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1.
JAMA Netw Open ; 4(2): e2036687, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33576816

RESUMO

Importance: In response to the increase in opioid overdose deaths in the United States, many states recently have implemented supply-controlling and harm-reduction policy measures. To date, an updated policy evaluation that considers the full policy landscape has not been conducted. Objective: To evaluate 6 US state-level drug policies to ascertain whether they are associated with a reduction in indicators of prescription opioid abuse, the prevalence of opioid use disorder and overdose, the prescription of medication-assisted treatment (MAT), and drug overdose deaths. Design, Setting, and Participants: This cross-sectional study used drug overdose mortality data from 50 states obtained from the National Vital Statistics System and claims data from 23 million commercially insured patients in the US between 2007 and 2018. Difference-in-differences analysis using panel matching was conducted to evaluate the prevalence of indicators of prescription opioid abuse, opioid use disorder and overdose diagnosis, the prescription of MAT, and drug overdose deaths before and after implementation of 6 state-level policies targeting the opioid epidemic. A random-effects meta-analysis model was used to summarize associations over time for each policy and outcome pair. The data analysis was conducted July 12, 2020. Exposures: State-level drug policy changes to address the increase of opioid-related overdose deaths included prescription drug monitoring program (PDMP) access, mandatory PDMPs, pain clinic laws, prescription limit laws, naloxone access laws, and Good Samaritan laws. Main Outcomes and Measures: The outcomes of interests were quarterly state-level mortality from drug overdoses, known indicators for prescription opioid abuse and doctor shopping, MAT, and prevalence of drug overdose and opioid use disorder. Results: This cross-sectional study of drug overdose mortality data and insurance claims data from 23 million commercially insured patients (12 582 378 female patients [55.1%]; mean [SD] age, 45.9 [19.9] years) in the US between 2007 and 2018 found that mandatory PDMPs were associated with decreases in the proportion of patients taking opioids (-0.729%; 95% CI, -1.011% to -0.447%), with overlapping opioid claims (-0.027%; 95% CI, -0.038% to -0.017%), with daily morphine milligram equivalent greater than 90 (-0.095%; 95% CI, -0.150% to -0.041%), and who engaged in drug seeking (-0.002%; 95% CI, -0.003% to -0.001%). The proportion of patients receiving MAT increased after the enactment of mandatory PDMPs (0.015%; 95% CI, 0.002% to 0.028%), pain clinic laws (0.013%, 95% CI, 0.005%-0.021%), and prescription limit laws (0.034%, 95% CI, 0.020% to 0.049%). Mandatory PDMPs were associated with a decrease in the number of overdose deaths due to natural opioids (-518.5 [95% CI, -728.5 to -308.5] per 300 million people) and methadone (-122.7 [95% CI, -207.5 to -37.8] per 300 million people). Prescription drug monitoring program access policies showed similar results, although these policies were also associated with increases in overdose deaths due to synthetic opioids (380.3 [95% CI, 149.6-610.8] per 300 million people) and cocaine (103.7 [95% CI, 28.0-179.5] per 300 million people). Except for the negative association between prescription limit laws and synthetic opioid deaths (-723.9 [95% CI, -1419.7 to -28.1] per 300 million people), other policies were associated with increasing overdose deaths, especially those attributed to non-prescription opioids such as synthetic opioids and heroin. This includes a positive association between naloxone access laws and the number of deaths attributed to synthetic opioids (1338.2 [95% CI, 662.5 to 2014.0] per 300 million people). Conclusions and Relevance: Although this study found that existing state policies were associated with reduced misuse of prescription opioids, they may have the unintended consequence of motivating those with opioid use disorders to access the illicit drug market, potentially increasing overdose mortality. This finding suggests that there is no easy policy solution to reverse the epidemic of opioid dependence and mortality in the US.


