the most socio-economically deprived third of the population in this age group in the Republic of Ireland. The prevalence for each PROMPT criterion and overall prevalence of PIP were calculated. Logistic regression was used to investigate the association between PIP and gender, age group and polypharmacy. RESULTS: This study included 441,925 patients from the EPD and 309,748 patients from the HSE-PCRS database. Polypharmacy was common in both datasets (46.7 % in the HSE-PCRS and 20.3 % in the EPD). The prevalence of PIP was 42.9 % (95%CI 42.7, 43.1) in the HSE-PCRS and 21.1 % (95%CI 21.0, 21.2) in the EPD. Age group, female gender and polypharmacy were significantly associated with PIP in both populations (p < 0.05) and polypharmacy had the strongest association. CONCLUSIONS: PIP is common amongst middle-aged people with the risk of PIP increasing with polypharmacy. Differences in the prevalence of polypharmacy and PIP between the two populations may relate to heterogeneity in healthcare services and different socio-economic profiles, with higher rates of multimorbidity and associated polypharmacy in more deprived groups.

The development of the PROMPT (PRescribing Optimally in Middle-aged People's Treatments) criteria.

BACKGROUND: Whilst multimorbidity is more prevalent with increasing age, approximately 30% of middle-aged adults (45-64 years) are also affected. Several prescribing criteria have been developed to optimise medication use in older people (≥65 years) with little focus on potentially inappropriate prescribing (PIP) in middle-aged adults. We have developed a set of explicit prescribing criteria called PROMPT (PRescribing Optimally in Middle-aged People's Treatments) which may be applied to prescribing datasets to determine the prevalence of PIP in this age-group. METHODS: A literature search was conducted to identify published prescribing criteria for all age groups, with the Project Steering Group (convened for this study) adding further criteria for consideration, all of which were reviewed for relevance to middle-aged adults. These criteria underwent a two-round Delphi process, using an expert panel consisting of general practitioners, pharmacists and clinical pharmacologists from the United Kingdom and Republic of Ireland. Using web-based questionnaires, 17 panellists were asked to indicate their level of agreement with each criterion via a 5-point Likert scale (1 = Strongly Disagree, 5 = Strongly Agree) to assess the applicability to middle-aged adults in the absence of clinical information. Criteria were accepted/rejected/revised dependent on the panel's level of agreement using the median response/interquartile range and additional comments. RESULTS: Thirty-four criteria were rated in the first round of this exercise and consensus was achieved on 17 criteria which were accepted into the PROMPT criteria. Consensus was not reached on the remaining 17, and six criteria were removed following a review of the additional comments. The second round of this exercise focused on the remaining 11 criteria, some of which were revised following the first exercise. Five criteria were accepted from the second round, providing a final list of 22 criteria [gastro-intestinal system (n = 3), cardiovascular system (n = 4), respiratory system (n = 4), central nervous system (n = 6), infections (n = 1), endocrine system (n = 1), musculoskeletal system (n = 2), duplicates (n = 1)]. CONCLUSIONS: PROMPT is the first set of prescribing criteria developed for use in middle-aged adults. The utility of these criteria will be tested in future studies using prescribing datasets.

An observational study examining the effect of comorbidity on the rates of persistence and adherence to newly initiated oral anti-hyperglycaemic agents.

PURPOSE: To examine whether the type of comorbid condition affects medication persistence and adherence in patients initiating oral anti-hyperglycaemic (OAH) therapy. METHODS: The Irish Health Services Executive pharmacy claims database was used to identify a cohort of incident OAH therapy users (anatomical therapeutic chemical A10B), ≥25 years, between June 2009 and December 2010. Persistence and adherence were examined at 6 and 12 months post-therapy initiation. Comorbidity was ascertained using modified versions of the RxRisk and RxRisk-V indices and classified as either concordant or discordant with diabetes. Adjusted odds ratios (ORs) and 95% confidence intervals (95%CIs) were determined in relation to comorbidity using logistic regression analysis, adjusting for age, gender and type of OAH prescribed. RESULTS: In the study cohort (n = 21 280), persistence was 74.0% and 62.6% and adherence was 70.0% and 66.7% for all OAHs at 6 and 12 months, respectively. Patients with only concordant comorbidity were significantly more likely to be persistent at 6 (OR 1.45, 95%CI 1.28, 1.65) and 12 months (OR 1.22, 95%CI 1.09, 1.38). Patients with only discordant comorbidity were significantly less likely to be persistent at 6 (OR 0.40, 95%CI 0.35, 0.46) and 12 months (OR 0.43 95%CI 0.38, 0.50) (p < 0.0001). Results were similar for adherence. CONCLUSION: The study suggests that the persistence and adherence of OAH therapy in incident users are affected by the type of comorbidity present; this may help in identifying effective interventions aimed at optimising medication use.

