The association between anticholinergic/sedative burden and physical frailty in people aging with HIV.

OBJECTIVE: This study aimed to estimate the strength of the association between anticholinergic/sedative burden and concurrent physical frailty in people aging with HIV. DESIGN: This cross-sectional analysis examined baseline data from 824 adults with a mean age of 53 enrolled in the Positive Brain Health Now study. METHODS: Anticholinergic medications were identified using four methods: Anticholinergic Cognitive Burden (ACB) Scale, Anticholinergic Risk Scale (ARS), Anticholinergic Drug Scale (ADS), and the anticholinergic list of the Anticholinergic and Sedative Burden Catalog (ACSBC). Sedatives were identified using the Sedative Load Model (SLM) and the sedative list of the ACSBC. Physical frailty was assessed using a modified Fried Frailty Phenotype (FFP) based on self-report items. Multivariable logistic regression models, adjusted for sociodemographic factors, lifestyle considerations, HIV-related variables, comorbidities, and co-medication use, were used to estimate odds ratios (ORs). RESULTS: Anticholinergic burden demonstrated associations with frailty across various methods: total anticholinergic burden (OR range: 1.22-1.32; 95% confidence interval (CI) range: 1.03-1.66), sedative burden (OR range: 1.18-1.24; 95% CI range: 1.02-1.45), high anticholinergic burden (OR range: 2.12-2.74; 95% CI range: 1.03-6.19), and high sedative burden (OR range: 1.94-2.18; 95% CI: 1.01-4.34). CONCLUSION: The anticholinergic and sedative burdens may represent modifiable risk factors for frailty in people aging with HIV. Future studies should evaluate the effects of reducing anticholinergic and sedative burdens on frailty outcomes and explore the prognostic value of diverse scoring methods.

Rates and risk factors for persistent opioid use after cardiothoracic surgery: A cohort study.

BACKGROUND: This study's aim was to estimate potential risk factors for persistent opioid use after cardiothoracic surgery. METHODS: This study included participants in the McGill University Health Centre clinical trial (2014 to 2016). Provincial medical services, prescription claims, and medical charts data were linked. Persistent opioid use was defined as an initial peri-operative opioid dispensation followed by an opioid dispensation between 91 and 180 days postdischarge. Multivariable Cox Proportional Hazards models were used to assess factors associated with persistent opioid use. RESULTS: A cohort of 815 patients (mean age: 68.9 [standard deviation = 8.9]) was assembled, of which 8.2% became persistent opioid users. Factors such as higher Charlson Comorbidity Index (adjusted hazard ratio: 3.4, 95% confidence interval: 1.1-10.6), history of diabetes (adjusted hazard ratio: 2.1, 95% confidence interval: 1.3-3.4), substance and alcohol abuse (adjusted hazard ratio: 16.3, 95% confidence interval: 5.3-49.5), and radiotherapy (adjusted hazard ratio: 2.4, 95% confidence interval: 1.5-4.1) were associated with a higher hazard of persistent opioid use. Previous opioid use (adjusted hazard ratio: 1.7, 95% CI: 1.0-2.8), daily peri-operative opioid dose (adjusted hazard ratio: 2.3, 95% confidence interval: 1.5-3.7), having an opioid dispensation 30 days pre-admission (adjusted hazard ratio: 1.7, 95% confidence interval: 1.0-2.8), and pre-admission analgesic use (adjusted hazard ratio: 1.7, 95% confidence interval: 1.0-2.8), were also associated with an increased hazard of persistent use. Being prescribed multimodal analgesia at discharge (adjusted hazard ratio: 0.54, 95% confidence interval: 0.32-0.92) was associated with a 46% decreased hazard of developing persistent opioid use. CONCLUSION: Multiple patient- and medication-related characteristics were associated with an increased hazard of persistent opioid use.

Type of infertility and prevalence of congenital malformations.

