Evaluation of the Potentially Inappropriate Cardiovascular Medication Prescription in Elderly: A Nationwide Study in Turkey.

BACKGROUND: Elderly comprises a specific group due to possible alterations in the effects of drugs and comorbidities. We aimed to identify for the first time the characteristics and rates regarding the inappropriate prescriptions of cardiovascular system medications in the geriatric age group in Turkey. METHODS: Cardiovascular system medications prescribed electronically by family physicians to patients aged 65 and over, in the years 2015 and 2016, were obtained through Prescription Information System administered by the Ministry of Health. Evaluation of potentially inappropriate prescriptions was done according to the 'Beers Criteria 2015 update.' Prescription rates for each group were evaluated under sub-breakdowns for the specialty of family physicians, gender, age groups, and 'Nomenclature of Territorial Units for Statistics' regions. RESULTS: Approximately 65 million prescriptions were evaluated. The rate of potentially inappropriate cardiovascular medication prescribing was 0.33%. This raised to 11.56% when 'drugs to be used with caution' were included. It was observed that potentially inappropriate drugs have been prescribed more by specialist family physicians. The most frequently prescribed potentially inappropriate drugs were doxazosin in the diagnosis of hypertension and methyldopa regardless of indication. Diclofenac-warfarin was the most commonly prescribed concomitant drug use in the potentially clinically important drug-drug interactions group. The rate of potentially inappropriate drug prescribing was higher in males and in aged 80 years and older. CONCLUSIONS: This pharmacoepidemiological study draws attention to potentially inappropriate cardiovascular system drugs prescribed in primary care settings to the elderly. The rate of potentially inappropriate cardiovascular system drug prescribed was found to be very low in Turkey.

Assessment of quarter billion primary care prescriptions from a nationwide antimicrobial stewardship program.

We described the significance of systematic monitoring nationwide antimicrobial stewardship programs (ASPs) in primary care. All the prescriptions given by family physicians were recorded in Prescription Information System established by the Turkish Medicines and Medical Devices Agency of Ministry of Health. We calculated, for each prescription, "antibiotics amount" as number of boxes times number of items per box for medicines that belong to antiinfectives for systemic use (i.e., J01 block in the Anatomical Therapeutic Chemical Classification System). We compared the antibiotics amount before (2015) and after (2016) the extensive training programs for the family physicians. We included 266,389,209 prescriptions from state-operated family healthcare units (FHUs) between January 1, 2015 and December 31, 2016. These prescriptions were given by 26,313 individual family physicians in 22,518 FHUs for 50,713,181 individual patients. At least one antimicrobial was given in 37,024,232 (28.31%) prescriptions in 2015 and 36,154,684 (26.66%) prescriptions in 2016. The most common diagnosis was "acute upper respiratory infections (AURI)" (i.e., J00-J06 block in the 10th revision of the International Statistical Classification of Diseases and Related Health Problems) with 28.05%. The average antibiotics amount over prescriptions with AURI decreased in 79 out of 81 provinces, and overall rate of decrease in average antibiotics amount was 8.33%, where 28 and 53 provinces experienced decreases (range is between 28.63% and -3.05%) above and below this value, respectively. In the most successful province, the highest decrease in average amount of "other beta-lactam antibacterials" per prescription for AURI was 49.63% in January. Computational analyses on a big data set collected from a nationwide healthcare system brought a significant contribution in improving ASPs.

Evaluation of more than one billion outpatient prescriptions and eight-year trend showing a remarkable reduction in antibiotic prescription in Turkey: A success model of governmental interventions at national level.

PURPOSE: To present the antibiotic prescription trend between 2011-2018 at primary healthcare in Turkey in order to evaluate the effects of interventions at national level for providing rational prescription of antibiotics. METHODS: Electronic prescription data of the family physicians collected from January 1, 2011 to December 31, 2018 in 81 provinces of Turkey were recorded through the Prescription Information System and screened for the antimicrobial drugs. The interventions to promote rational antibiotic use during 2011-2018 in Turkey includes reminding the legislation to stop access of antibiotics without prescription, monitoring of antibiotic prescription behaviors of primary healthcare physicians, and education of healthcare workers and the public on the appropriate use of antibiotics. RESULTS: A total of 1 054 261 396 prescriptions for outpatients of all age groups were recorded during this period. Of the prescriptions written by family physcians, 34.94% were containing at least one antibiotic in 2011, which declined to 24.55% in 2018. Antibiotics constituted 13.99% of all the items in prescriptions in 2011 and 10.47% in 2018. Percentage of total antibiotic expenditure to the total drug expanditure decreased from 14.14% to 4.12% during 2011-2018. The most commonly prescribed antibiotics were amoxicillin and enzyme inhibitor combination, cefdinir, and cefuroxime during 2011-2018, with an increasing trend for prescription of first-line antibiotic, amoxicillin, in recent years. CONCLUSIONS: Governmental interventions at national level have contributed to reducing antibiotic prescription and increasing preference of first-line antibiotics at primary healthcare level in Turkey over a course of 8 years. Turkey's model of governmental interventions may set an example for other countries with high consumption of antibiotics, and contribute to the actions against antimicrobial resistance worldwide.