The prevalence and ingredient cost of chronic comorbidity in the Irish elderly population with medication treated type 2 diabetes: a retrospective cross-sectional study using a national pharmacy claims database.

BACKGROUND: Comorbidity in patients with diabetes is associated with poorer health and increased cost. The aim of this study was to investigate the prevalence and ingredient cost of comorbidity in patients ≥ 65 years with and without medication treated type 2 diabetes using a national pharmacy claims database. METHODS: The Irish Health Service Executive Primary Care Reimbursement Service pharmacy claims database, which includes all prescribing to individuals covered by the General Medical Services scheme, was used to identify the study population (≥ 65 years). Patients with medication treated type 2 diabetes (T2DM) were identified using the prescription of oral anti-hyperglycaemic agents alone or in combination with insulin as a proxy for disease diagnosis. The prevalence and ingredient prescribing cost of treated chronic comorbidity in the study population with and without medication treated T2DM were ascertained using a modified version of the RxRiskV index, a prescription based comorbidity index. The association between T2DM and comorbid conditions was assessed using logistic regression adjusting for age and sex. Bootstrapping was used to ascertain the mean annual ingredient cost of treated comorbidity. Statistical significance at p < 0.05 was assumed. RESULTS: In 2010, 43165 of 445180 GMS eligible individuals (9.7%) were identified as having received medication for T2DM. The median number of comorbid conditions was significantly higher in those with T2DM compared to without (median 5 vs. 3 respectively; p < 0.001). Individuals with T2DM were more likely to have ≥ 5 comorbidities when compared to those without (OR = 2.82, 95% CI = 2.76-2.88, p < .0001). The mean annual ingredient cost for comorbidity was higher in the study population with T2DM (€1238.67, 95% CI = €1238.20 - €1239.14) compared to those without the condition (€799.28, 95% CI = €799.14 - € 799.41). CONCLUSIONS: Individuals with T2DM were more likely to have a higher number of treated comorbid conditions than those without and this was associated with higher ingredient costs. This has important policy and economic consequences for the planning and provision of future health services in Ireland, given the expected increase in T2DM and other chronic conditions.

The Prevalence of Chronic Kidney Disease and Albuminuria in Patients With Type 1 and Type 2 Diabetes Attending a Single Centre.

Background Diabetes is the leading cause of chronic kidney disease worldwide. Diabetic kidney disease is one of the microvascular complications of diabetes and it involves changes in glomerular hemodynamics, interstitial fibrosis, and tubular atrophy. Early detection and management of Diabetic kidney disease (DKD) help to reduce morbidity and mortality. This study aims to assess the prevalence of nephropathy and albuminuria in the diabetic population attending an Irish tertiary care center. Methods Retrospective data collection and analysis of patients diagnosed with Type 1 diabetes mellitus (T1DM) and Type 2 diabetes mellitus (T2DM) through the Development and Integration of Accurate Mathematical Operations in Numerical Data-Processing (DIAMOND) database in a single Irish tertiary care center. An audit tool was used to collect patients' information including gender, age, type of diabetes, serum creatinine, urinary albumin excretion, albumin creatinine ratio (ACR), body mass index, and last available glycated hemoglobin (HbA1c). Results Out of 7394 subjects with T2DM, 3139 (42%) were identified with chronic kidney disease (CKD). There were 1866 subjects with positive ACR out of 3139 subjects with CKD in the T2DM cohort. This shows that 25% of subjects have diabetic kidney disease and 17% have CKD of undetermined etiology. In the T1DM cohort with 1166 subjects, 209 (18%) were identified with CKD. Out of these 209 subjects with CKD, 164 (14%) were ACR-positive. The prevalence of CKD and albuminuria were related to age in both T1DM and T2DM populations. Albuminuria showed a linear relationship with age in subjects with no known CKD, which shows that age causally relates to albuminuria independent of type and duration of diabetes. Conclusion CKD is more prevalent in patients with T2DM as compared to T1DM, whereas the prevalence of albuminuria is higher in the T1DM population.

Potentially inappropriate prescribing and cost outcomes for older people: a national population study.

