Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study.

OBJECTIVE: To assess the appropriateness of outpatient antibiotic prescribing for privately insured children and non-elderly adults in the US using a comprehensive classification scheme of diagnosis codes in ICD-10-CM (international classification of diseases-clinical modification, 10th revision), which replaced ICD-9-CM in the US on 1 October 2015. DESIGN: Cross sectional study. SETTING: MarketScan Commercial Claims and Encounters database, 2016. PARTICIPANTS: 19.2 million enrollees aged 0-64 years. MAIN OUTCOME MEASURES: A classification scheme was developed that determined whether each of the 91 738 ICD-10-CM diagnosis codes "always," "sometimes," or "never" justified antibiotics. For each antibiotic prescription fill, this scheme was used to classify all diagnosis codes in claims during a look back period that began three days before antibiotic prescription fills and ended on the day fills occurred. The main outcome was the proportion of fills in each of four mutually exclusive categories: "appropriate" (associated with at least one "always" code during the look back period, "potentially appropriate" (associated with at least one "sometimes" but no "always" codes), "inappropriate" (associated only with "never" codes), and "not associated with a recent diagnosis code" (no codes during the look back period). RESULTS: The cohort (n=19 203 264) comprised 14 571 944 (75.9%) adult and 9 935 791 (51.7%) female enrollees. Among 15 455 834 outpatient antibiotic prescription fills by the cohort, the most common antibiotics were azithromycin (2 931 242, 19.0%), amoxicillin (2 818 939, 18.2%), and amoxicillin-clavulanate (1 784 921, 11.6%). Among these 15 455 834 fills, 1 973 873 (12.8%) were appropriate, 5 487 003 (35.5%) were potentially appropriate, 3 592 183 (23.2%) were inappropriate, and 4 402 775 (28.5%) were not associated with a recent diagnosis code. Among the 3 592 183 inappropriate fills, 2 541 125 (70.7%) were written in office based settings, 222 804 (6.2%) in urgent care centers, and 168 396 (4.7%) in emergency departments. In 2016, 2 697 918 (14.1%) of the 19 203 264 enrollees filled at least one inappropriate antibiotic prescription, including 490 475 out of 4 631 320 children (10.6%) and 2 207 173 out of 14 571 944 adults (15.2%). CONCLUSIONS: Among all outpatient antibiotic prescription fills by 19 203 264 privately insured US children and non-elderly adults in 2016, 23.2% were inappropriate, 35.5% were potentially appropriate, and 28.5% were not associated with a recent diagnosis code. Approximately 1 in 7 enrollees filled at least one inappropriate antibiotic prescription in 2016. The classification scheme could facilitate future efforts to comprehensively measure outpatient antibiotic appropriateness in the US, and it could be adapted for use in other countries that use ICD-10 codes.

[Errors in prescriptions and their preparation at the outpatient pharmacy of a regional hospital]. / Errores en las recetas médicas y en la preparación de estas en farmacia de pacientes ambulatorios: El caso del Hospital de Nueva Imperial.

BACKGROUND: Adverse effects of medications are an important cause of morbidity and hospital admissions. Errors in prescription or preparation of medications by pharmacy personnel are a factor that may influence these occurrence of the adverse effects Aim: To assess the frequency and type of errors in prescriptions and in their preparation at the pharmacy unit of a regional public hospital. MATERIAL AND METHODS: Prescriptions received by ambulatory patients and those being discharged from the hospital, were reviewed using a 12-item checklist. The preparation of such prescriptions at the pharmacy unit was also reviewed using a seven item checklist. RESULTS: Seventy two percent of prescriptions had at least one error. The most common mistake was the impossibility of determining the concentration of the prescribed drug. Prescriptions for patients being discharged from the hospital had the higher number of errors. When a prescription had more than two drugs, the risk of error increased 2.4 times. Twenty four percent of prescription preparations had at least one error. The most common mistake was the labeling of drugs with incomplete medical indications. When a preparation included more than three drugs, the risk of preparation error increased 1.8 times. CONCLUSIONS: Prescription and preparation of medication delivered to patients had frequent errors. The most important risk factor for errors was the number of drugs prescribed.

