Antipsychotic Drug Dispensations in Older Adults, Including Continuation After a Fall-Related Hospitalization: Identifying Adherence to Screening Tool of Older Persons' Potentially Inappropriate Prescriptions Criteria Using the Nova Scotia Seniors' Pharmacare Program and Canadian Institute for Health's Discharge Databases.

PURPOSE: Despite well-established concerns regarding adverse drug effects, antipsychotics are frequently prescribed for older adults. Our first objective was to identify trends in antipsychotic dispensations to older Nova Scotians. STOPP (Screening Tool of Older Persons' Potentially Inappropriate Prescriptions) criteria identify antipsychotic use in those with a history of falls as potentially inappropriate. Our second objective was to identify trends, predictors, and adherence with this STOPP criteria by identifying continued antipsychotic dispensations following a fall-related hospitalization. METHODS: A descriptive cross-sectional cohort study of Nova Scotia Seniors' Pharmacare Program (NSSPP) beneficiaries ≥ 66 years with at least one antipsychotic dispensation annually from April 1, 2009 to March 31, 2014 was completed. As well, unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 were linked to fall-related hospitalizations recorded in the Canadian Institute for Health Information Discharge Abstract Database. The relationship of age, sex, fiscal year, days supply and length-of-stay were studied to identify predictors of continued antipsychotic dispensation post-discharge. Descriptive statistics and multivariate logistic analysis were performed. Odds ratios for the association of risk factors and adherence to STOPP criteria were calculated. FINDINGS: We identified that in each year observed, there were 6% of eligible NSSPP beneficiaries that received at least one antipsychotic dispensation. Approximately 70% of antipsychotic dispensations were for second generation agents, primarily quetiapine and risperidone. Of the unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 who survived a fall-related hospitalization over 75% were dispensed an antipsychotic in the 100 days following hospital discharge. Logistic regression showed no statistically significant association between potentially inappropriate therapy and potential predictors in multivariate analysis. IMPLICATIONS: In each year from 2009 to 2014, 6% of Nova Scotia Seniors' Pharmacare beneficiaries were dispensed at least one antipsychotic prescription. Over 75% of the older adults who received an antipsychotic dispensation in the 100 days prior to a fall-related hospitalization, continued the drug class after discharge. This demonstrates that despite the recommendations of quality indicators such as the STOPP criteria, antipsychotics are continued in individuals at a high risk of falling. Future investigations are needed to inform health team, system, and policy interventions to improve concordance with this antipsychotic specific STOPP criterion when appropriate.

Antipsychotic Prescribing Practices in Those with Parkinsonism: Adherence to Guidelines.

Several evidence-informed treatment guidelines recommend against the use of typical antipsychotics in patients with Parkinson's disease; of the atypical antipsychotics, clozapine and quetiapine are preferred. The purpose of this study is to determine the frequency with which potentially inappropriate antipsychotics are dispensed to older adults in Nova Scotia who are on levodopa-containing medications. In this cohort, 59.9% were dispensed a preferred atypical antipsychotic and 12.6% a potentially harmful typical antipsychotic. Our results suggest that potentially inappropriate prescribing practices are common in the neuropsychiatric management of patients with parkinsonism and that there is an opportunity for education and improvement in prescribing practices.

A Cost Analysis of Salbutamol Administration by Metered-Dose Inhalers with Spacers versus Nebulization for Patients with Wheeze in the Pediatric Emergency Department: Evidence from Observational Data in Nova Scotia.