Assuntos
/mortalidade , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Epidemia de Opioides , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Política Pública , Governo Estadual , Analgésicos Opioides/uso terapêutico , Controle de Medicamentos e Entorpecentes , Redução do Dano , Política de Saúde , Acesso aos Serviços de Saúde/legislação & jurisprudência , Humanos , Naloxona , Antagonistas de Entorpecentes , Clínicas de Dor/legislação & jurisprudência , Padrões de Prática Médica/legislação & jurisprudência , Programas de Monitoramento de Prescrição de Medicamentos/legislação & jurisprudência , Prevalência , Estados Unidos/epidemiologia
3.
J Urol ; 205(1): 264-270, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32749908

RESUMO

PURPOSE: Postoperative opioids are overprescribed in the United States. In November 2016 the State of Pennsylvania required an opioid consent for minors. Our hypothesis is that this mandate decreased postoperative opioid prescriptions in our division. MATERIALS AND METHODS: All patients who received a urological outpatient or minor emergency procedure from August 2015 to August 2019 were identified. Surgeries performed within 6 months after mandate implementation were excluded to account for the transition period. Perioperative data including case type were extracted by a clinical data warehouse from preexisting fields within the health record. The frequencies of postoperative prescriptions, delayed prescriptions and emergency department encounters were assessed. A multivariable logistic regression to identify predictors of opioid prescription at discharge was performed. RESULTS: A total of 4,349 patients were analyzed. The frequency of postsurgical opioid prescriptions decreased from 45.3% to 2.6% (p <0.001). The median morphine milligram equivalent decreased by 22.5 among children prescribed an opioid (p <0.001). Rates of an emergency department visits (3% vs 2.7%) or delayed nonopioid prescriptions (0.8% vs 1.2%) within 30 days of discharge were unchanged (p >0.05). Fewer patients received a delayed opioid prescription after mandate implementation (0.03% vs 0.5%, p <0.001). Female patients were less likely (OR 0.309, 95% CI 0.195-0.491; p <0.001) to receive opioids prior to but not after the mandate (OR 0.309, 95% CI 0.544-2.035; p=0.122). Increasing age was predictive of receiving an opioid before (OR 1.187, 95% CI 1.157-1.218; p <0.001) and after (OR 1.241, 95% CI 1.186-1.299; p <0.001) the mandate. CONCLUSIONS: A state mandated opioid consent for minors greatly reduced post-urological surgery opioid prescription rates without increasing rates of readmission or delayed prescriptions.


Assuntos
Analgésicos Opioides/efeitos adversos , Consentimento Livre e Esclarecido/legislação & jurisprudência , Manejo da Dor/normas , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Analgésicos Opioides/normas , Criança , Pré-Escolar , Uso de Medicamentos/legislação & jurisprudência , Uso de Medicamentos/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Tratamento de Emergência/métodos , Feminino , Humanos , Lactente , Consentimento Livre e Esclarecido/normas , Masculino , Epidemia de Opioides/prevenção & controle , Manejo da Dor/métodos , Dor Pós-Operatória/etiologia , Readmissão do Paciente/estatística & dados numéricos , Pennsylvania , Padrões de Prática Médica/legislação & jurisprudência , Padrões de Prática Médica/normas , Estudos Retrospectivos , Governo Estadual , Procedimentos Cirúrgicos Urológicos/métodos , Urologistas/legislação & jurisprudência , Urologistas/normas , Urologistas/estatística & dados numéricos
4.
Neurology ; 95(7): e930-e935, 2020 08 18.
Artigo em Inglês | MEDLINE | ID: mdl-32680949

RESUMO

OBJECTIVE: To determine whether the 2013 nerve conduction study (NCS) reimbursement reduction changed Medicare use, payments, and patient access to Medicare physicians by performing a retrospective analysis of Medicare data (2012-2016 fee-for-service data from the CMS Physician and Other Supplier Public Use File). METHODS: Individual billable services were identified by Healthcare Common Procedure Coding System Current Procedural Terminology and G codes. Medicare use and payments were stratified by specialty and type of service (electrodiagnostic tests, including NCS and EMG, and other neurologic procedures). We also assessed access to Medicare physicians using the annual number of unique beneficiaries receiving initial Evaluation and Management (E/M) services. RESULTS: We identified 676,113 Medicare providers included in all analysis years from 2012 to 2016 (10,599 neurologists, 5,881 physiatrists, and 659,633 other specialties). Comparing 2016 to 2012 showed that 21.1% fewer neurologists, 28.6% fewer physiatrists, and 69.3% fewer other specialists performed NCS and 3.8% fewer neurologists, 21.7% fewer physiatrists, and 5.6% fewer other specialists performed EMG. For NCS providers in 2012, the mean number of unique Medicare beneficiaries increased for neurologists (1.2%) and physiatrists (4.8%) but decreased for other specialists (-6.5%) by 2016. After the NCS cut, the number of providers performing autonomic and evoked potential testing increased substantially. CONCLUSIONS: The Medicare NCS reimbursement policy resulted in a larger decrease in NCS providers than in EMG providers. Despite fewer neurologists and physiatrists performing NCS, Medicare access to these physicians for E/M services was not affected. Increased autonomic and evoked potential testing may be an unintended consequence of NCS reimbursement change.


