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1.
Pneumologie ; 74(3): 149-158, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32143230

RESUMO

INTRODUCTION: Inhalative treatments with metered dose aerosols and dry powder inhalers are the backbone of the pharmacotherapy for asthma and COPD. In the last decade many new and generic inhalative bronchodilators were launched at the German market, both monotherapies and fixed dose double bronchodilator (LABA/LAMA, beta adrenergic and antimuscarinic) or LABA and inhaled corticosteroid (ICS) and triple (LABA/LAMA/ICS) combinations. According to two surveys in 2015 among respiratory physicians we expected a high proportion of patients receiving duplicate prescriptions, e. g. a fixed dose new LABA/LAMA combination in addition to an existing ICS/LABA fixed dose combination. METHODOLOGY: We searched the database of a large mail order pharmacy (DocMorris) to identify duplicate prescriptions of inhalative drugs for a patient by the same or by two or more different physicians during a 3 months period. RESULTS: Unexpectedly, we found as little as around 1 % duplicate prescriptions for the same patient. Duplicate prescriptions involving combination products were found to be much more common than duplicate prescriptions of different mono-products. Irrespective the low percentage number of all prescriptions we saw in just one large mail order pharmacy several thousands of erroneous prescriptions. CONCLUSION: At least in the setting of this mail order pharmacy duplicate (i. e. contraindicated and potentially dangerous) prescriptions are relatively rare. Prescribers and pharmacists should be aware of the issue of duplicates - especially when prescribing or filling prescriptions with combination products.


Assuntos
Corticosteroides/administração & dosagem , Broncodilatadores/administração & dosagem , Prescrições de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica , Medicamentos sob Prescrição/uso terapêutico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Administração por Inalação , Agonistas de Receptores Adrenérgicos beta 2 , Bases de Dados Factuais , Quimioterapia Combinada , Humanos , Antagonistas Muscarínicos
2.
BMJ ; 368: l6968, 2020 01 29.
Artigo em Inglês | MEDLINE | ID: mdl-31996352

RESUMO

OBJECTIVE: To examine the distribution and patterns of opioid prescribing in the United States. DESIGN: Retrospective, observational study. SETTING: National private insurer covering all 50 US states and Washington DC. PARTICIPANTS: An annual average of 669 495 providers prescribing 8.9 million opioid prescriptions to 3.9 million patients from 2003 through 2017. MAIN OUTCOME MEASURES: Standardized doses of opioids in morphine milligram equivalents (MMEs) and number of opioid prescriptions. RESULTS: In 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. In absolute terms, the top 1% of providers prescribed an average of 748 000 MMEs-nearly 1000 times more than the middle 1%. At least half of all providers in the top 1% in one year were also in the top 1% in adjacent years. More than two fifths of all prescriptions written by the top 1% of providers were for more than 50 MMEs a day and over four fifths were for longer than seven days. In contrast, prescriptions written by the bottom 99% of providers were below these thresholds, with 86% of prescriptions for less than 50 MMEs a day and 71% for fewer than seven days. Providers prescribing high amounts of opioids and patients receiving high amounts of opioids persisted over time, with over half of both appearing in adjacent years. CONCLUSIONS: Most prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing. Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden. A large proportion of providers have established relationships with their patients over multiple years. Interventions to reduce inappropriate opioid prescribing should be focused on improving patient care, management of patients with complex pain, and reducing comorbidities rather than seeking to enforce a threshold for prescribing.


Assuntos
Analgésicos Opioides/uso terapêutico , Prescrição Inadequada/prevenção & controle , Administração dos Cuidados ao Paciente/normas , Médicos , Padrões de Prática Médica , Adulto , Prescrições de Medicamentos/normas , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Revisão da Utilização de Seguros/estatística & dados numéricos , Masculino , Médicos/classificação , Médicos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Padrões de Prática Médica/tendências , Medicamentos sob Prescrição/uso terapêutico , Melhoria de Qualidade , Estudos Retrospectivos , Estados Unidos/epidemiologia
4.
MMWR Morb Mortal Wkly Rep ; 68(49): 1129-1133, 2019 Dec 13.
Artigo em Inglês | MEDLINE | ID: mdl-31830009

RESUMO

The United States spends more per capita on prescription drugs than do other high-income countries (1). In 2017, patients paid 14% of this cost out of pocket (2). Prescription drug cost-saving strategies, including nonadherence to medications due to cost concerns, have been documented among U.S. adults (3) and can negatively affect morbidity and, in the case of persons with human immunodeficiency virus (HIV) infection, can increase transmission risk (4,5). However, population-based data on prescription drug cost-saving strategies among U.S. persons with HIV are lacking. CDC's Medical Monitoring Project* analyzed cross-sectional, nationally representative, surveillance data on behaviors, medical care, and clinical outcomes among adults with HIV infection. During 2016-2017, 14% of persons with HIV infection used a prescription drug cost-saving strategy for any prescribed medication, and 7% had cost saving-related nonadherence. Nonadherence due to prescription drug costs was associated with reporting an unmet need for medications from the Ryan White AIDS Drug Assistance Program (ADAP), not having Medicaid coverage, and having private insurance. Persons who were nonadherent because of cost concerns were more likely to have visited an emergency department, have been hospitalized, and not be virally suppressed. Reducing barriers to ADAP and Medicaid coverage, in addition to reducing medication costs for persons with private insurance, might help to decrease nonadherence due to cost concerns and, thus contribute to improved viral suppression rates and other health outcomes among persons with HIV infection.