Generic drug prescribing in primary care: A nationwide analysis.

INTRODUCTION: Dissemination of generic drug (GD) use could provide significant savings on drug expenditures and contribute to the long-term sustainability of healthcare. We aimed to exhibit the nationwide trend of GD use in primary care and investigate potentially relevant drug and patient factors. METHODS: Prescriptions written by primary care physicians in Turkey between 2013 and 2016 were analysed using the National Prescribing Information System. We determined the ratio of GD prescriptions with all prescriptions in terms of quantity and cost. In addition, we analysed the use of GD in terms of demographic characteristics of the patients, the most frequently prescribed preparations and frequent indications. RESULTS: In the 4-year period, we identified 518,335,821 prescriptions, those with at least one GD constituted 54.0% (n = 786,972,813) with a total cost-share of 36.9%-37.8%. GD use was the highest in 2016 (54.4%) and lowest in 2014 (53.6%). GD prescribing was higher in women than men every year (P < .001 for each), with the highest difference in 2016 as 54.7% vs 54.0%. GD utilisation decreased as the age group increased, which was 64.0%-64.5% in <18-year-old group and 46.0%-47.1% in ≥75-year-old group. Among the top ten encountered indications, the highest and lowest GD prescribing was detected in acute tonsillitis (68.1%) and hypertension (33.9%). Metformin had the highest percentage of GD prescribing (96.1%-97.7%), whereas esomeprazole showed the lowest GD prescribing (4.5%-14.8%) among the most frequently used preparations in primary care. CONCLUSION: This study shows a modest upward trend of GD utilisation in primary care, though its share appears to be lower than expected. GD use revealed a consistent reduction towards older age groups. GDs were more likely to be prescribed for acute conditions, particularly infectious diseases.

Knowledge, opinions and attitudes of primary care physicians about generic drugs: a cross-sectional study.

BACKGROUND: Generic drug (GD) use is affected by many factors, including physicians' approach. OBJECTIVE: This study aimed to investigate the knowledge, opinions and attitudes of primary care physicians (PCPs) about GDs and potentially associated factors. METHODS: An adequately representative sample (n = 354) of PCPs was determined via stratified and simple random sample selection method in this descriptive, cross-sectional study. The research data were collected through a face-to-face 40-item survey, where the knowledge, opinions and attitudes about GDs were questioned. The prescribing percentage of GDs overall was also examined. RESULTS: The survey was completed by 305 PCPs (mean age: 49.2 ± 7.9 years; 57.4% male). The rate of correct responses about GDs was 67.6% for basic knowledge and 46.6% for the development process. The percentages of PCPs who declared that GDs were 'less efficacious', 'of lower quality' and 'less safe' than original drugs were 65.2%, 53.4% and 35.4%, respectively. More than half (60.3%) of the PCPs declared not to pay attention to whether the drug is generic while prescribing. It was observed that, as the knowledge level of the physicians increased, negative opinions and prescribing attitudes regarding the effectiveness, quality and safety of the GDs decreased. The rate of GD prescribing (51.6%) in Izmir was lower than the rest of the country (54.6%; P < 0.001). CONCLUSION: This study shows that the knowledge of PCPs about GDs is generally inadequate, which reflects negatively on their opinions and attitudes regarding the use of GDs. Educational activities can help establish awareness that GDs can be used without doubt of their effectiveness, quality and safety.

Off-label drug use in pediatric patients: a comparative analysis with nationwide routine prescription data.