Assuntos
Medicare/legislação & jurisprudência , Políticas , Padrões de Prática Médica/legislação & jurisprudência , Mecanismo de Reembolso , Humanos , Medicare/economia , Médicos/legislação & jurisprudência , Estudos Retrospectivos , Estados Unidos
5.
Pain Physician ; 23(3): E297-E304, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32517406

RESUMO

BACKGROUND: Prescribing opioids has become a challenge. The US Drug Enforcement Agency (DEA) and Centers for Disease Control and Prevention (CDC) have become more involved, culminating in the March 2016 release of the CDC's "Guidelines for Prescribing Opioids for Chronic Pain." OBJECTIVES: Given the new guidelines, we wanted to see if there have been any changes in the numbers, demographics, physician risk factors, charges, and sanctions involving the DEA against physicians who prescribe opioids, when compared to a previous DEA database review from 1998 to 2006. STUDY DESIGN: This study involved an analysis of the DEA database from 2004 to 2017. SETTING: The review was conducted at the Henry Ford Health System Division of Pain Medicine. METHOD: After institutional review board approval at Henry Ford Health System, an analysis of the DEA database of criminal prosecutions of physician registrants from 2004-2017 was performed. The database was reviewed for demographic information such as age, gender, type of degree (doctor of medicine [MD] or doctor of osteopathic medicine [DO]), years of practice, state, charges, and outcome of prosecution (probation, sentencing, and length of sentencing). An internet-based search was performed on each registrant to obtain demographic data on specialty, years of practice, type of medical school (US vs foreign), board certification, and type of employment (private vs employed). RESULTS: Between 2004 and 2017, Pain Medicine (PM) had the highest percentage of in-specialty action at 0.11% (n = 5). There was an average of 18 prosecutions per year vs 14 in the previous review. Demographic risk factors for prosecution demonstrated the significance of the type of degree (MD vs. DO), gender, type of employment (private vs. employed), and board certification status for rates of prosecution. Having a DO degree and being male were associated with significantly higher risk as well as being in private practice and not having board certification (P < .001). In terms of type of criminal charges as a percent of cases, possession with intent to distribute (n = 90) was most prevalent, representing 52.3% of charges, with new charges being prescribing without medical purpose outside the usual course of practice (n = 71) representing 41.3% of charges. Comparison of US graduates (MD/DO) vs. foreign graduates showed higher rates of DEA action for foreign graduates but this was of borderline significance (P = .072). LIMITATIONS: State-by-state comparisons could not be made. Specialty type was sometimes self-reported, and information on all opioid prosecutions could not be obtained. The previous study by Goldenbaum et al included data beyond DEA prosecution, so direct comparisons may be limited. CONCLUSION: The overall risk of DEA action as a percentage of total physicians is small but not insignificant. The overall rates of DEA prosecution have increased. New risk factors include type of degree (DO vs. MD) and being in private practice with a subtle trend toward foreign graduates at higher risk. With the trend toward less prescribing by previously high-risk specialties such as Family Medicine, there has been an increase in the relative risk of DEA action for specialties treating patients with pain such as PM, Physical Medicine and Rehabilitation, neurology, and neurosurgery bearing the brunt of prosecutions. New, more subtle charges have been added involving interpretation of the medical purpose of opioids and standard of care for their use. KEY WORDS: Certification, CDC, criminal, DEA, opioid, prescribing, prosecution, sanctions.


