Quality of drug prescribing in elderly people in nursing homes and special care units for dementia: a cross-sectional computerized pharmacy register analysis.

BACKGROUND: Drug prescribing to the elderly is extensive and often inappropriate. Furthermore, the number of drugs used is the most important risk factor for adverse drug reactions. Despite this, drug prescribing in the elderly in Sweden is high and increasing. In 2003 the Swedish National Board of Health and Welfare launched a set of indicators to evaluate the quality of drug therapy in the elderly. Use of this tool in combination with the Swedish computerized national register covering all persons receiving multi-dose drug dispensing (drugs dispensed in one dose unit bag for each dose occasion) would enable detection of inappropriate drug prescribing and could help reduce the risk of drug-related problems among the elderly. OBJECTIVES: To assess the extent and quality of drug prescribing in younger and older elderly residents receiving multi-dose drug dispensing in ordinary nursing homes (NHs) and special care units for dementia (NHDs), and to evaluate the relationship between the quality of prescribing and the number of prescribers per resident, in a Swedish county. METHODS: The computerized national pharmacy drug register provided the database and a cross-sectional design was used. Selected drug-specific quality indicators proposed by the Swedish National Board of Health and Welfare in 2003 were used to assess the quality of drug prescribing. RESULTS: This study included 3705 residents. Their mean age was 85 years and 72% were women. The mean number of prescribed drugs was 10.3 per resident. The proportion of residents with prescriptions for psychotropic drugs was 80% in NHs and 85% in NHDs. The prevalence of each drug-specific quality indicator was as follows: long-acting benzodiazepines 16.4% (NHs) versus 11.7% (NHDs), anticholinergic drugs 20.7% versus 18.5%, drug duplication 14.6% versus 13.6%, three or more psychotropic drugs 25.6% versus 35.3%, class C interactions (drug combinations that may require dose adjustment) 41.9% versus 38.7% and class D interactions (drug combinations that should be avoided) 8.1% versus 5.6%. Younger elderly residents (age 65-79 years) had a lower quality of drug prescribing. An increasing number of prescribers per resident was associated with a lower quality of drug therapy. CONCLUSIONS: We found a lower quality of drug prescribing, e.g. anticholinergic drugs prescribed to approximately 20% of residents of NHs and NHDs, and a higher rate of psychotropic drug use (>/=80%) compared with previous studies in NHs. Our results also demonstrated a negative correlation between quality of prescribing and number of prescribers per resident.

Reduction in outpatient antibiotic sales for pre-school children: interrupted time series analysis of weekly antibiotic sales data in Sweden 1992-2002.

OBJECTIVES: The aim of this study was to use detailed weekly data on outpatient antibiotic sales for pre-school children in Sweden to test for the significance of trends during 1992-2002. We also report on the special features found in weekly antibiotic data, and how the interrupted time series (ITS) design can adjust for this. METHODS: Weekly data on the total number of dispensed outpatient antibiotic prescriptions to pre-school children were studied, as well as the individual subgroups commonly used to treat respiratory tract infections in children: narrow-spectrum penicillins, broad-spectrum penicillins and macrolides. In parallel, monthly data of paracetamol sales of paediatric dosages were analysed to reflect trends in symptomatic treatment. An ITS model controlling for seasonality and autocorrelation was used to examine the datasets for significant level and trend shifts. RESULTS: A significant increase in mean and change in level could be found in the total antibiotic data in 1997, also reflected in broad-spectrum penicillin data where a similar trend break occurred in 1996. For macrolides, a trend break with a decrease in mean was noted in 1996, but no trend breaks were found in narrow-spectrum penicillin data. In contrast to the general decreasing trends in antibiotic sales, the yearly over-the-counter sales of paracetamol in paediatric preparations increased during the same period, with no identified trend breaks. CONCLUSIONS: The overall decrease in antibiotic sales and increase in paediatric paracetamol sales might suggest that symptomatic treatment in the home has increased, as antibiotics are less commonly prescribed.

Variations in asthma treatment in five European countries--judgement analysis of case simulations.

OBJECTIVE: The aim of this study was to explore and compare treatment decisions and the influence of specific patient characteristics on asthma management in five European countries, and to relate this to existing guidelines. METHODS: Using the technique of clinical judgement analysis, doctors in The Netherlands, Norway, Germany, Sweden and the Slovak Republic (40-100 doctors per country) were presented with sets of written simulated cases on asthma treatment. Patient characteristics were varied to determine their influence on the doctors' decisions. Decisions indicating over- and under-prescribing in relation to a gold standard derived from guidelines were also determined. RESULTS: Doctors in The Netherlands prescribed more oral steroid courses and fewer antibiotics than doctors in Norway and Sweden, whereas doctors in Germany and the Slovak Republic prescribed the least oral steroids and the most antibiotics. Partially, this variation could be explained by differences in the underlying propensity to prescribe, but differences in the use of patient characteristics also contributed to the variation. Norwegian doctors were most inclined to increase the maintenance treatment of inhaled corticosteroids, which could best be explained by their relatively high focus on the patient's peak expiratory flow value. Compared with the gold standard, there was 25-56% under-prescribing of oral steroids, and 21-45% over-prescribing of antibiotics. CONCLUSIONS: The variation in treatment of asthma patients between doctors in different countries may, in part, be attributed to variations in the underlying propensity to prescribe, and in part to different use of clinical patient characteristics. These findings can be used in tailoring educational programmes to improve treatment practices.