AIMS: Optimization of drug prescribing in older populations is a priority due to the significant clinical and economic costs of drug-related illness. This study aimed to: (i) estimate the prevalence of potentially inappropriate prescribing (PIP) in a national Irish older population using European specific explicit prescribing criteria; (ii) investigate the association between PIP, number of drug classes, gender and age and; (iii) establish the total cost of PIP. METHODS: This was a retrospective national population study (n= 338 801) using the Health Service Executive Primary Care Reimbursement Service (HSE-PCRS) pharmacy claims database. The HSE-PCRS uses the WHO Anatomical Therapeutic Chemical (ATC) classification system and details of every drug dispensed and claimants' demographic data are available. Thirty PIP indicators (STOPP) were applied to prescription claims for those >or=70 years in Ireland in 2007. STOPP is a physiological system based screening tool of older persons' potentially inappropriate prescriptions assessing drug-drug and drug-disease interactions, dose and duration. RESULTS: In our study population PIP prevalence was 36% (121 454 claimants). The main contributors to this were: 56 560 (17%) prescribed proton pump inhibitors at maximum therapeutic dose for >8 weeks, 29 691 (9%) prescribed non-steroidal anti-inflammatories for >3 months, 17 676 (5%) prescribed long-acting benzodiazepines for >1 month and 16 201 (5%) prescribed duplicate drugs. The main determinant of PIP was polypharmacy. The likelihood of PIP increased with a significant linear and quadratic trend (P < 0.0001) with the number of drug classes.The maximum net ingredient cost of PIP was estimated to be euro38 664 640. Total PIP expenditure was estimated to be euro45 631 319, 9% of the overall expenditure on pharmaceuticals in those >or=70 years in 2007. CONCLUSIONS: The findings identify a high prevalence of PIP in Ireland with significant cost consequences.

Trends in attention-deficit and hyperactivity disorder (ADHD) medications among children and young adults in Ireland: a repeated cross-sectional study from 2005 to 2015.

OBJECTIVE: This study examined the prescribing patterns of attention-deficit hyperactivity disorder (ADHD) medications in Ireland between 2005 and 2015 in children, adolescents and young adults, and concomitant use of psychotropic medication. DESIGN: Repeated cross-sectional study. SETTING: Community setting using pharmacy claims data in Ireland. PARTICIPANTS: Children and young adults aged 0-24 years. PRIMARY AND SECONDARY OUTCOMES: Authorised medications used to treat ADHD during the study period, methylphenidate, dexamfetamine, lisdexamfetamine dimesylate and atomoxetine were extracted from a national pharmacy claims database. Dispensing of concomitant psychotropic medications including antipsychotics, anxiolytics, hypnotics/sedatives and antidepressants were examined. RESULTS: The number on any ADHD medication ranged from 1913 in 2005 to 4853 in 2015, and the prevalence rate per 1000 eligible population aged <25 years increased significantly over time from 5.61 (95% CI 5.36 to 5.86) in 2005 to 8.36 (95% CI 8.13 to 8.60) in 2015 (p<0.0001). Negative binomial regression showed significant changes over time for ADHD prescribing (p<0.001), with significantly higher rates across the different age groups. The rates overall were three to five times higher in males. There was a significant increase in the percentage on concomitant antidepressants from 2% in 2005 to 6% in 2015 (p<0.001). CONCLUSIONS: There were significantly higher rates of ADHD prescribing in children/adolescents and a significant increase in the coprescribing of antidepressants. The reasons for the increase are unclear but may reflect increasing awareness and diagnosis of the condition.

Introduction of an academic internship in Ireland: views of undergraduate medical students.

INTRODUCTION: A combined academic and clinical training programme for junior doctors in Ireland, the academic track for internship, has recently been launched. The academic track offers newly graduated doctors protected time within the working week to undertake a research project in addition to funding, an academic supervisor, and additional training in research skills. This study seeks to investigate the views of undergraduate medical students. METHODS: The study population was undergraduate medical students at Trinity College Dublin in their penultimate year of study. An online questionnaire was designed and disseminated via a gatekeeper. Descriptive statistics were used to carry out data analysis on students' responses. RESULTS: The response rate was 50/203 (24.6%). All respondents indicated that protected time would be 'very important' or 'important'. The most frequently cited reason for participating in the academic track was 'To progress my career in a particular specialty' (28/42). The most frequently cited anticipated achievement was research publication (39/42). The most common response when asked what concerns (if any) students had about participating in the programme was 'I am not sure I could achieve all the clinical competencies of an intern in addition to research' (58%). DISCUSSION: There was a significant interest in the academic track for internship, and it is perceived by students as being of benefit to their careers. The value of protected time and an academic supervisor were recognised, and a research publication was the most frequently cited anticipated outcome. The data gathered in this questionnaire will help inform curriculum development and the identification of suitable learning outcomes.