Assuntos
Infecções por HIV/tratamento farmacológico , Adesão à Medicação/estatística & dados numéricos , Medicamentos sob Prescrição/economia , Medicamentos sob Prescrição/uso terapêutico , Honorários por Prescrição de Medicamentos , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
5.
PLoS Med ; 16(11): e1002922, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31689290

RESUMO

BACKGROUND: Prescription opioid misuse has become a leading cause of unintentional injury and death among adolescents and young adults in the United States. However, there is limited information on how adolescents and young adults obtain prescription opioids. There are also inadequate recent data on the prevalence of additional drug abuse among those misusing prescription opioids. In this study, we evaluated past-year prevalence of prescription opioid use and misuse, sources of prescription opioids, and additional substance use among adolescents and young adults. METHODS AND FINDINGS: This was a retrospective analysis of the National Survey on Drug Use and Health (NSDUH) for the years 2015 and 2016. Prevalence of opioid use, misuse, use disorder, and additional substance use were calculated with 95% confidence intervals (CIs), stratified by age group and other demographic variables. Sources of prescription opioids were determined for respondents reporting opioid misuse. We calculated past-year prevalence of opioid use and misuse with or without use disorder, sources of prescription opioids, and prevalence of additional substance use. We included 27,857 adolescents (12-17 years of age) and 28,213 young adults (18-25 years of age) in our analyses, corresponding to 119.3 million individuals in the extrapolated national population. There were 15,143 respondents (27.5% [95% CI 27.0-28.0], corresponding to 32.8 million individuals) who used prescription opioids in the previous year, including 21.0% (95% CI 20.4-21.6) of adolescents and 32.2% (95% CI 31.4-33.0) of young adults. Significantly more females than males reported using any prescription opioid (30.3% versus 24.8%, P < 0.001), and non-Hispanic whites and blacks were more likely to have had any opioid use compared to Hispanics (28.9%, 28.1%, and 25.8%, respectively; P < 0.001). Opioid misuse was reported by 1,050 adolescents (3.8%; 95% CI 3.5-4.0) and 2,207 young adults (7.8%; 95% CI 7.3-8.2; P < 0.001). Male respondents using opioids were more likely to have opioid misuse without use disorder compared with females (23.2% versus 15.8%, respectively; P < 0.001), with similar prevalence by race/ethnicity. Among those misusing opioids, 55.7% obtained them from friends or relatives, 25.4% from the healthcare system, and 18.9% through other means. Obtaining opioids free from friends or relatives was the most common source for both adolescents (33.5%) and young adults (41.4%). Those with opioid misuse reported high prevalence of prior cocaine (35.5%), hallucinogen (49.4%), heroin (8.7%), and inhalant (30.4%) use. In addition, at least half had used tobacco (55.5%), alcohol (66.9%), or cannabis (49.9%) in the past month. Potential limitations of the study are that we cannot exclude selection bias in the study design or socially desirable reporting among participants, and that longitudinal data are not available for long-term follow-up of individuals. CONCLUSIONS: Results from this study suggest that the prevalence of prescription opioid use among adolescents and young adults in the US is high despite known risks for future opioid and other drug use disorders. Reported prescription opioid misuse is common among adolescents and young adults and often associated with additional substance abuse, underscoring the importance of drug and alcohol screening programs in this population. Prevention and treatment efforts should take into account that greater than half of youths misusing prescription opioids obtain these medications through friends and relatives.


Assuntos
Transtornos Relacionados ao Uso de Opioides/epidemiologia , Adolescente , Adulto , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Feminino , Inquéritos Epidemiológicos , Humanos , Masculino , Medicamentos sob Prescrição/efeitos adversos , Medicamentos sob Prescrição/uso terapêutico , Prevalência , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
6.
PLoS Med ; 16(11): e1002941, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31689302