BACKGROUND: Children conceived with assisted reproductive technologies (ART) or after a long waiting time have a higher prevalence of congenital malformations, but few studies have examined the contribution of type of infertility. OBJECTIVES: To quantify the association between causes of infertility and prevalence of malformations. METHODS: We compared the prevalence at birth of all and severe malformations diagnosed up to age 2 between 6656 children born in 1996-2017 to parents who had previously been assessed for infertility a an academic fertility clinic ("exposed") and 10,382 children born in the same period to parents with no recent medical history of infertility ("reference"). We estimated prevalence ratios (PR) and prevalence differences (PD), by infertility status, type of treatment (non-ART, ART), and infertility diagnosis, in all children and among singletons. RESULTS: Compared with children of parents with no infertility, children of parents with infertility had a higher prevalence of malformations (both definitions), particularly following ART conceptions. After accounting for treatment, ovulatory disorders were associated with a higher prevalence of both all (PR 1.49, 95% confidence interval (CI) 1.15, 1.93; PD 3.8, 95% CI 1.0, 6.6) and severe (PR 1.53, 95% CI 1.02, 2.29; PD 1.8, 95% CI -0.2, 3.7) malformations (the estimates refer to exposed children conceived without treatment). Unexplained and male factor infertility were associated with all and severe malformations, respectively. Estimates among singletons were similar. A diagnosis of ovulatory disorders was associated with all malformations also in analyses restricted to exposed children, regardless of treatment (we did not examine severe malformations, due to limited power). CONCLUSIONS: In this study, ovulatory disorders were consistently associated with a higher prevalence of congenital malformations (including severe malformations) among live births, regardless of mode of conception.

Clinical competence, communication ability and adherence to choosing wisely recommendations for lipid reducing drug use in older adults.

BACKGROUND: Although lipid-lowering drugs are not recommended for primary prevention in patients 75+, prevalence of use is high and there is unexplained variation in prescribing between physicians. The objective of this study was to determine if physician communication ability and clinical competence are associated with prescribing lipid-lowering drugs for primary and secondary prevention. METHODS: We used a cohort of 4,501 international medical graduates, 161,214 U.S. Medicare patients with hyperlipidemia (primary prevention) and 49,780 patients with a history of cardiovascular disease (secondary prevention) not treated with lipid-lowering therapy who were seen by study physicians in ambulatory care. Clinical competence and communication ability were measured by the ECFMG clinical assessment examination. Physician citizenship, age, gender, specialty and patient characteristics were also measured. The outcome was an incident prescription of lipid-lowering drug, evaluated using multivariable GEE logistic regression models for primary and secondary prevention for patients 75+ and 65-74. RESULTS: Patients 75+ were less likely than those 65-74 to receive lipid-lowering drugs for primary (OR 0.62, 95% CI 0.59-0.66) and secondary (OR 0.70, 95% CI 0.63-0.78) prevention. For every 20% increase in clinical competence score, the odds of prescribing therapy for primary prevention to patients 75+ increased by 24% (95% CI 1.02-1.5). Communication ability had the opposite effect, reducing the odds of prescribing for primary prevention by 11% per 20% score increase (95% CI 0.8-0.99) for both age groups. Physicians who were citizens of countries with higher proportions of Hispanic (South/Central America) or Asian (Asia/Oceania) people were more likely to prescribe treatment for primary prevention, and internal medicine specialists were more likely to treat for secondary prevention than primary care physicians. CONCLUSION: Clinical competence, communication ability and physician citizenship are associated with lipid-lowering drug prescribing for primary prevention in patients aged 75+.

Do clinical and communication skills scores on credentialing exams predict potentially inappropriate antibiotic prescribing?

BACKGROUND: There is considerable variation among physicians in inappropriate antibiotic prescribing, which is hypothesized to be attributable to diagnostic uncertainty and ineffective communication. The objective of this study was to evaluate whether clinical and communication skills are associated with antibiotic prescribing for upper respiratory infections and sinusitis. METHODS: A cohort study of 2,526 international medical graduates and 48,394 U.S. Medicare patients diagnosed by study physicians with an upper respiratory infection or sinusitis between July 2014 and November 2015 was conducted. Clinical and communication skills were measured by scores achieved on the Clinical Skills Assessment examination administered by the Educational Commission for Foreign Medical Graduates (ECFMG) as a requirement for entry into U.S residency programs. Medicare Part D data were used to determine whether patients were dispensed an antibiotic following an outpatient evaluation and management visit with the study physician. Physician age, sex, specialty and practice region were retrieved from the ECFMG databased and American Medical Association (AMA) Masterfile. Multivariate GEE logistic regression was used to evaluate the association between clinical and communication skills and antibiotic prescribing, adjusting for other physician and patient characteristics. RESULTS: Physicians prescribed an antibiotic in 71.1% of encounters in which a patient was diagnosed with sinusitis, and 50.5% of encounters for upper respiratory infections. Better interpersonal skills scores were associated with a significant reduction in the odds of antibiotic prescribing (OR per score decile 0.93, 95% CI 0.87-0.99), while greater proficiency in clinical skills and English proficiency were not. Female physicians, those practicing internal medicine compared to family medicine, those with citizenship from the US compared to all other countries, and those practicing in southern of the US were also more likely to prescribe potentially unnecessary antibiotics. CONCLUSIONS: Based on this study, physicians with better interpersonal skills are less likely to prescribe antibiotics for acute sinusitis and upper respiratory infections. Future research should examine whether tailored interpersonal skills training to help physicians manage patient expectations for antibiotics could reduce unnecessary antibiotic prescribing.