Errores en las recetas médicas y en la preparación de estas en farmacia de pacientes ambulatorios: El caso del Hospital de Nueva Imperial / Errors in prescriptions and their preparation at the outpatient pharmacy of a regional hospital

Background: Adverse effects of medications are an important cause of morbidity and hospital admissions. Errors in prescription or preparation of medications by pharmacy personnel are a factor that may influence these occurrence of the adverse effects Aim: To assess the frequency and type of errors in prescriptions and in their preparation at the pharmacy unit of a regional public hospital. Material and Methods: Prescriptions received by ambulatory patients and those being discharged from the hospital, were reviewed using a 12-item checklist. The preparation of such prescriptions at the pharmacy unit was also reviewed using a seven item checklist. Results: Seventy two percent of prescriptions had at least one error. The most common mistake was the impossibility of determining the concentration of the prescribed drug. Prescriptions for patients being discharged from the hospital had the higher number of errors. When a prescription had more than two drugs, the risk of error increased 2.4 times. Twenty four percent of prescription preparations had at least one error. The most common mistake was the labeling of drugs with incomplete medical indications. When a preparation included more than three drugs, the risk of preparation error increased 1.8 times. Conclusions: Prescription and preparation of medication delivered to patients had frequent errors. The most important risk factor for errors was the number of drugs prescribed.

Uso de anticatarrales en menores de 14 años en consultas de Atención Primaria / Use of cold and cough medications prescribed in Primary Care clinics for children less than 14 years

OBJETIVO: Conocer el perfil de prescripción de anticatarrales en las consultas de Pediatría de Atención Primaria en el Área V del Servicio de Salud del Principado de Asturias y valorar su idoneidad. Material y métodos; Estudio transversal, descriptivo y retrospectivo. Se analizaron las prescripciones para el tratamiento de los procesos respiratorios en 6 consultas de Pediatría de Atención Primaria en el Área Sanitaria V del Servicio de Salud del Principado de Asturias en el año 2011. Se valoraron la idoneidad de los tratamientos prescritos mediante las fichas técnicas de los fármacos y las indicaciones clínicas según el diagnóstico, siguiendo las recomendaciones de guías clínicas, protocolos o en su defecto la bibliografía disponible más actual. RESULTADOS: Se analizaron 424 anticatarrales: 249 antitusígenos, 155 mucolíticos y 20 clasificados en otros. La media de edad de los pacientes es de 5 años. Un 85,1% de las prescripciones se consideran inadecuadas. El 11,6% de ellos fueron prescritos fuera de ficha técnica. Se consideraron inadecuados el 82,8% de los asociados al diagnóstico R74 y el 73% al R05. Todos los fármacos de los menores de 6 años se consideraron inadecuados. El 99,4% de los mucolíticos/otros y el 75,1% de los antitusígenos se consideraron inadecuados. CONCLUSIONES: Se observa un alto porcentaje de prescripción de fármacos anticatarrales en menores de 14 años en nuestro medio, encontrándose un 85% de las prescripciones inadecuadas. Los niños deberían recibir solo medicamentos con una relación beneficio-riesgo favorable; para ello es necesario mejorar la información sobre el uso pediátrico y promover acciones formativas dirigidas a los padres y a los profesionales sanitarios

OBJECTIVE:To evaluate cold and cough medications and their suitability in children in Primary Health Care in Area V of the Asturian Health Service. MATERIAL AND METHODS: A cross-sectional, descriptive and retrospective study was conducted in which an analysis was performed of the respiratory diseases and the prescriptions of 6 Primary Health Care paediatricians who worked in Area V of the Asturian Health Service in 2011. An evaluation was made on the suitability of these medications. An analysis was also made of the drug datasheet and clinical recommendations (clinical guidelines, protocols or reports). RESULTS: A total of 424 cold and cough drugs: 249 antitussives, 155 mucolytics, and 20 'others' were analyzed. The mean age was 5 years old. There was a total of 85.1% unsuitable prescriptions. Off-label drugs were used in 11.6%. The prescribing was considered unsuitable in 82.8% of prescriptions associated with R74, and 73% of R05. All of the prescription drugs in children under 6 years old were unsuitable. Mucolytics/'others' were not suitable in 99.4%, nor antitussives in 75.1%. CONCLUSIONS: There is a high level of cold and cough drugs being prescribed in children, with 85% of these being unsuitable. Children should only receive drugs with a good risk and benefit ratio. Pediatricians should try to improve the information about pediatric drug use and spread this information to parents, doctors and nurses