RESUMO

BACKGROUND: With governments' increasing efforts to curb opioid prescription use and limit dose below the Centers for Disease Control and Prevention (CDC)-recommended threshold of 90 morphine milligram equivalents per day, little is known about prescription opioid patterns preceding opioid use disorder (OUD) or overdose. This study aimed to determine prescribed opioid fills and dose trajectories in the year before an incident OUD or overdose diagnosis using a 2005-2016 commercial healthcare database. METHODS AND FINDINGS: This cross-sectional study identified individuals aged 18 to 64 years with incident OUD or overdose in the United States. We measured the prevalence of opioid prescription fills and trajectories of opioid morphine equivalent dose (MED) prescribed during the 12-month period before the diagnosis. Of 227,038 adults with incident OUD or overdose, 33.1% were aged 18 to 30 years, 52.9% were males, and 85.0% were metropolitan residents. Half (50.5%) of the patients had a diagnosis of chronic pain, 32.7% had depression, and 20.3% had anxiety. Overall, 79,747 (35.1%) patients filled no opioid prescription in the 12 months before OUD or overdose diagnosis, with the proportion significantly increasing between 2006 and 2016 (adjusted prevalence ratio, 1.86; 95% CI 1.79-1.93; P < 0.001). Patients without (versus with) prescribed opioids tended to be younger males and metropolitan and Northeast US residents. Of 145,609 patients who filled opioid prescriptions, 5 distinct prescribed daily dose trajectories preceding diagnosis emerged: consistent low dose (<3 mg MED, 34.6%), consistent moderate dose (20 mg MED, 27.3%), consistent high dose (150 mg MED, 15.0%), escalating dose (from <3 to 20 mg MED, 13.7%), and de-escalating dose (from 20 to <3mg MED, 9.4%). Overall, over two-thirds of patients with OUD or overdose with prescription opioids were prescribed a mean daily dose below 90 mg MED before diagnosis. Major limitations include the limited generalizability of the study findings and lack of information on out-of-pocket drug spending, race/ethnicity, and socioeconomic status of participants, which prevents analyses addressing these characteristics. CONCLUSIONS: In this study, we found that absence of opioid prescription fills in the year before incident OUD or overdose diagnosis was prevalent, and the majority of the patients received prescription opioid doses below the risk threshold of 90 mg MED. An increasing proportion of high-risk patients could be missed by current programs solely based on opioid prescribing and dispensing information in this new era of limited access to prescription opioids.


Assuntos
Analgésicos Opioides/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Padrões de Prática Médica/tendências , Adulto , Idoso , Analgésicos Opioides/uso terapêutico , Dor Crônica , Estudos Transversais , Overdose de Drogas , Feminino , Inquéritos Epidemiológicos , Humanos , Masculino , Pessoa de Meia-Idade , Medicamentos sob Prescrição/efeitos adversos , Medicamentos sob Prescrição/uso terapêutico , Prevalência , Estados Unidos/epidemiologia , Adulto Jovem
7.
Med Care ; 57(11): 898-904, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31634269

RESUMO

BACKGROUND: Medication overlap leading to medication excess is a form of therapeutic duplication, itself a type of potentially inappropriate prescribing. OBJECTIVE: To determine the prevalence of potential medication excess in the Veterans Health Administration (VHA) and identify associated medication-level, patient-level, and system-level factors. RESEARCH DESIGN: A retrospective database study. SUBJECTS: All veterans who received ≥1 prescription dispensed by a VHA pharmacy in fiscal year 2014. MEASURES: The primary outcome of "medication excess" was defined for each patient as the number of excess days' worth of medications for all overlap episodes (concurrently dispensed medications with the same name for >10 d). Predictors included medication-level, patient-level, and system-level factors. Multivariable negative binomial regression analyses estimated the rate ratio of each predictor with medication excess. RESULTS: Among 4,687,453 veterans, 64% had ≥1 medication overlap episodes. Patients were prescribed a median of 7 [interquartile range (IQR), 3-12] unique medications, had a median of 2 (IQR, 0-5) overlap episodes, and a median of 27 (IQR, 0-96) days of medication excess. In adjusted regression models, factors associated with greater risk of medication excess included having more comorbidities, multiple prescribers, a combination of filling locations (consolidated mail-order pharmacy vs. local pharmacy), and multiple prescription durations (≥90 d vs. less). CONCLUSIONS: Medication excess was high among VHA users, with nearly two-thirds of patients experiencing at least 1 duplicative medication. As systems such as mail-order pharmacies and 90-day supply are increasingly implemented to reduce costs and improve medication adherence, it is important to recognize the potential for systems-level inefficiencies and potentially inappropriate prescribing.


Assuntos
Farmácias/estatística & dados numéricos , Lista de Medicamentos Potencialmente Inapropriados/estatística & dados numéricos , Medicamentos sob Prescrição/uso terapêutico , Idoso , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polimedicação , Prevalência , Estudos Retrospectivos , Estados Unidos/epidemiologia , United States Department of Veterans Affairs
8.
Hosp Pract (1995) ; 47(5): 231-240, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31662005

RESUMO

Background and aims: Medication dosage adjustments for renally impaired patients have not been studied in Botswana. This study was conducted to determine prescribing practices among patients with renal impairment in medical wards to improve future patient care.Methods: We conducted a retrospective study involving medical charts of patients admitted at a tertiary level hospital in Gaborone Botswana. Study participants included all patients admitted between August and October 2016 who were hospitalized for ≥24 h. 'Drug prescribing in renal failure: dosing guidelines for adults and children'. was used to determine the extent of dosage adjustments. A logistic regression model was used to assess which patient factors were associated with inappropriate dosage adjustment.Results: Twenty-nine percent (233/804) of patients had renal impairment. Of these, 184 patients with renal impairment were included in the final analysis. There were 1143 prescription entries, of which 20.5% (n = 234) required dosage adjustment for renal function but only 45.7% (n = 107) were adjusted correctly. Of note, 112 patients were prescribed at least one drug that required dosage adjustment and only 30.4% (n = 34) patients had all of their medications appropriately adjusted. Patient factors associated with inappropriate dosage adjustment included a higher number of medicines being prescribed. Mortality among patients with renal impairment was independently associated with higher scores of the Charlson comorbidity index and hospital stay duration of 1-7 days.Conclusion: The renal function status of patients was not sufficiently taken into account when prescribing medicines especially in patients with severely impaired kidney function in Botswana. Continuous medical education needs to be encouraged to address this, which is being implemented. We will be following this up in future studies.