Ranking versus rating in peer review of research grant applications.

The allocation of public funds for research has been predominantly based on peer review where reviewers are asked to rate an application on some form of ordinal scale from poor to excellent. Poor reliability and bias of peer review rating has led funding agencies to experiment with different approaches to assess applications. In this study, we compared the reliability and potential sources of bias associated with application rating with those of application ranking in 3,156 applications to the Canadian Institutes of Health Research. Ranking was more reliable than rating and less susceptible to the characteristics of the review panel, such as level of expertise and experience, for both reliability and potential sources of bias. However, both rating and ranking penalized early career investigators and favoured older applicants. Sex bias was only evident for rating and only when the applicant's H-index was at the lower end of the H-index distribution. We conclude that when compared to rating, ranking provides a more reliable assessment of the quality of research applications, is not as influenced by reviewer expertise or experience, and is associated with fewer sources of bias. Research funding agencies should consider adopting ranking methods to improve the quality of funding decisions in health research.

Predictors of frequent emergency department visits among hospitalized cancer patients: a comparative cohort study using integrated clinical and administrative data to improve care delivery.

BACKGROUND: Frequent emergency department (FED) visits by cancer patients represent a significant burden to the health system. This study identified determinants of FED in recently hospitalized cancer patients, with a particular focus on opioid use. METHODS: A prospective cohort discharged from surgical/medical units of the McGill University Health Centre was assembled. The outcome was FED use (≥ 4 ED visits) within one year of discharge. Data retrieved from the universal health insurance system was analyzed using Cox Proportional Hazards (PH) model, adopting the Lunn-McNeil approach for competing risk of death. RESULTS: Of 1253 patients, 14.5% became FED users. FED use was associated with chemotherapy one-year pre-admission (adjusted hazard ratio (aHR) 2.60, 95% CI: 1.80-3.70), ≥1 ED visit in the previous year (aHR: 1.80, 95% CI 1.20-2.80), ≥15 pre-admission ambulatory visits (aHR 1.54, 95% CI 1.06-2.34), previous opioid and benzodiazepine use (aHR: 1.40, 95% CI: 1.10-1.90 and aHR: 1.70, 95% CI: 1.10-2.40), Charlson Comorbidity Index ≥ 3 (aHR: 2.0, 95% CI: 1.2-3.4), diabetes (aHR: 1.60, 95% CI: 1.10-2.20), heart disease (aHR: 1.50, 95% CI: 1.10-2.20) and lung cancer (aHR: 1.70, 95% CI: 1.10-2.40). Surgery (cardiac (aHR: 0.33, 95% CI: 0.16-0.66), gastrointestinal (aHR: 0.34, 95% CI: 0.14-0.82) and thoracic (aHR: 0.45, 95% CI: 0.30-0.67) led to a decreased risk of FED use. CONCLUSIONS: Cancer patients with higher co-morbidity, frequent use of the healthcare system, and opioid use were at increased risk of FED use. High-risk patients should be flagged for preventive intervention.

The Prognostic Utility of Anticholinergic Burden Scales: An Integrative Review and Gap Analysis.

BACKGROUND: Anticholinergic drugs are commonly prescribed, especially to older adults. Anticholinergic burden scales (ABS) have been used to evaluate the cumulative effects of multiple anticholinergics. However, studies have shown inconsistent results regarding the association between anticholinergic burden assessed with ABS and adverse clinical outcomes such as cognitive impairment, functional decline, and frailty. This review aims to identify gaps in research on the development, validation, and evaluation of ABS, and provide recommendations for future studies. METHOD: A comprehensive search of five databases (MEDLINE, Embase, PsychInfo, CINAHL, CENTRAL) was conducted for relevant studies published from inception until 25 May 2023. Two reviewers screened for eligibility and assessed the quality of studies using different tools based on the study design and stage of the review framework. Research evidence was evaluated, and gaps were identified and grouped into evidence, knowledge, and methodological gaps, using evidence tables to summarize data. RESULTS: Several evidence, knowledge, and methodological gaps in existing development, validation, and evaluation studies of ABS were identified. There is no universally accepted scale, and there is a need to define a clinically relevant threshold for measuring total anticholinergic burden. The current evidence has limitations, underrepresenting low- and middle-income countries, younger individuals, and populations with cognitive disabilities. The impact of anticholinergic burden on frailty is also understudied. Existing evaluation studies provide limited evidence on the benefit of reducing anticholinergic burden on clinical outcomes or the safety of anticholinergic deprescribing. There is also uncertainty regarding optimal reduction, clinically significant anticholinergic burden thresholds, and cost effectiveness. CONCLUSIONS: Future research recommendations to bridge knowledge gaps include developing a risk assessment framework, refining ABS scales, establishing a standardized consensus scale, and creating a longitudinal measure of cumulative anticholinergic risk. Strategies to minimize bias, consider frailty, and promote multidisciplinary and multinational collaborations are also necessary to improve patient outcomes.