Assuntos
Analgésicos Opioides/uso terapêutico , Médicos/legislação & jurisprudência , Padrões de Prática Médica/legislação & jurisprudência , Má Conduta Profissional/legislação & jurisprudência , Adulto , Prescrições de Medicamentos , Disciplina no Trabalho/estatística & dados numéricos , Feminino , Órgãos Governamentais/legislação & jurisprudência , Regulamentação Governamental , Fidelidade a Diretrizes , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
6.
Med Sci (Paris) ; 36(5): 515-520, 2020 May.
Artigo em Francês | MEDLINE | ID: mdl-32452374

RESUMO

The genetic tests for "non-rare thrombophilias" (TNR) were introduced into clinical setting immediately after the identification of genetic variants in the mid-90s to predict and prevent venous thromboembolism (VTE). Although being a rare example of a genetic test of susceptibility for complex diseases that has been integrated in medical routine, it is the most widespread post-natal genetics inquiry in France nowadays. Yet, determining whom to test and how to use the results is still controversial. This article outlines the trajectory of its clinical regulation and illustrates the importance of the context of use to understand its diffusion. This analysis is intended to feed a more general reflection on the issues raised by the clinical integration of genetic surveys for common diseases, particularly with regard to the clinical utility of a test (statistical vs. biological), the subjects to be tested (the case index and/or her/his relatives), and the criteria underlying access to these tests (modalities of medico-economic assessment).


Assuntos
Testes Genéticos , Trombofilia/diagnóstico , Trombofilia/genética , Acesso à Informação/legislação & jurisprudência , Revelação/ética , Revelação/legislação & jurisprudência , França/epidemiologia , Predisposição Genética para Doença , Testes Genéticos/ética , Testes Genéticos/legislação & jurisprudência , Testes Genéticos/métodos , Acesso aos Serviços de Saúde/ética , Acesso aos Serviços de Saúde/legislação & jurisprudência , História do Século XXI , Humanos , Recém-Nascido , Legislação Médica , Futilidade Médica/ética , Futilidade Médica/legislação & jurisprudência , Triagem Neonatal/ética , Triagem Neonatal/legislação & jurisprudência , Triagem Neonatal/métodos , Padrões de Prática Médica/ética , Padrões de Prática Médica/legislação & jurisprudência , Padrões de Prática Médica/tendências , Valor Preditivo dos Testes , Trombofilia/epidemiologia
7.
PLoS One ; 15(2): e0228495, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32074113

RESUMO

Our objective was to quantify the impact on the use of zolpidem of the obligation implemented in France in 2017 to use secure prescription pads to prescribe it. We conducted a cohort study within the French SNDS healthcare database. Patients aged over 18 years of age were considered for inclusion. The number of prevalent users and incident episodes of zolpidem use were compared before the change in law (July 1, 2016 to January 1, 2017) and after (July 1, 2017 to January 1, 2018). A prevalent user was a patient who has been reimbursed for zolpidem at least once. An incident episode of zolpidem use was defined by a first administration of zolpidem without any prior administration within the previous six months. Regarding prevalence of zolpidem users, we observed a decrease from 2.79% (CI95%:2.75-2.83) to 1.48% (1.44-1.51), with a number of patients who stopped taking it after the change in law being approximately 4.3 times higher than the number of patients who started. We observed a negative association between the post-law change period (OR = 0.52 (0.51-0.53)) and the probability of receiving zolpidem, adjusting for sex, aging, low income and chronic disease. We observed a decrease from 183 treatment episodes per 100,000 insured months on average to 79 episodes per 100,000 insured months, with an incidence rate ratio (IRR) equal to 0.43 (0.38-0.49). The use of secure prescription pads seems to have reduced the exposure of the French population to zolpidem.