Assuntos
Cálculos da Dosagem de Medicamento , Insuficiência Renal/tratamento farmacológico , Adolescente , Adulto , Idoso , Botsuana , Estudos Transversais , Assistência à Saúde/normas , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Medicamentos sob Prescrição/uso terapêutico , Melhoria de Qualidade , Estudos Retrospectivos , Adulto Jovem
9.
Nursing ; 49(12): 32-39, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31658229

RESUMO

Many patients are prescribed antidepressants. This article discusses depression, as well as the available first- and second-line prescription medications used to manage the disorder in adults.


Assuntos
Antidepressivos/uso terapêutico , Depressão/tratamento farmacológico , Medicamentos sob Prescrição/uso terapêutico , Adulto , Depressão/enfermagem , Humanos
10.
Pediatrics ; 144(5)2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31575622

RESUMO

OBJECTIVES: Little is known about the risk for overdose after opioid prescription. We assessed associations between the type of opioid, quantity dispensed, daily dose, and risk for overdose among adolescents who were previously opioid naive. METHODS: Retrospective analysis of 1 146 412 privately insured adolescents ages 11 to 17 years in the United States captured in the Truven MarketScan commercial claims data set from January 2007 to September 2015. Opioid overdose was defined as any emergency department visit, inpatient hospitalization, or outpatient health care visit during which opioid overdose was diagnosed. RESULTS: Among our cohort, 725 participants (0.06%) experienced an opioid overdose, and the overall rate of overdose events was 28 events per 100 000 observed patient-years. Receiving ≥30 opioid tablets was associated with a 35% increased risk for overdose compared to receiving ≤18 tablets (hazard ratio [HR] = 1.35; 95% confidence interval: 1.05-1.73; P = .02). Daily prescribed opioid dose was not independently associated with an increased risk for overdose. Tramadol exposure was associated with a 2.67-fold increased risk for opioid overdose compared to receiving oxycodone (adjusted HR = 2.67; 95% confidence interval: 1.90-3.75; P < .0001). Adolescents with preexisting mental health conditions demonstrated increased risk for overdose, with HRs ranging from 1.65 (anxiety) to 3.09 (substance use disorders). CONCLUSIONS: One of 1600 (0.06%) previously opioid-naive adolescents who received a prescription for opioids experienced an opioid overdose a median of 1.75 years later that resulted in medical care. Preexisting mental health conditions, use of tramadol, and higher number of dispensed tablets (>30 vs <18) were associated with an increased risk of opioid overdose.


Assuntos
Analgésicos Opioides/uso terapêutico , Overdose de Drogas/epidemiologia , Prescrições de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Analgésicos Opioides/envenenamento , Criança , Conjuntos de Dados como Assunto , Feminino , Humanos , Masculino , Transtornos Mentais/complicações , Oxicodona/envenenamento , Medicamentos sob Prescrição/envenenamento , Medicamentos sob Prescrição/uso terapêutico , Estudos Retrospectivos , Tramadol/envenenamento , Estados Unidos/epidemiologia
11.
BMC Health Serv Res ; 19(1): 626, 2019 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-31481056

RESUMO

BACKGROUND: Regional variation in medical care costs can indicate heterogeneity in clinical practice, inequities in access, or inefficiencies in service delivery. We aimed to estimate regional variation in medical costs for people living with HIV (PLHIV), adjusting for demographics and case-mix. METHODS: We conducted a retrospective cohort study using linked health administrative databases of PLHIV, from 2010 to 2014, in British Columbia (BC), Canada. Quarterly health care costs (2018 CAD) were derived from inpatient, outpatient, prescription drugs, antiretroviral therapy (ART), and HIV diagnostics. We used a two-part model with a logit link for the probability of incurring costs, and a log link and gamma distribution for observations with positive costs. We also estimated quarterly utilization rates for hospitalization-, physician billing- and prescription drug-days. Primary variables were indicators of individuals' Health Service Delivery Area (HSDA). We adjusted cost and utilization estimates for demographic characteristics, HIV-disease progression, and comorbidities. RESULTS: Our cohort included 9577 PLHIV (median age 45.5 years, 80% male). Adjusted total quarterly costs for all 16 HSDAs were within 20% of the provincial mean, 8/16 for hospitalization costs, 16/16 for physician billing costs and 10/16 for prescription drug costs. Northern Interior and Northeast HSDAs had 38 and 44% lower quarterly non-ART prescription drug costs, and 2 and 5% higher quarterly inpatient costs, respectively. CONCLUSIONS: We observed limited variation in medical care costs and utilization among PLHIV in BC. However, lower levels of outpatient care and higher levels of inpatient care indicate possible barriers to accessing care among PLHIV in the most rural regions of the province.