Comparison of Different Modeling Approaches for Prescription Opioid Use and Its Association With Adverse Events.

Previous research linking opioid prescribing to adverse drug events has failed to properly account for the time-varying nature of opioid exposure. This study aimed to explore how the risk of opioid-related emergency department visits, readmissions, or deaths (composite outcome) varies with opioid dose and duration, comparing different novel modeling techniques. A prospective cohort of 1,511 hospitalized patients discharged from 2 McGill-affiliated hospitals in Montreal, 2014-2016, was followed from the first postdischarge opioid dispensation until 1 year after discharge. Marginal structural Cox proportional hazards models and their flexible extensions were used to explore the association between time-varying opioid use and the composite outcome. Weighted cumulative exposure models assessed cumulative effects of past use and explored how its impact depends on the recency of exposure. The patient mean age was 69.6 (standard deviation = 14.9) years; 57.7% were male. In marginal structural model analyses, current opioid use was associated with a 71% increase in the hazard of opioid-related adverse events (adjusted hazard ratio = 1.71, 95% confidence interval: 1.21, 2.43). The weighted cumulative exposure results suggested that the risk cumulates over the previous 50 days of opioid consumption. Flexible modeling techniques helped assess how the risk of opioid-related adverse events may be associated with time-varying opioid exposures while accounting for nonlinear relationships and the recency of past use.

Determinants of long-term opioid use in hospitalized patients.

BACKGROUND: Long-term opioid use is an increasingly important problem related to the ongoing opioid epidemic. The purpose of this study was to identify patient, hospitalization and system-level determinants of long term opioid therapy (LTOT) among patients recently discharged from hospital. DESIGN: To be eligible for this study, patient needed to have filled at least one opioid prescription three-months post-discharge. We retrieved data from the provincial health insurance agency to measure medical service and prescription drug use in the year prior to and after hospitalization. A multivariable Cox Proportional Hazards model was utilized to determine factors associated with time to the first LTOT occurrence, defined as time-varying cumulative opioid duration of ≥ 60 days. RESULTS: Overall, 22.4% of the 1,551 study patients were classified as LTOT, who had a mean age of 66.3 years (SD = 14.3). Having no drug copay status (adjusted hazard ratio (aHR) 1.91, 95% CI: 1.40-2.60), being a LTOT user before the index hospitalization (aHR 6.05, 95% CI: 4.22-8.68) or having history of benzodiazepine use (aHR 1.43, 95% CI: 1.12-1.83) were all associated with an increased likelihood of LTOT. Cardiothoracic surgical patients had a 40% lower LTOT risk (aHR 0.55, 95% CI: 0.31-0.96) as compared to medical patients. Initial opioid dispensation of > 90 milligram morphine equivalents (MME) was also associated with higher likelihood of LTOT (aHR 2.08, 95% CI: 1.17-3.69). CONCLUSIONS AND RELEVANCE: Several patient-level characteristics associated with an increased risk of ≥ 60 days of cumulative opioid use. The results could be used to help identify patients who are at high-risk of continuing opioids beyond guideline recommendations and inform policies to curb excessive opioid prescribing.

Assessing the potential for virtualizable care in the pediatric emergency department.