BACKGROUND: Children constitute a special population for off-label drug use (OLDU), yet limited drug-focused data exist regarding pediatric OLDU in clinical practice. This study aimed to investigate pediatric OLDU practice and compare it with pediatric drug utilization patterns of routine prescribing data. METHODS: This cross-sectional study examined all approved pediatric OLDU applications, compared with electronic prescription data on national Prescription Information System of Turkish Medicines and Medical Devices Agency in 2015. OLDU applications and prescriptions were analyzed for demographic characteristics, healthcare/socioeconomic indices as well as details of drugs and diagnoses. RESULTS: We found 7,896 OLDU applications and 7,029,512 prescriptions for the pediatric population in 2015. OLDU applications and prescriptions were mostly practiced for `2-11-year-old` children (52.7% vs. 63.4%, respectively; p < 0.01). OLDU applications and prescriptions were detected to have a positive correlation with socio-economic development index (r = 0.45, p < 0.0001 and r: 0.40, p = 0.0002; respectively) and the physician density (r = 0.66, p < 0.0001 and r: 0.43, p < 0.0001; respectively). In addition, OLDU was also positively correlated with the number of hospital beds per province (r = 0.39, p = 0.0003). Antineoplastic/immunomodulating agents were the most commonly applied drug category in OLDU (47.0%), compared with respiratory system drugs (36.6%) in routine prescribing. Eculizumab (6.5%), mycophenolate (5.6%), and canakinumab (4.4%) were the top drugs used as off-label. OLDU applications and routine prescription data revealed the most frequent diagnosis as `I27-other pulmonary heart diseases` (7.4%) and `J06-acute upper respiratory infections` (12.6%), respectively. CONCLUSIONS: This is the first nationwide study to show indication- and drug-centered aspects of pediatric OLDU and prescribing practice. Though OLDU applications is overall consistent with routine clinical practice in terms of demographics and institutional capacity, substantial variations exist regarding main drug classes and diseases. Our findings are expected to shed light on interventions focused on improving `indicated` pediatric use of drugs currently applied as off-label.

Relative risk of tuberculosis in patients with rheumatic diseases managed with anti-tumour necrosis factor-alpha therapy: A nationwide cohort study.

WHAT IS KNOWN AND OBJECTIVE: Anti-tumour necrosis factor-alpha (anti-TNF-α) therapy is known to raise the risk of granulomatous infections, leading to development of risk management strategies at national or global level. This study aimed to determine the relative risk (RR) of tuberculosis (TB) due to anti-TNF-α usage in patients with rheumatologic diseases (RDs) in a nationwide basis. METHOD: This retrospective cohort study included patients with rheumatoid arthritis (RA), ankylosing spondylitis, juvenile idiopathic arthritis or psoriatic arthritis (PsA) that treated with or without anti-TNF-α agents, as registered in the national prescription information system between years 2013 and 2015. Two-year RR of TB after anti-TNF-α therapy initiation was calculated in this RD population, including main subgroups. RESULTS AND DISCUSSION: The study cohort included 413 500 RD patients, where anti-TNF-α(+) arm (n = 2117) had mean age of 41.9 ± 13.4 years and male distribution of 54.3%. Four patients among anti-TNF-α users developed TB compared to 128 patients in anti-TNF-α-naïve group (189 vs 31 cases per 100 000 patients, respectively), yielding a 2-year RR of 6.07 (95% CI, 2.25-16.42) with an attributable risk of 0.16%. These RRs (95% CI), which were particularly pronounced, were 5.39 (1.69-7.17) in men, 6.12 (2.26-16.55) in adults, and 5.70 (1.41-23.08) in RA and 13.46 (1.58-114.40) in PsA patients. There was no difference between the anti-TNF-α users who developed and undeveloped TB regarding drug utilization characteristics, except significantly less immunosuppressive drug exposure in TB patients. WHAT IS NEW AND CONCLUSION: This study is the first prescription-based nationwide study to suggest an elevated RR of TB in a comparably younger population with a broad spectrum of RDs managed with any approved anti-TNF-α drug in Turkey.

Antimicrobial Medicines Consumption in Eastern Europeand Central Asia - An Updated Cross-National Study and Assessment of QuantitativeMetrics for Policy Action.

Introduction: Surveillance of antimicrobial medicines consumption is central to improving their use and reducing resistance rates. There are few published data on antibiotic consumption in Eastern Europe and Central Asia. To address this, 18 non-European Union (EU) countries and territories contribute to the WHO Regional Office for Europe (WHO Europe) Antimicrobial Medicines Consumption (AMC) Network. Objectives: (i) Analyze 2015 consumption of J01 class antibacterials for systemic use from 16 AMC Network members; (ii) compare results with 2011 data and 2015 ESAC-Net estimates; (iii) assess consumption against suggested indicators; (iv) evaluate the impact of planned changes to defined daily doses (DDDs) in 2019 for some commonly used antibiotics; and (v) consider the utility of quantitative metrics of consumption for policy action. Methods: Analysis methods are similar to ESAC-Net for EU countries. The Anatomical Therapeutic Chemical (ATC) classification and DDD methodology were used to calculate total consumption (DDD/1000 inhabitants/day [DID]), relative use measures (percentages), extent of use of WHO Watch and Reserve group antibiotics and impact of DDD changes. Findings: Total J01 consumption in 2015 ranged 8.0-41.5 DID (mean 21.2 DID), generally lower than in 2011 (6.4-42.3 DID, mean 23.6 DID). Beta-lactam penicillins, cephalosporins, and quinolones represented 16.2-56.6, 9.4-28.8, and 7.5-24.6% of total J01 consumption, respectively. Third-generation cephalosporins comprised up to 90% of total cephalosporin consumption in some countries. Consumption of WHO Reserve antibiotics was very low; Watch antibiotics comprised 17.3-49.5% of total consumption (mean 30.9%). Variability was similar to 2015 ESAC-Net data (11.7-38.3 DID; mean 22.6 DID). DDD changes in 2019 impact both total and relative consumption estimates: total DIDs reduced on average by 12.0% (7.3-35.5 DID), mostly due to reduced total DDDs for commonly used penicillins; impact on rankings and relative use estimates were modest. Discussion: Quantitative metrics of antibiotic consumption have value. Improvements over time reflect national activities, however, changes in total volumes may conceal shifts to less desirable choices. Relative use measures targeting antibiotics of concern may be more informative. Some, including WHO Watch and Reserve classifications, lend themselves to prescribing targets supported by guidelines and treatment protocols.