Assuntos
Fármacos Anti-HIV/economia , Infecções por HIV/economia , Adulto , Assistência Ambulatorial/economia , Fármacos Anti-HIV/uso terapêutico , Colúmbia Britânica/epidemiologia , Estudos de Coortes , Comorbidade , Bases de Dados Factuais , Progressão da Doença , Custos de Medicamentos , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Medicamentos sob Prescrição/uso terapêutico , Características de Residência , Estudos Retrospectivos , Saúde da População Rural
12.
J Manag Care Spec Pharm ; 25(10): 1102-1110, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31556820

RESUMO

BACKGROUND: The management of schizophrenia, a chronic, multifaceted mental health condition, is associated with considerable health care resource utilization (HCRU) and costs. Current evidence indicates that a high-risk and costly prodromal period, during which patients are likely symptomatic, precedes diagnosis. Better characterization and disease management during this stage could help to improve patient outcomes. OBJECTIVE: To describe and compare HCRU and costs for up to 5 years before diagnosis in a cohort with schizophrenia versus a demographically matched cohort without schizophrenia in a commercially insured U.S. METHODS: This retrospective study identified newly diagnosed schizophrenia patients using enrollee claims in the HealthCore Integrated Research Database between January 1, 2007, and April 30, 2016. The index date was defined as the date of the first medical claim with a schizophrenia diagnosis code. Schizophrenia patients were directly matched (1:4) by age, sex, and region to comparators without schizophrenia who were assigned the same index dates as their matched schizophrenia counterparts. Observation periods were 0-12, 13-24, 25-36, 37-48, and 49-60 months before the index date. Outcomes included HCRU and costs for inpatient admissions, emergency room visits, outpatient care (office visits and other outpatient services), and medications. Means, standard deviations, medians, and 95% confidence intervals were calculated for continuous variables; relative frequencies and percentages were calculated for categorical variables. Cohorts were compared with t-tests for continuous variables and chi-square tests for categorical variables. Differences across cohorts were estimated with individual generalized linear models for each observation period, controlling for gender, age, geographic region of residence, health plan type and subscriber status, behavioral pre-index comorbidities and chronic comorbidities during the period before diagnosis. RESULTS: 6,732 schizophrenia patients were matched to 26,928 patients without schizophrenia. All-cause inpatient admissions were more prevalent among schizophrenia patients than their comparators for all time periods (49-60 months prediagnosis: 9% vs. 4%; 0-12 months prediagnosis: 33% vs. 4%). The schizophrenia cohort had higher adjusted all-cause per-patient per-month health care costs relative to comparators from the earliest period of 49-60 months prediagnosis ($557 [95% CI = 474-639] vs. $321 [95% CI = 288-355]) through 0-12 months prediagnosis ($1,058 [95% CI = 998-1,115] vs. $338 [95% CI = 320-355]). Behavioral health-related costs were different in each time period as were cost ratios (schizophrenia costs: comparator costs), which increased from 5.4 in the earliest period to 14.8 in the year before diagnosis. CONCLUSIONS: Schizophrenia patients had higher all-cause and behavioral health-related HCRU and costs before diagnosis than matched controls. Costs increased from 5 years to 1 year prediagnosis for schizophrenia patients driven primarily by inpatient hospital stays and prescription drug costs, but remained stable for comparators. Additional research is needed for the development of predictive models to aid in the identification of high-risk patients. DISCLOSURES: This study was sponsored by Boehringer Ingelheim Pharmaceuticals. Barron is an employee of HealthCore, which received funding from Boehringer Ingelheim to conduct this study. Wallace and York were employed by HealthCore at time of this study. Isenberg is an employee of Anthem. Franchino-Elder, Sidovar, and Sand are employees of Boehringer Ingelheim.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Medicamentos sob Prescrição/uso terapêutico , Esquizofrenia/economia , Adolescente , Adulto , Assistência Ambulatorial/economia , Assistência Ambulatorial/estatística & dados numéricos , Custos de Medicamentos , Feminino , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Medicamentos sob Prescrição/economia , Estudos Retrospectivos , Esquizofrenia/diagnóstico , Esquizofrenia/terapia , Adulto Jovem
13.
Drugs Aging ; 36(11): 1035-1045, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31552597