INTRODUCTION: There is increasing interest for patient-to-provider telemedicine in pediatric acute care. The suitability of telemedicine (virtualizability) for visits in this setting has not been formally assessed. We estimated the proportion of in-person pediatric emergency department (PED) visits that were potentially virtualizable, and identified factors associated with virtualizable care. METHODS: This was a retrospective analysis of in-person visits at the PED of a Canadian tertiary pediatric hospital (02/2018-12/2019). Three definitions of virtualizable care were developed: (1) a definition based on "resource use" classifying visits as virtualizable if they resulted in a home discharge, no diagnostic testing, and no return visit within 72 h; (2) a "diagnostic definition" based on primary ED diagnosis; and (3) a stringent "combined definition" by which visits were classified as virtualizable if they met both the resource use and diagnostic definitions. Multivariable logistic regression was used to identify factors associated with telemedicine suitability. RESULTS: There were 130,535 eligible visits from 80,727 individual patients during the study period. Using the most stringent combined definition of telemedicine suitability, 37.9% (95% confidence interval (CI) 37.6%-38.2%) of in-person visits were virtualizable. Overnight visits (adjusted odds ratio (aOR) 1.16-1.37), non-Canadian citizenship (aOR 1.10-1.18), ethnocultural vulnerability (aOR 1.14-1.22), and a consultation for head trauma (aOR 3.50-4.60) were associated with higher telemedicine suitability across definitions. DISCUSSION: There is a high potential for patient-to-provider telemedicine in the PED setting. Local patient and visit-level characteristics must be considered in the design of safe and inclusive telemedicine models for pediatric acute care.

The influence of regulation of medically assisted reproduction on the risk of hospitalization in the first 2 years of life.

STUDY QUESTION: Do publicly funded fertility treatment and single embryo transfer (SET) result in lower hospitalization rates of children of parents with infertility? SUMMARY ANSWER: Following the 2010 Quebec law introducing free fertility treatment and SET, neonatal intensive care unit (NICU) admissions decreased among all children born to parents with infertility, but not among singletons, whose risk remained slightly higher than that of children of parents without infertility, even accounting for treatment and maternal age. WHAT IS KNOWN ALREADY: Previous studies reported lower NICU admission rates among children conceived with ART after the 2010 law; however, children conceived without ART by parents with infertility were not considered. STUDY DESIGN, SIZE, DURATION: Cohort study of children born in 1997-2017 to patients evaluated for infertility ('exposed') at an academic fertility center in Montreal (Canada) in 1996-2015. A random sample of births to Montreal residents served as comparison. Outcomes were identified from Quebec administrative databases. PARTICIPANTS/MATERIALS, SETTING, METHODS: We compared children's healthcare utilization before and after the 2010 law in 6273 exposed and 12 583 randomly sampled births (6846 and 12 775 children, respectively). We repeated the analysis among children conceived in the 63 months before and after the law ('restricted period'), and examined whether differences in twinning, fertility treatment, and maternal age explained the higher risk of NICU admission among children of parents with infertility. MAIN RESULTS AND THE ROLE OF CHANCE: In the exposed cohort, the proportion of twin births and of several adverse outcomes declined after the law. NICU admission and duration of NICU stay decreased overall, but not in singletons. Both measures remained higher in exposed children. Except for NICU admission, hospitalization rates were similar in exposed and random sample children. After accounting for fertility treatment and maternal age, exposed singletons were 17% more likely to be admitted to the NICU than children of parents with no medical history of infertility. LIMITATIONS, REASONS FOR CAUTION: Sample size was relatively small; infertile patients were from a single center and the random sample from one city. Despite some limitations, administrative databases are likely to accurately reflect healthcare utilization. WIDER IMPLICATIONS OF THE FINDINGS: Universal access to treatment and, particularly, SET results in an overall reduction of adverse outcomes among children conceived with treatment; however, children of parents with infertility are at a slightly higher risk, regardless of treatment. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by the Canadian Institutes for Health Research (CIHR, grant no. 123362). No competing interests. TRIAL REGISTRATION NUMBER: N/A.

'Improving smart medication management': an online expert discussion.

Medication safety continues to be a problem inside and outside the hospital, partly because new smart technologies can cause new drug-related challenges to prescribers and patients. Better integrated digital and information technology (IT) systems, improved education on prescribing for prescribers and greater patient-centred care that empowers patients to take control of their medications are all vital to safer and more effective prescribing. In July 2021, a roundtable discussion was held as a spin-off meeting of the International Forum on Quality and Safety in Health Care Europe 2021 to discuss challenges and future direction in smart medication management. This manuscript summarises the discussion focusing on the aspects of digital and IT systems, safe prescribing, improved communication and education, and drug adherence.

The MedSafer Study-Electronic Decision Support for Deprescribing in Hospitalized Older Adults: A Cluster Randomized Clinical Trial.