Prescripción inapropiada de medicamentos en el paciente anciano y criterios para la mejora / Inappropriate drug therapy prescription in the elderly and criteria for improvement

No disponible

Adaptación española de los criterios Beers / Spanish adaptation of Beers criteria

Fundamento: Los Criterios de Beers, de procedencia estadounidense y actualizados en 2012, son una herramienta asesora en la prescripción en pacientes ancianos. Dadas las diferencias entre nuestro catálogo de medicamentos y el norteamericano, el objetivo del estudio fue obtener una adaptación española de dichos criterios. Material y método: La comparación de los Criterios de Beers con el catálogo español de medicamentos de 2012 permitió detectar los principios activos, presentes en los criterios, no comercializados en España. Además se buscaron medicamentos comercializados en España similares a los presentes en los criterios. Se asume que los medicamentos comercializados en Estados Unidos ya fueron evaluados en la elaboración de los Beers. Así, sobre los medicamentos similares, disponibles en España y no en Estados Unidos, se realizó una evaluación de acuerdo a 3 tipos de fuentes: los artículos presentados por la American Geriatrics Society para avalar la evidencia de los Beers; las fichas técnicas y prospectos; y los criterios europeos STOPP/START, NORGEP y PRISCUS. Resultados: De los 199 principios activos presentes en los criterios Beers, se detectaron 54 (27,0%) no comercializados en España. Además se incorporaron 50 principios activos. Entre el grupo de los "Criterios Directos" se detectaron 47 (34,3%) no disponibles y 40 posibles inclusiones, y en el grupo de los "Criterios Dependientes de Enfermedad" 33 (21,3%) y 48 respectivamente. Conclusiones: Se ha detectado una importante presencia de medicamentos no comercializados en España, así como un elevado número de principios activos no incluidos en la versión original. Este trabajo facilita una adaptación de los Criterios de Beers a los profesionales de nuestro entorno (AU)

Background: The Beers criteria, which were drawn up in the USA and updated in 2012, were developed to detect potentially inappropriate prescriptions in older adults. Since there are significant differences between the Spanish and North American drug catalogues, our aim was to produce a Spanish adaptation of the criteria. Patients and methods: A comparison of the drugs mentioned in the Beers list with the 2012 Spanish Drugs Catalogue identified those active substances that were on the list in the USA but not commercially available in Spain. We also searched for Spanish drugs that were similar to those listed in the criteria. If these drugs were available in the USA, it was assumed that they had been evaluated by the Beers authors. On the other hand, if similar active substances were not available in the USA, they were evaluated by reference to three information sources: articles reviewed by the American Geriatrics Society in support of the Beers criteria, the product characteristics and information leaflets, and the European STOPP/START, NORGEP and PRISCUS criteria. Results: Of the 199 active substances listed in the Beers criteria, 54 (27.0%) were not commercially available in Spain, but 50 new active substances could be included. These figures differed when "Direct Criteria" were considered: 47 (34.3%) active substances were not commercially available in Spain and 40 new ones could be included in the Beers list. As regards "Disease Dependent Criteria" the figures were 33 (21.3%) and 48, respectively. Conclusions: A great number of drugs on the Beers list were not commercially available in Spain, and we added many active substances not included in the original version. This study is thus an adaptation of the Beers Criteria to the Spanish health care scenario (AU)

Impact of pharmacy-led medication reconciliation on medication errors during transition in the hospital setting / Impacto de la reconciliación de medicación por el servicio de farmacia en los errores de medicación durante la transición en el hospital