RESUMO

BACKGROUND: Synthetic oral cannabinoids (nabilone and dronabinol) may have adverse respiratory effects. Our purpose was to describe the scope, pattern, and patient characteristics associated with incident off-label synthetic oral cannabinoid use among older adults with chronic obstructive pulmonary disease (COPD) compared to older adults without COPD. METHODS: This was a retrospective, population-based, cohort study using Ontario, Canada, heath administrative data. Individuals aged 66 years or older were included, and physician-diagnosed COPD was identified using a previously validated, highly specific algorithm. Incident off-label oral cannabinoid use was examined between April 1, 2005 and March 31, 2015. Descriptive statistics were used to describe drug use patterns. Multiple logistic regression was used to identify patient characteristics associated with incident drug use. RESULTS: There were 172,282 older adults with COPD and 1,068,256 older adults without COPD identified between April 1, 2005 and March 31, 2015. Incident synthetic oral cannabinoid use during this period occurred with significantly greater (p < 0.001) frequency among older adults with COPD (0.6%) versus older adults without COPD (0.3%). Compared to those without COPD, older adults with COPD used synthetic cannabinoids for significantly longer durations and more frequently at higher doses. CONCLUSIONS: Although incident off-label oral cannabinoid use was relatively low among all older Ontarian adults, this drug class was used with greater frequency and more often in potentially concerning ways among older adults with COPD. These findings raise possible safety concerns, but further research on the respiratory safety of oral cannabinoids among individuals with COPD is needed.


Assuntos
Dronabinol/análogos & derivados , Uso de Medicamentos/estatística & dados numéricos , Prescrição Inadequada/estatística & dados numéricos , Uso Off-Label/estatística & dados numéricos , Medicamentos sob Prescrição/administração & dosagem , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Idoso , Algoritmos , Estudos de Coortes , Dronabinol/administração & dosagem , Dronabinol/efeitos adversos , Dronabinol/uso terapêutico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/etiologia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Ontário , Medicamentos sob Prescrição/efeitos adversos , Medicamentos sob Prescrição/uso terapêutico , Estudos Retrospectivos
14.
R I Med J (2013) ; 102(6): 24-26, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31398964

RESUMO

The opioid epidemic presents an urgent public health problem. Rhode Island has enacted comprehensive rules to address primary prevention of opioid overdose. This study evaluates the efficacy of those regulations in altering prescribing behavior, specifically regarding the initial prescription. Using data extracted from the Rhode Island Prescription Drug Monitoring Program (PDMP), before and after the publication of updated acute pain management regulations, we studied the rate of opioid prescribing using statistical process control (SPC) charts and found that the rate of prescribing unsafe doses of opioids, more than 30 morphine milligram equivalents (MMEs) per day or more than 20 doses to opioid naïve patients, decreased significantly.


Assuntos
Overdose de Drogas/epidemiologia , Prescrição Inadequada/legislação & jurisprudência , Padrões de Prática Médica/legislação & jurisprudência , Programas de Monitoramento de Prescrição de Medicamentos/legislação & jurisprudência , Analgésicos Opioides/uso terapêutico , Overdose de Drogas/prevenção & controle , Humanos , Prescrição Inadequada/prevenção & controle , Análise de Séries Temporais Interrompida , Padrões de Prática Médica/normas , Programas de Monitoramento de Prescrição de Medicamentos/normas , Medicamentos sob Prescrição/uso terapêutico , Rhode Island/epidemiologia
16.
J Manag Care Spec Pharm ; 25(8): 879-887, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31347977

RESUMO

BACKGROUND: Disease-modifying antirheumatic drugs (DMARDs) are recommended as the standard of care for patients with rheumatoid arthritis (RA) due to their ability to reduce pain and disability; however, DMARD use is low in some subgroups of the RA population. OBJECTIVE: To identify characteristics associated with DMARD use in the overall cohort of patients with RA and newly diagnosed RA patients. METHODS: This retrospective observational study used claims from a large national health plan. Use of DMARDs was measured according to the Healthcare Effectiveness Data and Information Set (HEDIS) as the proportion of patients with RA receiving DMARDs. Following HEDIS measure technical specifications, we identified patients aged 18-89 years with continuous enrollment during 2014 (measurement year) with ≥ 2 claims for RA outpatient visits and/or discharges on different dates between January and November 2014. Additionally, we identified a subset of patients newly diagnosed with RA in 2014 based on absence of any claims for RA or DMARDs in 2013. Descriptive analyses and bivariate associations were used to compare demographic and clinical characteristics of patients with RA with or without DMARD use in 2014. Health care resource utilization (HCRU) and costs were compared in 2014 for patients enrolled in Medicare Advantage Prescription Drug (MAPD) plans during both 2014 and 2015. Regression models were used to evaluate patient and provider characteristics associated with DMARD use in 2014 and the effect on HCRU and costs. RESULTS: Among the 33,880 patients identified with RA in 2014, most patients received a DMARD (75.2%); 29.4% of patients newly diagnosed with RA had been treated with DMARDs in 2014. Patients with DMARD use, on average, were younger (aged 67 years ± 10.7 vs. 69 years ± 10.7) and healthier (Deyo-Charlson Comorbidity Index [DCCI] 2.4 ± 1.9 vs. 2.6 ± 2.1) and included a greater proportion of women (75.9% vs. 71.0%) than those with no DMARD use (P < 0.0001). Use of DMARDs (P < 0.0001) was associated with 14.5% fewer hospitalizations and 18.0% fewer emergency department visits. Although total costs increased by 15.0% with use of DMARDs, when the cost of DMARDs was excluded, the total cost decreased by 13.7% (P < 0.0001). Female gender (32.2%), higher claims-based index for RA severity score (47.0%), higher RxRisk-V score (26.7%), visit to a rheumatologist (34.3%), and use of glucocorticoids (17.7%) increased the odds of DMARD use (P < 0.0001). Use of certain classes of medication, such as nonsteroidal anti-inflammatory drugs (12.3%), opioids (19.5%), antidepressants (20.0%), muscle relaxants (12.5%), and anticonvulsants (15.5%), were associated with lower use of DMARDs (P < 0.0001). CONCLUSIONS: We found significant differences in demographic and clinical characteristics between patients with and without DMARD use, which can potentially inform treatment decisions regarding DMARD use as deemed necessary by the provider. Future research should investigate the reasons for lack of treatment. DISCLOSURES: This study was supported by funding from Eli Lilly to Humana as a collaborative research project involving employees of both companies. Boytsov, Saverno, Zhang, and Gaich are employees of Eli Lilly. Nair, Bhattacharya, Abbott, and Dixon are employees of Humana, which received funding from Eli Lilly to complete this research.