Rational use of medicine in dentistry: do dentists prescribe antibiotics in appropriate indications?

PURPOSE: There are concerns regarding appropriate use of antibiotics in dentistry practice. Data on dental antibiotic prescribing patterns by dentists is relatively limited. This nationwide study aimed to examine dentists' antibiotic prescriptions in a diagnosis-based manner in Turkey. METHODS: This retrospective study on utilization of systemic antibiotics for dental problems was based on the national health data of the dentists obtained from Prescription Information System between January 2013 and August 2015. Only those prescriptions containing single diagnosis and at least one systemic antibiotic were included in the study. Antibiotic prescribing was compared by diagnoses and expertise of dentists. RESULTS: A total of 9,293,410 antibiotics were detected in 9,214,956 prescriptions that contained "single diagnosis and at least one antibiotic." The number of antibiotics per prescription was 1.01. "Periapical abscess without sinus" (28.1%), "dental examination" (20.7%), and "dental caries" (16.2%) were the three most common indications in which antibiotics were prescribed by dentists. While only 3.4% of antibiotics were prescribed upon the single and appropriate "cellulitis and abscess of mouth" diagnosis, the remaining 96.6% was prescribed for irrational/uncertain indications. Consistent in all diagnoses, "amoxicillin + enzyme inhibitor" (58.6%) was the mainly prescribed antibiotic. Analysis of the most preferred "amoxicillin + enzyme inhibitor" prescriptions by expertise of dentists showed significantly much higher prescription rates among Group A specialists and Group B specialists (67.0 and 67.8%, respectively) than those in unidentified dental practitioners (58.2%, p < 0.0001). CONCLUSIONS: This study showed that dentists prescribed antibiotics in an arbitrary and mostly unnecessary manner. In general, their antibiotic choices for examined diagnoses could be regarded as irrational. These results indicate the urgent need for improvement of rational antibiotic prescribing habits of dentists.

Variation of antibiotic consumption and its correlated factors in Turkey.

BACKGROUND: Presentation of antibiotic utilization data by reliable and comparable analyses constitutes an important way of ensuring rational use of antibiotics. This study aimed to evaluate antibiotic consumption (AC) of Turkey by each city/region and to investigate any association of such consumption with socio-economic factors. METHOD: For 81 provinces and 12 regions in Turkey, AC data from IMS (Intercontinental Medical Statistics) in 2011 was analyzed in accordance with "ATC/DDD, DID" (Anatomical Therapeutic Chemical/Defined Daily Doses, DID = DDD/1000 inhabitants/day) methodology supported by World Health Organization. Association between provincial AC rates and socio-economic development index (SEDI)-2011 and between regional AC rates and some health indicators were analyzed. RESULTS: While provincial AC data of Turkey was detected to vary between 17.2 and 55.2 DID (Hakkari and Usak, respectively), regional AC ranged from 28.4 to 48.9 DID (Middle Eastern Anatolia and Western Anatolia, respectively). Mostly consumed antibiotic group among all regions were beta-lactamase inhibitor/penicillin combinations (range: 9.9-17.6 DID). SEDI and AC of each city showed positive correlation (rho = 0.683, p < 0.001). While regional AC was positively associated with percentage of 14-year-old population (p = 0.002) and pharmacist density (p < 0.001), it was negatively associated with physician density (p = 0.038). CONCLUSION: It is remarkable that Turkey, at both provincial and regional levels, exhibits important variations in AC, which is proportional to socio-economic status. Besides, the consumption is found to be closely associated with recognized critical factors of access to healthcare. These findings are expected to provide important insights to the activities promoting rational use of antibiotics.