Assuntos
Implementação de Plano de Saúde , Padrões de Prática Médica/estatística & dados numéricos , Programas de Monitoramento de Prescrição de Medicamentos , Medidas de Segurança , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Zolpidem/uso terapêutico , Adulto , Idoso , Estudos de Coortes , Confidencialidade/legislação & jurisprudência , Confidencialidade/normas , Bases de Dados Factuais , Registros Eletrônicos de Saúde/estatística & dados numéricos , Feminino , França/epidemiologia , Implementação de Plano de Saúde/legislação & jurisprudência , Implementação de Plano de Saúde/normas , Humanos , Hipnóticos e Sedativos/uso terapêutico , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/legislação & jurisprudência , Padrões de Prática Médica/normas , Padrões de Prática Médica/tendências , Programas de Monitoramento de Prescrição de Medicamentos/legislação & jurisprudência , Programas de Monitoramento de Prescrição de Medicamentos/organização & administração , Programas de Monitoramento de Prescrição de Medicamentos/normas , Prescrições/normas , Prescrições/estatística & dados numéricos , Prevalência , Vigilância de Produtos Comercializados/métodos , Vigilância de Produtos Comercializados/normas , Medidas de Segurança/legislação & jurisprudência , Medidas de Segurança/normas , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Fatores de Tempo
8.
JAMA Netw Open ; 3(1): e1920310, 2020 01 03.
Artigo em Inglês | MEDLINE | ID: mdl-32003819

RESUMO

Importance: Between 2015 and 2017, Ohio had the second highest number of opioid-related deaths. In July 2015, the Ohio General Assembly approved a law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol. This change in the law allowed pharmacists to have more opportunity to participate in the management of patients who were addicted to opioids. Objective: To determine the association between the implementation of an Ohio law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol and naloxone dispensing rates. Design, Setting, and Participants: A segmented regression analysis of an interrupted time series was performed for 30 consecutive months to evaluate the change in the naloxone dispensing rate before and after the implementation of the state law. Ohio Medicaid naloxone claims and Kroger Pharmacy naloxone claims for all 88 counties in Ohio were examined. Any patient 18 years or older with at least 1 naloxone order dispensed through Ohio Medicaid or by a Kroger Pharmacy in Ohio during the study period of July 16, 2014, to January 15, 2017, was included in the study. Data were analyzed from April 23, 2018, to July 7, 2019. Exposures: The primary independent variable was implementation of an Ohio law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol, which took effect in July 2015. Main Outcomes and Measures: The primary outcome measure was the naloxone dispensing rate per month per county. Results: In the Ohio Medicaid population, the number of naloxone orders dispensed after the policy was implemented increased by 2328%, from 191 in the prepolicy period to 4637 in the postpolicy period. The rate of naloxone orders dispensed per month per county after the policy was implemented increased by 4% in the Ohio Medicaid population and 3% in the Kroger Pharmacy population compared with the prepolicy period. The rate of naloxone orders dispensed after the policy was implemented increased by 18% per month in low-employment counties compared with high-employment counties in the Ohio Medicaid population. Conclusions and Relevance: The implementation of a state law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol was associated with an increase in the number of naloxone orders dispensed in the Ohio Medicaid and Kroger Pharmacy populations. Moreover, a significant increase was observed in the naloxone dispensing rate among the Ohio Medicaid population in counties with low employment and high poverty.


Assuntos
Overdose de Drogas/tratamento farmacológico , Prescrições de Medicamentos/estatística & dados numéricos , Prescrições de Medicamentos/normas , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Padrões de Prática Médica/legislação & jurisprudência , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , Medicaid/legislação & jurisprudência , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Ohio , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
9.
Am J Epidemiol ; 189(9): 885-893, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32077469

RESUMO

In 2011, Florida established a prescription drug monitoring program and adopted new regulations for independent pain-management clinics. We examined the association of those reforms with drug overdose deaths and other injury fatalities. Florida's postreform monthly mortality rates-for drug-involved deaths, motor vehicle crashes, and suicide by means other than poisoning-were compared with a counterfactual estimate of what those rates would have been absent reform. The counterfactual was estimated using a Bayesian structural time-series model based on mortality trends in similar states. By December 2013, drug overdose deaths were down 17% (95% credible interval: -21, -12), motor vehicle crash deaths were down 9% (95% credible interval: -14, -4), and suicide deaths were unchanged compared with what would be expected in the absence of reform. Florida's opioid prescribing reform substantially reduced drug overdose deaths. Reforms may also have reduced motor vehicle crash deaths but were not associated with a change in suicides. More research is needed to understand these patterns. Bayesian structural time-series modeling is a promising new approach to interrupted time-series studies.