BACKGROUND: Despite evidence demonstrating the advantages of metered-dose inhalers with spacers (MDI-s), nebulization (NEB) remains the primary method of asthma treatment in some pediatric emergency departments (PEDs). There is a perception that delivering salbutamol by MDI-s is more costly than by NEB. This research evaluates the relative costs of MDI-s and NEB using local, hospital-specific, patient-level data. METHODS: Regression models estimated associations between the salbutamol inhalation method and costs, length of stay (LOS) in the PED and hospital, and the probability of admission. Our population was a random sample of 822 patients presenting with wheeze to the PED in 2008/2009. Control variables included age, sex, triage acuity, time of PED visit, other medications, and vitals. Costs were calculated using the prices and quantities of medical resources used per treatment. Probabilistic sensitivity analysis was used. RESULTS: Treatment with MDI-s versus NEB was associated with an absolute decrease in hospitalization of 4.4% (p<0.05) and a 25-hour (p<0.001) reduction in average inpatient stay, after controlling for triage acuity and patient characteristics. This resulted in savings of $24/patient in the PED and $180/patient overall (p<0.001). Inpatient care accounted for more than 90% of total patient costs. CONCLUSIONS: Our results suggest economic gains associated with MDI-s for salbutamol inhalation in PEDs. Sensitivity analyses show that this conclusion is not affected by changes in model parameters that may differ by jurisdiction. Since most facilities already collect the data used for this study, our methods could be adopted for a cross-jurisdictional account of the cost effectiveness of MDI-s.

Evaluating a clinical practice intervention to promote delivery of salbutamol by metered-dose inhalers with holding chambers in a pediatric emergency department.

OBJECTIVE: The primary objective of this study was to quantify the impact of a clinical practice intervention to promote the delivery of salbutamol by metered-dose inhaler (MDI) in a pediatric emergency department (PED). A secondary objective was to retrospectively document the components of the intervention. METHODS: PED inventory data for salbutamol inhalation solution (nebules), MDIs, and holding chambers were obtained from the pharmacy department. Patient data were obtained from the hospital's decision support unit. Interrupted time series analysis was used to evaluate trends in salbutamol inventory data, patient triage acuity, and hospital admissions from January 1, 2003, to May 31, 2010. Interviews and administrative documents were used to identify components of the intervention, which began in 2006. RESULTS: There was a 1,215% increase in the proportion of salbutamol delivered as MDIs compared to total inhaled salbutamol (MDI plus nebulization solution) following the intervention (95% CI 1,032% to 1,396%, p < 0.001). Increases in salbutamol MDI use were associated with the implementation of an institution-specific asthma care map. A relative decrease of 32% in the hospital admission rate (absolute -7.25%: 95% CI -8.31 to -6.19, p < 0.001) was associated with the change in salbutamol MDI use and the use of the asthma care map. CONCLUSIONS: A multifaceted intervention, designed and implemented by local PED clinical leaders, resulted in a pronounced change in salbutamol inhalation practice, with an associated decrease in admission rates. This intervention demonstrated many of the criteria for successful health system change. Findings from this research may be contextualized to inform change elsewhere.

Medication records in the emergency department: agreement between paper-based charts and automated dispensing device.

BACKGROUND: Research exploring the agreement between traditional medication records and electronic records generated by an automated dispensing device has been limited. OBJECTIVE: To evaluate the extent of agreement between medication administration records written in paper-based emergency department charts and records generated by an automated dispensing device with regard to the presence or absence of a single, prespecified medication. METHODS: Medication administration records in paper-based emergency department charts and medication dispensation records generated by an automated dispensing device were evaluated for concordance. The primary outcome measure was agreement between the 2 sources with regard to the presence or absence of a record for salbutamol by metered-dose inhaler (MDI) for randomly selected patients who presented to a pediatric emergency department with wheeze-related illness from January 1, 2008, to December 31, 2009. RESULTS: In total, 1172 patient visits met the inclusion criteria. Of these, records for 1013 visits showed agreement between the paper-based emergency department chart and the dispensation record of the automated dispensing device (kappa = 0.71, 95% confidence interval 0.67-0.75). This value did not meet the target kappa of 0.80. Stratification by time of day, day of week, month, season, or year of presentation at triage or by triage level or disposition (whether or not the patient was admitted to the hospital ward) did not significantly affect the level of agreement between the 2 sources. CONCLUSIONS: Agreement between records of salbutamol MDI administration in paper-based charts and dispensation records from an automated dispensing device was substantial, but discrepancies were present. There are significant quality management, legal, clinical, and research reasons to strive for concordance between multiple records with respect to medication use in the emergency department. Data generated by automated dispensing devices have potential value for research, but their strengths and limitations need to be understood.