Assuntos
Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Idoso , Anti-Inflamatórios não Esteroides/uso terapêutico , Antirreumáticos/economia , Artrite Reumatoide/economia , Produtos Biológicos/economia , Produtos Biológicos/uso terapêutico , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Aceitação pelo Paciente de Cuidados de Saúde , Medicamentos sob Prescrição/economia , Medicamentos sob Prescrição/uso terapêutico , Estudos Retrospectivos
17.
Value Health ; 22(7): 792-798, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31277826

RESUMO

BACKGROUND: Estimates of drug spending are often central to the public policy debate on how to manage healthcare spending in the United States. Nevertheless, common estimates of prescription drug spending vary substantially by source, which can inhibit productive policy dialogue. OBJECTIVES: To review publicly reported estimates of drug spending and uncover the underlying methodological inputs that drive the substantial variation in estimates of prescription drug spending. METHODS: We systematically evaluated 5 estimates of drug spending to identify differences in the underlying methodological inputs and approaches. To uniformly assess and compare estimates, we developed a model to identify the inputs of 3 primary components associated with each estimate: numerator (How is drug cost measured?), denominator (How is healthcare cost measured?), and population (What group of individuals is included in the measurement?). We then applied standardized methodological inputs to each estimate to assess whether variation among estimates could be reconciled. We then conducted a sensitivity analysis to address important limitations. RESULTS: We found that the 18.8 percentage point range in the publicly reported estimates is predominately attributed to methodological differences. Reconciling estimates using a standardized methodological approach reduces this range to 4.0 percentage points. CONCLUSIONS: Because variation in estimates of drug spending is primarily driven by methodological differences, stakeholders should seek to establish a mutually agreed upon methodological approach that is appropriate for the policy question at hand to provide a sound basis for health spending policy discussions.


Assuntos
Custos de Medicamentos , Gastos em Saúde , Seguro Saúde/economia , Medicamentos sob Prescrição/economia , Redução de Custos , Análise Custo-Benefício , Custos de Medicamentos/tendências , Gastos em Saúde/tendências , Humanos , Seguro Saúde/tendências , Modelos Econômicos , Medicamentos sob Prescrição/uso terapêutico , Fatores de Tempo , Estados Unidos
18.
Indian J Public Health ; 63(2): 151-153, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31219066

RESUMO

Avoidance in seeking prescribed medical treatment can result in adverse consequences. The study was conducted to find out the reasons to avoid prescribed medical treatment and associations with various socioeconomic variables in India. Data from the National Sample Survey Organisation 71st Round on "Key Indicators of Social Consumption: Health" (January and June 2014) have been used. Variables such as place of residence, social categories, religion, and socioeconomic status have been used to study the associations with the various reasons to avoid prescribed medical treatment. Nonseriousness about the ailment was found to be the primary reason for not seeking prescribed medical treatment. Lack of availability of medical facility, long-waiting time, and financial constraints were other important reasons. Understanding the socioeconomic differentials among the reasons why people avoid prescribed medical treatment is critical in improving the effectiveness of health-care facilities in India.


Assuntos
Adesão à Medicação/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Medicamentos sob Prescrição/uso terapêutico , Atitude Frente a Saúde , Humanos , Índia/epidemiologia , Adesão à Medicação/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Classe Social , Fatores Socioeconômicos
19.
BMC Vet Res ; 15(1): 218, 2019 Jun 27.
Artigo em Inglês | MEDLINE | ID: mdl-31248411