Assuntos
Acidentes de Trânsito/mortalidade , Analgésicos Opioides/envenenamento , Monitoramento de Medicamentos/métodos , Overdose de Drogas/mortalidade , Controle de Medicamentos e Entorpecentes/legislação & jurisprudência , Suicídio/estatística & dados numéricos , Teorema de Bayes , Causas de Morte , Feminino , Florida/epidemiologia , Humanos , Análise de Séries Temporais Interrompida , Aplicação da Lei , Masculino , Clínicas de Dor/legislação & jurisprudência , Padrões de Prática Médica/legislação & jurisprudência
10.
Zhonghua Yu Fang Yi Xue Za Zhi ; 54(1): 37-38, 2020 Jan 06.
Artigo em Chinês | MEDLINE | ID: mdl-31914566

RESUMO

This standard stipulates the principles, institutional requirements, inspection items, service modes, data management and utilization requirements for carrying out the health check-up for rural residents. It is applicable to the standardized management of the health check-up for rural residents aged 15 years old and above under the relevant national laws and regulations.


Assuntos
Exame Físico/normas , Guias de Prática Clínica como Assunto/normas , População Rural , Adolescente , Adulto , China , Humanos , Padrões de Prática Médica/legislação & jurisprudência
11.
J Minim Invasive Gynecol ; 27(3): 583-592, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31954185

RESUMO

Power morcellation in laparoscopic surgery enables specialists to carry out minimally invasive procedures such as hysterectomies and myomectomies by cutting specimens into smaller pieces using a rotating blade and removing pieces through a laparoscope. Unexpected uterine sarcoma treated by surgery involving tumor disruption could be associated with poor prognosis. The current study aims to shed light on power morcellation from a medicolegal perspective: the procedure has resulted in adverse outcomes and litigation, and compensation for plaintiffs, as published in various journals cited in PubMed and MEDLINE, Cochrane Library, EMBASE, and GyneWeb. Considering the claims after the US Food and Drug Administration warnings on morcellation, the current study broadens the scope of research by including search engines, legal databases, and court filings (DeJure, Lexis Nexis, Justia, superior court of New Jersey, and US district court of Minnesota) between 1995 and 2019. Legal records show that courts determine professional responsibility regarding complications, making it essential to document adherence to safety protocols and specific guidelines, when available. Sound medical practices and clearly stated institute best practices result in better patient outcomes and are important when unfavorable clinical outcomes occur; adverse legal decisions can be avoided if there are grounds to prove professional conformity with specific guidelines and the unpredictability of an event.


Assuntos
Ginecologia/legislação & jurisprudência , Responsabilidade Legal , Morcelação/legislação & jurisprudência , Miomectomia Uterina/legislação & jurisprudência , Neoplasias Uterinas/cirurgia , Feminino , Ginecologia/estatística & dados numéricos , História do Século XX , História do Século XXI , Humanos , Histerectomia/instrumentação , Histerectomia/legislação & jurisprudência , Histerectomia/métodos , Jurisprudência/história , Laparoscopia/instrumentação , Laparoscopia/legislação & jurisprudência , Laparoscopia/métodos , Responsabilidade Legal/história , Morcelação/instrumentação , Morcelação/métodos , Relações Médico-Paciente , Padrões de Prática Médica/legislação & jurisprudência , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Prognóstico , Sarcoma/diagnóstico , Sarcoma/epidemiologia , Sarcoma/cirurgia , Resultado do Tratamento , Estados Unidos/epidemiologia , United States Food and Drug Administration , Miomectomia Uterina/instrumentação , Miomectomia Uterina/métodos , Neoplasias Uterinas/diagnóstico , Neoplasias Uterinas/epidemiologia
12.
Drug Alcohol Depend ; 206: 107754, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-31786399