Objective: To assess if the pharmacy department should be more involved in the medication reconciliation process to assist in the reduction of medication errors that occur during transition of care points in the hospital setting. Methods: This was an observational prospective cohort study at a 531-bed hospital in Pensacola, FL from June 1, 2014 to August 31, 2014. Patients were included in the study if they had health insurance and were taking five or more medications. Patients with congestive heart failure were excluded from the study. Student pharmacists collected and evaluated medication histories obtained from patients’ community pharmacies, and directed patient interviews. Primary care providers were only contacted on an as needed basis. The information collected was presented to the clinical pharmacist, where interventions were made utilizing clinical judgment. Results: During the three month study, 1045 home medications were reviewed by student pharmacist. Of these, 290 discrepancies were discovered (27.8%; p=0.02). The most common medication discrepancy found was dose optimization (45.5%). The remaining discrepancies included: added therapy (27.6%), other (15.2%), and discontinued therapy (11.7%). Pharmacists made 143 interventions based on clinical judgment (49.3%; p=0.04). Conclusion: Involvement of pharmacy personnel during the medication reconciliation process can be an essential component in reducing medical errors. With the addition of the pharmacy department during the admission process, accuracy, cost savings, and patient safety across all phases and transition points of care were achieved (AU)

Objetivo: Evaluar si un servicio de farmacia debería estar más involucrado en el proceso de reconciliación de la medicación para ayudar a reducir los errores de medicación que ocurren durante la transición de servicio en un hospital. Métodos: Este fue un estudio de cohorte prospectiva observacional en un hospital de 531 camas en Pensacola, FL desde 1 de junio a 31 de agosto de 2014. Se incluyó a los pacientes si tenían seguro de salud y estaban tomando 5 o más medicamentos. Los pacientes con fallo cardiaco congestivo fueron excluidos del estudio. Los estudiantes de farmacia recogieron y evaluaron las historais de medicación obtenidas de las farmacias comunitarias de los pacientes y realizaron entrevistas a los pacientes. Solo se contactaba a los médicos de atención primaria si era necesario. La información recogida era presentada al farmacéutico clínico, que hacía intervenciones si lo consideraba adecuado. Resultados: Durante los 3 meses de estudio, se revisaron 1045 medicaciones ambulatorias. De ellas, se descubrieron 290 discrepancias (27,8%; p=0,02). La discrepancia más común fue la optimización de dosis (45,5%). Las restantes discrepancias incluían: tratamiento añadido (27.6%), otras (15.2%), y tratamiento discontinuado (11.7%). Los farmacéuticos realizaron 143 intervenciones basadas en su juicio clínico (49.3%; p=0.04). Conclusión: La participación de l personal de farmacia durante el proceso de reconciliación de la medicación puede ser un componente esencial para reducir errores de medicación. Con la inclusión del servicio de farmacia durante el proceso de ingreso, se consiguió precisión, ahorro de costes y aumento de seguridad del paciente en todas las fases de la transición de servicio (AU)

Evaluation of inappropriate prescribing according to Beers criteria in cardiology and respiratory medicine departments

Objetivo. Conocer la incidencia de prescripciones potencialmente inapropiadas (PPI) de los pacientes mayores de 65 años ingresados en las unidades de neumología y cardiología, así como los fármacos principalmente implicados y su severidad clínica. Métodos. Estudio observacional, prospectivo, de 6 meses de duración. Se revisaron los tratamientos de los pacientes mayores de 65 años ingresados en estas unidades. Se consideraron como PPI las incluidas en la lista de Beers de 2003. Se recogió la unidad clínica, edad, sexo, fármaco inapropiado, dosis y vía de administración. Se calculó la incidencia de PPI (número de PPI/número de pacientes) global y en función la unidad clínica, así como según el sexo, fármaco implicado y severidad clínica. Resultados. Se recogieron datos de 385 pacientes (190 en cardiología y 195 en neumología). Se encontraron 111 PPI (0,29 PPI/paciente). Teniendo en cuenta la unidad de origen, se encontraron 53 PPI en cardiología (0,28 PPI/paciente) y 58 PPI en neumología (0,30 PPI/paciente). El 66,6% (n=74) de las PPI ocurrieron en hombres y el 33,4% (n=37) en mujeres. Los principales fármacos implicados fueron amiodarona (24,3%), digoxina (19,8%), doxazosina (17,1%) y diazepam (16,2%). El 68,5% de las PPI encontradas fueron de severidad alta según los criterios de Beers. Conclusión. La prescripción de medicamentos inapropiados en ancianos es elevada. Esto es importante ya que son una de las causas de aparición de reacciones adversas a medicamentos, las cuales provocan a su vez una parte importante de los ingresos hospitalarios. La inclusión de alertas en el programa de prescripción asistida y la difusión de boletines informativos al respecto en el personal implicado mejoraría la calidad de la asistencia sanitaria y minimizaría los problemas relacionados con la medicación(AU)