IMPORTANCE: Scalable deprescribing interventions may reduce polypharmacy and the use of potentially inappropriate medications (PIMs); however, few studies have been large enough to evaluate the impact that deprescribing may have on adverse drug events (ADEs). OBJECTIVE: To evaluate the effect of an electronic deprescribing decision support tool on ADEs after hospital discharge among older adults with polypharmacy. DESIGN, SETTING, AND PARTICIPANTS: This was a cluster randomized clinical trial of older (≥65 years) hospitalized patients with an expected survival of more than 3 months who were admitted to 1 of 11 acute care hospitals in Canada from August 22, 2017, to January 13, 2020. At admission, participants were taking 5 or more medications per day. Data analyses were performed from January 3, 2021, to September 23, 2021. INTERVENTIONS: Personalized reports of deprescribing opportunities generated by MedSafer software to address usual home medications and measures of prognosis and frailty. Deprescribing reports provided to the treating team were compared with usual care (medication reconciliation). MAIN OUTCOMES AND MEASURES: The primary outcome was a reduction of ADEs within the first 30 days postdischarge (including adverse drug withdrawal events) captured through structured telephone surveys and adjudicated blinded to intervention status. Secondary outcomes were the proportion of patients with 1 or more PIMs deprescribed at discharge and the proportion of patients with an adverse drug withdrawal event (ADWE). RESULTS: A total of 5698 participants (median [range] age, 78 [72-85] years; 2858 [50.2%] women; race and ethnicity data were not collected) were enrolled in 3 clusters and were adjudicated for the primary outcome (control, 3204; intervention, 2494). Despite cluster randomization, there were group imbalances, eg, the participants in the intervention arm were older and had more PIMS prescribed at baseline. After hospital discharge, 4989 (87.6%) participants completed an ADE interview. There was no significant difference in ADEs within 30 days of discharge (138 [5.0%] of 2742 control vs 111 [4.9%] of 2247 intervention participants; adjusted risk difference [aRD] -0.8%; 95% CI, -2.9% to 1.3%). Deprescribing increased from 795 (29.8%) of 2667 control to 1249 (55.4%) of 2256 intervention participants [aRD, 22.2%; 95% CI, 16.9% to 27.4%]. There was no difference in ADWEs between groups. Several post hoc sensitivity analyses, including the use of a nonparametric test to address the low cluster number, group imbalances, and potential biases, did not alter study conclusions. CONCLUSIONS AND RELEVANCE: This cluster randomized clinical trial showed that providing deprescribing clinical decision support during acute hospitalization had no demonstrable impact on ADEs, although the intervention was safe and led to improvements in deprescribing. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03272607.

Association of clinical competence, specialty and physician country of origin with opioid prescribing for chronic pain: a cohort study.

BACKGROUND: Although little is known about why opioid prescribing practices differ between physicians, clinical competence, specialty training and country of origin may play a role. We hypothesised that physicians with stronger clinical competence and communication skills are less likely to prescribe opioids and prescribe lower doses, as do medical specialists and physicians from Asia. METHODS: Opioid prescribing practices were examined among international medical graduates (IMGs) licensed to practise in the USA who evaluated Medicare patients for chronic pain problems in 2014-2015. Clinical competence was assessed by the Educational Commission for Foreign Medical Graduates (ECFMG) Clinical Skills Assessment. Physicians in the ECFMG database were linked to the American Medical Association Masterfile. Patients evaluated for chronic pain were obtained by linkage to Medicare outpatient and prescription files. Opioid prescribing was measured within 90 days of evaluation visits. Prescribed dose was measured using morphine milligram equivalents (MMEs). Generalised estimating equation logistic and linear regression estimated the association of clinical competence, specialty, and country of origin with opioid prescribing and dose. RESULTS: 7373 IMGs evaluated 65 012 patients for chronic pain; 15.2% received an opioid prescription. Increased clinical competence was associated with reduced opioid prescribing, but only among female physicians. For every 10% increase in the clinical competence score, the odds of prescribing an opioid decreased by 16% for female physicians (OR 0.84, 95% CI 0.75 to 0.94) but not male physicians (OR 0.99, 95% CI 0.92 to 1.07). Country of origin was associated with prescribed opioid dose; US and Canadian citizens prescribed higher doses (adjusted MME difference +3.56). Primary care physicians were more likely to prescribe opioids, but surgical and hospital-based specialists prescribed higher doses. CONCLUSIONS: Clinical competence at entry into US graduate training, physician gender, specialty and country of origin play a role in opioid prescribing practices.

Association of Antidepressant Prescription Filling With Treatment Indication and Prior Prescription Filling Behaviors and Medication Experiences.