RESUMO

OBJECTIVES: States in the US are controlling opioid prescribing to combat the opioid epidemic. Prescription Drug Monitoring Programs (PDMPs) were widely adopted, whereas less attention was given to pain clinic laws. This study examined the associations of mandatory use of PDMPs and pain clinic laws with prescription opioid exposures. METHODS: State-level quarterly prescription opioid exposures reported to the National Poison Data System during 2010-2017 were analyzed. The primary outcome was age-adjusted rates of prescription opioid exposures per 1,000,000 population. The primary policy variables included the implementation of mandatory use of PDMPs alone, the implementation of pain clinic laws alone, and the implementation of both mandatory use of PDMPs and pain clinic laws. Linear regressions were used to examine the associations, controlling for other opioid policies, marijuana policies, socioeconomic factors, state fixed effects, time fixed effects, and state-specific time trends. RESULTS: Requiring mandatory use of PDMPs alone was not associated with significant changes in prescription opioid exposures. The implementation of pain clinic laws with or without concurrent mandatory use of PDMPs was associated with 5 fewer prescription opioid exposures per 1,000,000 population or a 9 % reduction compared to the pre-policy period (p < 0.01). Further analysis revealed that the reduction associated with pain clinic laws was pronounced in exposures reported by healthcare facilities. CONCLUSIONS: This multi-state study provided new evidence that the implementation of pain clinic laws was associated with a significant reduction in prescription opioid exposures. Pain clinic laws may deserve further evaluation and consideration.


Assuntos
Analgésicos Opioides/envenenamento , Clínicas de Dor/legislação & jurisprudência , Dor/tratamento farmacológico , Dor/epidemiologia , Centros de Controle de Intoxicações/legislação & jurisprudência , Programas de Monitoramento de Prescrição de Medicamentos/legislação & jurisprudência , Adulto , Analgésicos Opioides/efeitos adversos , Feminino , Humanos , Masculino , Clínicas de Dor/tendências , Centros de Controle de Intoxicações/tendências , Padrões de Prática Médica/legislação & jurisprudência , Padrões de Prática Médica/tendências , Programas de Monitoramento de Prescrição de Medicamentos/tendências , Estados Unidos/epidemiologia
14.
J Microbiol Immunol Infect ; 53(1): 133-140, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29886011

RESUMO

OBJECTIVE: A policy initiated in 2001 by Taiwan's National Health Insurance (NHI) Administration has effectively reduced outpatient antibiotic use except fluoroquinolones (FQs). The influence of differential regulation policy of narrow-spectrum versus broad-spectrum FQs on the prescriptions is unknown. METHODS: This study analyzed the claim records of oral FQs prescription at outpatient visits during 2000-2010 using the NHI Research Database and compared prescriptions for narrow-spectrum FQs, which are inactive against Streptococcus pneumoniae and lack formulary restriction, with those for broad-spectrum FQs. RESULTS: Oral antibiotics were prescribed in 13.3% of visits and FQs accounted for 2.2% of them. During the study period the population-based rates of FQ prescription visits to children decreased, which was offset by increased use in the adult and geriatric populations (all p < 0.001). The most common encoded diagnoses for all FQs were urinary tract infection (19.2%) and sinusitis (10.9%), skin/bone/joint infections (7.9%), and lower respiratory tract infections (LRTI, 4.8%). Narrow-spectrum FQs accounted for 88.4% of all FQ prescriptions. Up to 95.4% of visits from patients with sinusitis and 34.3% of those with LRTI used narrow-spectrum FQs, while S. pneumoniae is an important etiology. Otorhinolaryngologists in non-hospital-based clinics prescribed most of narrow-spectrum FQs to patients with sinusitis or LRTI. CONCLUSIONS: We found debatable prescription of narrow-spectrum FQ based on claim records, particularly for LRTI and sinusitis, possibly due to the lack of formulary restriction. Additional efforts are needed to improve the appropriate selection of optimal FQs.


Assuntos
Antibacterianos/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Fluoroquinolonas/uso terapêutico , Padrões de Prática Médica/legislação & jurisprudência , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Adulto , Idoso , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Infecções Respiratórias/tratamento farmacológico , Taiwan , Adulto Jovem
15.
Drug Alcohol Depend ; 206: 107591, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-31765860