Objective. To determine the incidence of potentially inappropriate prescriptions (PPI) for patients older than 65 years admitted to the cardiology and respiratory medicine units, as well as the main drugs involved and their clinical severity. Methods. A prospective, observational study was carried out over a 6 month period. We reviewed the treatment of patients over 65 years old admitted to these units. PPI is considered as those included in the Beers criteria 2003. We recorded clinical unit, age, sex, inappropriate drug, dosage and route of administration. We calculated the overall incidence of PPI (number of PPI/number of patients) and according to the clinical unit, sex, drug involved, and clinical severity. Results. Data were collected from 385 patients (190 in cardiology and 195 respiratory medicine unit). We found 111 PPI (0.29 PPI/patient). If we take into account the clinical unit, there were 53 PPI in cardiology (0.28 PPI/patient) and 58 PPI in respiratory medicine (0.30 PPI/patient). Two-thirds (66.6%, n=74) of the PPI occurred in men and 33.4% (n=37) in women. The main drugs involved were amiodarone (24.3%), digoxin (19.8%), doxazosin (17.1%) and diazepam (16.2%). According to the Beers criteria, 68.5% of those were high severity PPI. Conclusion. The prescription of inappropriate medications in the elderly is high. This is important because they are a cause of adverse reactions, which leads to a significant proportion of hospital admissions. The inclusion of warnings in the program of assisted prescribing and distributing of newsletters about these to the personnel involved, improves the quality of health care and minimises medication-related problems(AU)

Responsabilidad por daños producidos por medicamentos / Responsability due to damages produces by drugs

Un medicamento, desde la fase de ensayos clínicos, hasta que es administrado a un paciente, pasa por diferentes situaciones de riesgo que conviene conocerlas para evitarlas en lo posible, y poderlas controlar. En la fase de ensayos clínicos, el riesgo es claro, los conocimientos del fármaco son muy limitados, por ello la normativa obliga a contratar una importante póliza de responsabilidad por posibles daños. En la fase de fabricación, son frecuentes los lotes defectuosos que escapan al control y suponen un riesgo. En la fase de comercialización (dispensación y administración) es donde se dan el mayor número de daños, puesto que al prescribir el medicamento ante la generalidad de pacientes (distinto del ensayo clínico donde el enfermo es elegido cuidadosamente), es cuando aparecen reacciones adversas desconocidas, etc. que generan responsabilidad para el laboratorio fabricante o comercializador. La ficha técnica de nuevos productos, que deben recibirla todos los sanitarios prescriptores, es la mejor guía para hacer un buen uso del medicamento, puesto que aparece la frecuencia y gravedad de reacciones adversas, las interacciones y cualquier acción que deba tenerse en cuenta. Finalmente, debemos tener en cuenta la farmacovigilancia, o sea, que el prescriptor, en el caso de cualquier sospecha de una reacción adversa o cualquier circunstancia, tiene la obligación de comunicarla a la Consejería, por cualquier medio, del posible evento será tenida en cuenta en el seguimiento del producto (AU)

A drug, from the phase of its clinical trial until the administration to a patient, goes through different situations of risk that we should know in order to avoid and control. In the clinical trial phase, the risk is clear, the familiarity with the drug is limited. This is why the rules oblige to hire a liability policy for possible future damages. In the manufacturing phase, there exists defective batches that escape from the control and involve a risk. In the marketing phase (dispensation and administration) is where there exists the highest number of damages, because when the drug is administred to different kind of patients (different from the clinical trial where the patient is chosen) is when there appears unknown adverse reactions, etc... that generate responsibility for the manufacturer or the marketer laboratory. The technical data sheet of the new product, that must be received by all the medical prescribers is the best guide in order to make a good use of the drug, because it shows the frequency and seriousness of the adverse reactions, the interactions and any other action that should be taken into account. Finally, we should take into account the pharmaco-surveillance, that is to say, the prescriber, under any question of an adverse reaction or any circumstance, has the obligation to inform to the Ministry, of any way, about the possible fact that is going to be taken into account (AU)

Polimedicación e inadecuación farmacológica: ¿dos caras de la misma moneda? / Polymedication and medication inadequacy: two sides of the same token?