What therapies have replaced rofecoxib in Ireland?

AIMS: To examine prescription patterns of nonsteroidal anti-inflammatory drugs (NSAIDs) or analgesics in patients prescribed chronic rofecoxib treatment prior to withdrawal from the Irish market, and to determine the impact on proton pump inhibitor (PPI) co-prescription. METHODS: Using a national prescribing database, adults (> or =16 years) prescribed rofecoxib for > or =3 months, but not analgesics, from January to September 2004 were identified. A longitudinal prescribing history was used to determine switching patterns to other cyclooxygenase (COX)-2 inhibitors, NSAIDs or analgesics during 3 and 12 months after withdrawal. Concomitant PPI prescription was examined. Logistic regression was used to determine the likelihood of switching to a COX-2 inhibitor vs. nonselective NSAID and factors influencing concomitant PPI prescription. RESULTS: After rofecoxib withdrawal, 30.2% (1558) and 17.9% (922) of the 5155 study subjects received no further NSAID prescription during 3 and 12 months, respectively. During the 12-month period, approximately one-third of NSAID prescriptions were for <3 months; 40.7% (2096) received sequential prescriptions for different NSAIDs. Co-prescription of analgesics occurred in 49.3% (2539) of subjects. Neither age nor gender influenced the type of NSAID prescribed in the 12 months post rofecoxib withdrawal. PPI prescription increased by 5.5% during the study, associated with use of nonselective NSAIDs, prior use of PPIs and increasing age. CONCLUSIONS: The majority of those receiving chronic rofecoxib therapy were prescribed either no further NSAID or short-term NSAID therapy only during the 12 months post withdrawal, which suggests the subsequent controversy may have encouraged prescribers to adhere more closely to published guidelines.

Characterizing new users of NSAIDs before and after rofecoxib withdrawal.

AIMS: To characterize patients initiated on nonsteroidal anti-inflammatory drugs (NSAIDs), pre and postrofecoxib withdrawal, by age, gender and concomitant cardiovascular (CV) therapy. METHODS: A national primary care prescription database was used to identify patients who initiated NSAID therapy pre and postrofecoxib withdrawal. Patients receiving CV therapy were identified in the same periods also. Adjusted odds ratios (OR) and 95% confidence intervals are presented. RESULTS: Female patients [OR = 1.15 (1.11, 1.19)], those over 65 years [OR = 2.76 (2.65, 2.86)] and those at CV risk [OR = 1.72 (1.67, 1.79)] were more likely to start on celecoxib (over a nonselective NSAID) than male patients, those under 65 years and those not at CV risk. Similar results were found for rofecoxib and nimesulide. Post-withdrawal analysis showed results comparable to the pre-withdrawal period. CONCLUSION: The results highlight a possible uncertainty experienced by prescribers of treatment alternatives available and a lack of unbiased information at this time for at-risk groups.

Usage of paracetamol-containing combination analgesics remains high in primary care.

AIMS: Paracetamol-containing combination analgesics are widely prescribed but the use of paracetamol/dextropropoxyphene (co-proxamol) is particularly controversial. We aim to examine the prescribing patterns of the paracetamol-containing analgesics in Ireland. METHODS: A national primary care prescribing database was used to investigate patterns of usage. Twenty-six thousand three hundred and eighteen patients who were new to therapy with paracetamol and paracetamol-containing analgesics between January and June 2002 were identified as follows: no previous analgesic medication in the 6 months prior to enrolment into the study, and followed up for at least 12 months from the time of enrolment. Duration of therapy and the number of prescriptions received post enrolment were analyzed according to age. Odds ratios for receiving long-term (>1 month) compared with short-term (1 month) prescriptions for co-proxamol, paracetamol only or a paracetamol combination-type analgesic were calculated for women vs. men, and in those aged over 65 vs. those aged under 65 years. RESULTS: Co-proxamol was the most commonly prescribed analgesic, accounting for 42% of all prescriptions dispensed during 2003. Long-term use of paracetamol-containing analgesic preparations was uncommon, with 56.7% receiving only 1 month's prescription during the study period. However, women (OR = 1.18, 95% CI 1.07, 1.28, P < 0.0001) and those over 65 years (OR = 1.71, 95% CI 1.57, 1.86, P < 0.0001) were more likely to receive a follow-up prescription for co-proxamol, but also for paracetamol (women, OR = 1.28, 95% CI 1.16, 1.39; over 65 year olds, OR = 2.67, 95% CI 2.44, 2.93) and the paracetamol combinations (women, OR = 1.33, 95% CI 1.20, 1.47; over 65 year olds, OR = 1.69, 95% CI 1.53, 1.87). CONCLUSIONS: Co-proxamol was the most commonly prescribed paracetamol-containing analgesic preparation in Ireland. The results may indicate inappropriate use in primary care.