BACKGROUND: Given the wide range of uses for antidepressants, understanding indication-specific patterns of prescription filling for antidepressants provide valuable insights into how patients use these medications in real-world settings. OBJECTIVE: The objective of this study was to determine the association of antidepressant prescription filling with treatment indication, as well as prior prescription filling behaviors and medication experiences. DESIGN: This retrospective cohort study took place in Quebec, Canada. PARTICIPANTS: Adults with public drug insurance prescribed antidepressants using MOXXI (Medical Office of the XXIst Century)-an electronic prescribing system requiring primary care physicians to document treatment indications and reasons for prescription stops or changes. MEASURES: MOXXI provided information on treatment indications, past prescriptions, and prior medication experiences (treatment ineffectiveness and adverse drug reactions). Linked claims data provided information on dispensed medications and other patient-related factors. Multivariable logistic regression models estimated the independent association of not filling an antidepressant prescription (within 90 d) with treatment indication and patients' prior prescription filling behaviors and medication experiences. RESULTS: Among 38,751 prescriptions, the prevalence of unfilled prescriptions for new and ongoing antidepressant therapy was 34.2% and 4.1%, respectively. Compared with depression, odds of not filling an antidepressant prescription varied from 0.74 to 1.57 by indication and therapy status. The odds of not filling an antidepressant prescription was higher among adults filling < 50% of their medication prescriptions in the past year and adults with an antidepressant prescription stopped or changed in the past year due to treatment ineffectiveness. CONCLUSION: Antidepressant prescription filling behaviors differed by treatment indication and were lower among patients with a history of poor prescription filling or ineffective treatment with antidepressants.

Opioid prescribing among new users for non-cancer pain in the USA, Canada, UK, and Taiwan: A population-based cohort study.

BACKGROUND: The opioid epidemic in North America has been driven by an increase in the use and potency of prescription opioids, with ensuing excessive opioid-related deaths. Internationally, there are lower rates of opioid-related mortality, possibly because of differences in prescribing and health system policies. Our aim was to compare opioid prescribing rates in patients without cancer, across 5 centers in 4 countries. In addition, we evaluated differences in the type, strength, and starting dose of medication and whether these characteristics changed over time. METHODS AND FINDINGS: We conducted a retrospective multicenter cohort study of adults who are new users of opioids without prior cancer. Electronic health records and administrative health records from Boston (United States), Quebec and Alberta (Canada), United Kingdom, and Taiwan were used to identify patients between 2006 and 2015. Standard dosages in morphine milligram equivalents (MMEs) were calculated according to The Centers for Disease Control and Prevention. Age- and sex-standardized opioid prescribing rates were calculated for each jurisdiction. Of the 2,542,890 patients included, 44,690 were from Boston (US), 1,420,136 Alberta, 26,871 Quebec (Canada), 1,012,939 UK, and 38,254 Taiwan. The highest standardized opioid prescribing rates in 2014 were observed in Alberta at 66/1,000 persons compared to 52, 51, and 18/1,000 in the UK, US, and Quebec, respectively. The median MME/day (IQR) at initiation was highest in Boston at 38 (20 to 45); followed by Quebec, 27 (18 to 43); Alberta, 23 (9 to 38); UK, 12 (7 to 20); and Taiwan, 8 (4 to 11). Oxycodone was the first prescribed opioid in 65% of patients in the US cohort compared to 14% in Quebec, 4% in Alberta, 0.1% in the UK, and none in Taiwan. One of the limitations was that data were not available from all centers for the entirety of the 10-year period. CONCLUSIONS: In this study, we observed substantial differences in opioid prescribing practices for non-cancer pain between jurisdictions. The preference to start patients on higher MME/day and more potent opioids in North America may be a contributing cause to the opioid epidemic.

Smart About Meds (SAM): a pilot randomized controlled trial of a mobile application to improve medication adherence following hospital discharge.

OBJECTIVE: The objectives of this pilot study were (1) to assess the feasibility of a larger evaluation of Smart About Meds (SAM), a patient-centered medication management mobile application, and (2) to evaluate SAM's potential to improve outcomes of interest, including adherence to medication changes made at hospital discharge and the occurrence of adverse events. MATERIALS AND METHODS: We conducted a pilot randomized controlled trial among patients discharged from internal medicine units of an academic health center between June 2019 and March 2020. Block randomization was used to randomize patients to intervention (received access to SAM at discharge) or control (received usual care). Patients were followed for 30 days post-discharge, during which app use was recorded. Pharmacy claims data were used to measure adherence to medication changes made at discharge, and physician billing data were used to identify emergency department visits and hospital readmissions during follow-up. RESULTS: Forty-nine patients were eligible for inclusion in the study at hospital discharge (23 intervention, 26 control). In the 30 days of post-discharge, 15 (65.2%) intervention patients used the SAM app. During this period, intervention patients adhered to a larger proportion of medication changes (83.7%) than control patients (77.8%), including newly prescribed medications (72.7% vs 61.7%) and dose changes (90.9% vs 81.8%). A smaller proportion of intervention patients (8.7%) were readmitted to hospital during follow-up than control patients (15.4%). CONCLUSION: The high uptake of SAM among intervention patients supports the feasibility of a larger trial. Results also suggest that SAM has the potential to enhance adherence to medication changes and reduce the risk of downstream adverse events. This hypothesis needs to be tested in a larger trial. TRIAL REGISTRATION: Clinicaltrials.gov, registration number NCT04676165.