Existen diversas fórmulas en la bibliografía para definir los conceptos de polimedicación y adecuación farmacológica. Esta diversidad de criterios hace difícil delimitar con claridad uno y otro fenómeno, lo cual limita su abordaje y estudio. La polimedicación se puede definir atendiendo a criterios cuantitativos o cualitativos. Los primeros son los más utilizados, aunque no parece haber consenso en el límite a partir del cual se podría hablar de polimedicación. Los segundos se basan en la existencia de medicamentos adecuados o no, y no tanto en el número final de éstos. Definiríamos la adecuación terapéutica como el proceso de elección de la terapia del paciente en el que, mediante la indicación, la prescripción, la dispensación, la administración y el seguimiento, el profesional puede conseguir unos resultados apropiados a las condiciones y circunstancias del propio paciente y del conjunto de la comunidad. Así, podríamos considerar como utilización inadecuada de los fármacos la sobremedicación, la inframedicación y el uso inapropiado. Cuanto mayor es número de medicamentos consumidos, mayor es la probabilidad de que haya alguno inadecuado. Por tanto, la polimedicación y la inadecuación farmacológica podrían considerarse las dos caras de la misma moneda (AU)

There are several formulas in the literature to define the concepts of polymedication and medication adjustment. This diversity of criterions makes it difficult to determine clearly what is one and another phenomenon, fact that limits there approach and study. Polymedication can be defined on the basis of quantitative or qualitative criteria. The first are the most used, although there seems to be no consensus on where to draw the limit at which we would be talking about polymedication. Regarding to the latter, they are based on the existence of appropriate or not appropriate medications, rather than on the final number of them. Therapeutic appropriateness would be defined as the process of choice of the patients’ therapy where, by indicating, prescribing, dispensing, administrating and monitoring, the professional is able to achieve results that satisfy the conditions and circumstances of the patient and the whole community. In such a way, we could consider the following as an improper use of the medication: overdose, misuse and inappropriate use. It is known that the greater number of drugs taken, the greater the probability that one of them could be inadequate. Therefore, polymedication and inappropriate pharmacological could be considered both sides of the same token (AU)

Potentially inappropriate medications in the elderly: the PRISCUS list.

BACKGROUND: Certain drugs are classified as potentially inappropriate medications (PIM) for the elderly because they carry an increased risk of adverse drug events in this patient group. PIM lists from other countries are of limited usefulness in Germany because different drugs are on the market in each country and prescribing practices vary as well. Thus, a list of potentially inappropriate medications for the elderly was developed specifically for use in Germany. METHODS: A preliminary PIM list suitable for the German market was created on the basis of a selective literature search and a qualitative analysis of published international PIM lists. The final German PIM list was developed by means of a comprehensive, structured expert survey in two rounds (a so-called Delphi process). RESULTS: 83 drugs in a total of 18 drug classes were rated as potentially inappropriate for elderly patients. For 46 drugs, the experts came to no clear decision after the second Delphi round. For cases in which the administration of a PIM is clinically necessary, the final PRISCUS list contains recommendations for clinical practice, e.g. monitoring of laboratory values and dose adaptation. Therapeutic alternatives are also listed. CONCLUSION: Potentially inappropriate medications carry the risk of causing adverse drug events in the elderly. A drawback of using a Delphi process to generate a PIM list, as was done for the new German list, is that little scientific evidence is currently available for the evaluation of active substances, potential therapeutic alternatives, and indicated monitoring procedures. Thus, the validity and practicability of the PRISCUS list remain to be demonstrated (and the same holds for PIM lists already published in other countries). It should be used as a component of an overall concept for geriatric pharmacotherapy in which polypharmacy and interacting medications are avoided, and doses are regularly re-evaluated.