RESUMO

BACKGROUND: Antimicrobial use (AMU) in livestock is a debated topic, mainly due to the risk of associated development of antimicrobial resistance. There is focus on reducing AMU in the Danish pig production, which accounts for the largest proportion of AMU for animals in Denmark. Due to special restriction on AMU in organic pig production, the AMU in organic pig production is lower than in conventional pig production. There is concern that reduced AMU could jeopardize animal health and welfare, if it reflects insufficient treatment of sick animals, which might be reflected by the prevalence and types of lesions found at meat inspection. However, little is known about the associations between AMU and meat inspection findings in pigs from organic farms. Furthermore, excess amount of antimicrobial product after a treatment cannot be re-prescribed in organic pig herds. The initial prescription is recorded in the national database VetStat, but the unused amount is not deducted leading to uncertainty when reporting AMU. The objectives of this study were to 1) describe AMU patterns based on prescription data for organic pig production and compare with those of the conventional pig production for year 2016, 2) study the associations between herd-level AMU prescription data and meat inspection data for organic pig herds and 3) validate herd-level AMU prescription data in VetStat against treatment records collected on-farm in organic Danish pig herds. RESULTS AND CONCLUSIONS: Gastrointestinal indications account for the largest proportion of AMU in both organic pig herds (65 and 54% of treatment doses for weaners and finishers, respectively) and conventional pig herds (80 and 68% of doses for weaners and finishers, respectively). A larger proportion is prescribed for respiratory indications in organic than conventional weaners and arthropathic indications in finishers. No associations between AMU and meat inspection data were found. This needs further investigation as the prevalence of lesions at slaughter was slightly (non-significantly) higher in herds with no registered AMU than with AMU prescriptions. Only 8 out of 31 herds had recorded their AMU sufficiently detailed to compare, and using VetStat as a proxy for AMU led to 9-88% overestimation of the actual use in 7 out of these 8 herds and 120% underestimation in one herd.


Assuntos
Anti-Infecciosos/uso terapêutico , Agricultura Orgânica , Medicamentos sob Prescrição/uso terapêutico , Doenças dos Suínos/tratamento farmacológico , Matadouros , Animais , Bases de Dados Factuais , Dinamarca , Revisão de Uso de Medicamentos , Registros Eletrônicos de Saúde , Suínos , Doenças dos Suínos/patologia
20.
JAMA Netw Open ; 2(6): e195345, 2019 06 05.
Artigo em Inglês | MEDLINE | ID: mdl-31173123

RESUMO

Importance: Implementation of pharmacogenetic testing to guide drug prescribing has potential to improve drug response and prevent adverse events. Robust data exist for more than 30 gene-drug pairs linking genotype to drug response phenotypes; however, it is unclear which pharmacogenetic tests, if implemented, would provide the greatest utility for a given patient population. Objectives: To project the proportion of veterans in the US Veterans Health Administration (VHA) with actionable pharmacogenetic variants and evaluate how testing might be associated with prescribing decisions. Design, Setting, and Participants: This cross-sectional study included veterans who used national VHA pharmacy services from October 1, 2011, to September 30, 2017. Data analyses began April 26, 2018, and were completed February 6, 2019. Exposures: Receipt of level A drugs based on VHA pharmacy dispensing records. Main Outcomes and Measures: Projected prevalence of actionable pharmacogenetic variants among VHA pharmacy users based on variant frequencies from the 1000 Genomes Project and veteran demographic characteristics; incident number of level A prescriptions, and proportion of new level A drug recipients projected to carry an actionable pharmacogenetic variant. Results: During the study, 7 769 359 veterans (mean [SD] age, 58.1 [17.8] years; 7 021 504 [90.4%] men) used VHA pharmacy services. It was projected that 99% of VHA pharmacy users would carry at least 1 actionable pharmacogenetic variant. Among VHA pharmacy users, 4 259 153 (54.8%) received at least 1 level A drug with 1 188 124 (15.3%) receiving 2 drugs, and 912 189 (11.7%) receiving 3 or more drugs. The most common incident prescriptions during the study were tramadol (923 671 new recipients), simvastatin (533 928 new recipients), citalopram (266 952 new recipients), and warfarin (205 177 new recipients). Gene-drug interactions projected to have substantial clinical impacts in the VHA population include the interaction of SLCO1B1 with simvastatin (1 988 956 veterans [25.6%]), CYP2D6 with tramadol (318 544 veterans [4.1%]), and CYP2C9 or VKORC1 with warfarin (7 163 349 veterans [92.2%]). Conclusions and Relevance: Clinically important pharmacogenetic variants are highly prevalent in the VHA population. Almost all veterans would carry an actionable variant, and more than half of the population had been exposed to a drug affected by these variants. These results suggest that pharmacogenetic testing has the potential to affect pharmacotherapy decisions for commonly prescribed outpatient medications for many veterans.


Assuntos
Frequência do Gene/genética , Variantes Farmacogenômicos/genética , Medicamentos sob Prescrição/uso terapêutico , Saúde dos Veteranos , Estudos Transversais , Citocromo P-450 CYP2C9/genética , Citocromo P-450 CYP2D6/genética , Interações de Medicamentos/genética , Utilização de Instalações e Serviços , Feminino , Genótipo , Humanos , Transportador 1 de Ânion Orgânico Específico do Fígado/genética , Masculino , Pessoa de Meia-Idade , Assistência Farmacêutica/estatística & dados numéricos , Polimorfismo Genético/genética , Prevalência , Sinvastatina/farmacologia , Tramadol/farmacologia , Estados Unidos , United States Department of Veterans Affairs/estatística & dados numéricos , Vitamina K Epóxido Redutases/genética , Varfarina/farmacologia
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