Smart about medications (SAM): a digital solution to enhance medication management following hospital discharge.

OBJECTIVE: To outline the development of a software solution to improve medication management after hospital discharge, including its design, data sources, intrinsic features, and to evaluate the usability and the perception of use by end-users. MATERIALS AND METHODS: Patients were directly involved in the development using a User Center Design (UCD) approach. We conducted usability interviews prior to hospital discharge, before a user started using the application. A technology acceptance questionnaire was administered to evaluate user self-perception after 2 weeks of use. RESULTS: The following features were developed; pill identification, patient-friendly drug information leaflet, side effect checker, and interaction checker, adherence monitoring and alerts, weekly medication schedule, daily pill reminders, messaging service, and patient medication reviews. The usability interviews show a 98.3% total success rate for all features, severity (on a scale of 1-4) 1.4 (SD 0.79). Regarding the self-perception of use (1-7 agreement scale) the 3 highest-rated domains were: (1) perceived ease of use 5.65 (SD 2.02), (2) output quality 5.44 (SD 1.65), and (3) perceived usefulness 5.29 (SD 2.11). DISCUSSION: Many medication management apps solutions have been created and most of them have not been properly evaluated. SAM (Smart About Medications) includes the user perspective, integration between a province drug database and the pharmacist workflow in real time. Its features are not limited to maintaining a medication list through manual entry. CONCLUSION: We can conclude after evaluation that the application is usable and has been self-perceived as easy to use by end-users. Future studies are required to assess the health benefits associated with its use.

Association of Opioid Consumption Profiles After Hospitalization With Risk of Adverse Health Care Events.

Importance: Although better pain management has guided policies for opioid use over the past few decades, evidence is limited regarding how patterns of use are associated with the risk of potentially avoidable opioid-related adverse events. Objective: To estimate the risk of harms associated with opioid dose and duration of use, and to ascertain whether the risk is modified by treatment indication and age. Design, Setting, and Participants: This ad hoc cohort study followed up patients who were enrolled in a cluster randomized trial of medication reconciliation between October 1, 2014, and November 30, 2016, 12 months after they were discharged from the McGill University Health Centre in Montreal, Quebec, Canada. To be eligible for this study, patients needed to have filled at least 1 opioid prescription 3 months after discharge. Patients with a history of using methadone or buprenorphine were excluded. Data analyses were performed between February 1, 2019, and February 28, 2020. Exposures: Time-varying measures of opioid use included current use, daily morphine milligram equivalent (MME) dose, cumulative and continuous use duration, and type of ingredients in prescription opioids used. Hospitalization records, dispensed prescriptions records, and postdischarge interviews were used to evaluate adherence to the opioid prescriptions after discharge. Main Outcomes and Measures: Opioid-related emergency department visits, hospital readmissions, or all-cause death. Outcomes were ascertained using provincial medical services claims and hospitalization databases. Results: Of 3486 participants in the cluster randomized trial (mean [SD] age of 69.6 [14.9] years; 2010 men [57.7%]), 1511 patients were included in this ad hoc cohort study. Among those with at least 1 opioid dispensation, 241 patients (15.9%) experienced an opioid-related emergency department visit, hospital readmission, or death. Results from marginal structural Cox proportional hazards regression models showed more than a 2-fold increase in the risk of opioid-related adverse events associated with a cumulative use duration of more than 90 days (adjusted hazard ratio, 2.56; 95% CI, 1.25-5.27) compared with 1 to 30 days. A 3-fold risk increase was found with a mean daily dose higher than 90 MME (adjusted hazard ratio, 3.51; 95% CI, 1.58-7.82) compared with 90 MME or lower. Conclusions and Relevance: This study found an association between risk of adverse health care events and higher opioid doses and longer treatment duration. This finding can inform policies for limiting opioid duration and dose to attenuate the risk of avoidable morbidity.