Have COX-2 inhibitors influenced the co-prescription of anti-ulcer drugs with NSAIDs?

AIMS: To quantify usage of COX-2 inhibitors compared with nonselective NSAIDs and to determine their impact (including financial) on the co-prescription of antipeptic ulcer (anti-PU) drugs. METHODS: The Irish General Medical Services prescription database (covering 1.2 million people) was examined for NSAID prescriptions during December 1999-November 2001. NSAID users were excluded during the first 6 months. During the next 12 months (study period) patients on NSAIDs (>or= 3 prescriptions) were identified. The study period and final 6 months provided data on co-prescription of anti-PU drugs. Age, gender, number of concomitant prescriptions, co-prescribing of anti-PU drugs and monthly cost were evaluated for 8 NSAIDs (n= 4 non-selective NSAIDs and n= 4 COX-2 inhibitors) and odds ratios (OR) calculated using logistic regression. RESULTS: COX-2 inhibitors were prescribed more frequently in older, female patients and those receiving multiple medications. After adjustment for age, gender and polypharmacy, anti-PU drugs were prescribed more frequently with COX-2 inhibitors (OR = 1.31 (1.23,1.40)). COX-2 inhibitors were up to 10-fold more expensive, median monthly costs (including anti-PU drugs) ranging from Euros 34.61 (COX-2 inhibitors) to Euros 3.26 (nonselective NSAIDs). CONCLUSIONS: Since COX-2 inhibitors are associated with increased rates of co-prescription of anti-PU drugs and are more expensive than non-selective NSAIDs, these results suggest that the expected cost-savings with COX-2 inhibitors may not be occurring in practice.

"Selective" switching from non-selective to selective non-steroidal anti-inflammatory drugs.

BACKGROUND: Non-steroidal anti inflammatory drugs (NSAIDs) are thought to account for almost 25% of all reported adverse drug reactions, primarily gastrointestinal (GI) toxicity. Selective cyclo-oxygenase-2 (COX-2) inhibitors have been shown to preferentially inhibit activity of the COX-2 enzyme, which maintains anti-inflammatory activity but reduces GI toxicity. OBJECTIVE: To determine the degree of switching from non-selective NSAIDs to COX-2 inhibitors and to examine the factors that were associated with switching. METHODS: The General Medical Services prescription database (1.2 million people) was examined for NSAID prescriptions from December 1999 through November 2001. All those receiving non-selective NSAIDs and those switching to selective COX-2 inhibitors after at least 1 month on a non-selective NSAID were identified (non-switchers and switchers, respectively). Age, sex, dose of non-selective NSAID and co-prescribing of anti-peptic ulcer (anti-PU) drugs were considered between switchers and non-switchers, and odds ratios (OR) calculated using logistic regression. The effect of chronic use (> or =3 months prescription of a non-selective NSAID during the study period) on switching was also evaluated. RESULTS: A total of 81,538 of 480,573 patients (17%) initially prescribed non-selective NSAIDs were switched to COX-2 inhibitors during the study. The elderly (65 years or older) were more likely to be switched to a COX-2 inhibitor [OR=1.81, 95% confidence interval (CI) 1.79, 1.84]. Women were also more likely to be switched to COX-2 inhibitor therapy (OR=1.25, 95% CI 1.23, 1.27). Previous but not subsequent prescribing of anti-PU drugs was also associated with switching. Chronic users showed similar switching patterns. CONCLUSIONS: Prescribers are more likely to switch older female patients and those with a past history of peptic ulcers from non-selective NSAIDs to COX-2 inhibitors. This suggests that doctors take risk factors into consideration when prescribing NSAIDs. The relatively low rate of switching may suggest that prescribers still have concerns over the place of COX-2 inhibitors and reserve their use to those patients particularly at risk of NSAID-induced GI toxicity.