RESUMO

BACKGROUND: Pain clinic laws are designed to cease or modify high-risk prescribing behavior. However, prior evaluations have not differentiated between these types of prescriber responses in their analysis, even though they may have different implications for patients. The purpose of this analysis is to investigate the effect of a 2016 Tennessee pain clinic law on the two types of prescriber responses. METHODS: We used data on opioid prescriptions from the Tennessee Controlled Substances Monitoring Database (CSMD) between July 1st, 2015 and July 1st, 2017. Prescribers were assigned to the cessation or modification group based on the date of their last opioid prescription during the time period July 1st, 2015 to July 1st, 2018 and its relationship to the change in law. A risk score was developed based on five indicators to capture two categories of risky prescriber behavior: increased risk for diversion or increased patient's risk of overdose. Within-prescriber differences were used to assess the effect of the law on several outcomes that capture the quantity and content of opioid prescriptions. RESULTS: There was a significant decline in the number of prescriptions (cessation mean = -45.18 pval<0.001; continuation mean = -24.41 pval<0.001) and patients (cessation mean = -16.68pval<0.001; continuation mean = -10.92 pval<0.001) in both prescriber response groups, but the magnitude of decline was much larger in the cessation group. High-risk prescribers were more likely to cease prescribing than modify. CONCLUSIONS: Prescribers who ceased prescribing in response to the pain clinic law disproportionately contributed to overall declines in opioid prescriptions.


Assuntos
Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Prescrição Inadequada/estatística & dados numéricos , Clínicas de Dor/legislação & jurisprudência , Padrões de Prática Médica/estatística & dados numéricos , Substâncias Controladas , Feminino , Humanos , Prescrição Inadequada/legislação & jurisprudência , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/legislação & jurisprudência , Tennessee
16.
N Z Med J ; 132(1488): 49-54, 2019 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-31851661

RESUMO

AIM: To describe disciplinary cases for inappropriate prescribing of drugs of dependence by doctors in New Zealand, 1997-2016. METHODS: A retrospective analysis of disciplinary decisions to describe characteristics of cases (setting, drugs, outcome) and doctors (sex, specialty, years since qualification). RESULTS: There were 25 disciplinary decisions involving 24 doctors. Disciplined doctors were mostly male (19;76%), working in general practice (19;76%), and older (mean 24 years in practice). Pharmacists were the most common source of notification to the authorities (6;24%); medical colleagues reported only four (16%). The alleged misconduct often involved behaviour in addition to inappropriate prescribing. In all cases the doctor was found guilty of professional misconduct. Penalties were severe: six doctors were removed from practice, 11 were suspended, and of the remainder all but one had restrictions on practice imposed. In many decisions there was no patient harm documented. CONCLUSION: Disciplinary cases for inappropriate prescribing of drugs of dependence by doctors in New Zealand are not common, but the consequences can be dire. The role of discipline in doctors with drug dependence is unclear.


Assuntos
Prescrição Inadequada , Médicos/legislação & jurisprudência , Padrões de Prática Médica/legislação & jurisprudência , Má Conduta Profissional/legislação & jurisprudência , Feminino , Humanos , Prescrição Inadequada/economia , Prescrição Inadequada/legislação & jurisprudência , Masculino , Nova Zelândia/epidemiologia , Estudos Retrospectivos , Transtornos Relacionados ao Uso de Substâncias
19.
JAMA Facial Plast Surg ; 21(6): 487-490, 2019 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-31600382

RESUMO

Importance: Opioid prescriptions have increased substantially over the last 2 decades, contributing to the opioid epidemic. Physician practices and legislative changes play a key role in decreasing prescription opioid use. Objective: To evaluate changes in opioid prescribing habits for patients undergoing rhinoplasty and/or septoplasty before and after the adoption of new opioid legislation. Design, Setting, and Participants: This single-institution case-control study examined opioid prescribing habits for 80 patients who were undergoing rhinoplasty and septoplasty with or without turbinate reduction at the University of Vermont between March 2016 and May 2018. Patients were excluded if they underwent concomitant endoscopic sinus surgery or were younger than 14 years. Patients were divided by surgery date before or after legislative changes on July 1, 2017. Exposures: Rhinoplasty and septoplasty with or without turbinate reduction. Main Outcomes and Measures: Patient demographics and opioid prescriptions were recorded. Patients were evaluated if they reported pain during follow-up, called the office, or received a second prescription. The Vermont Prescription Monitoring System was queried to determine if opioid prescriptions were filled within 30 days of the procedure. The 2 groups were compared to test the hypothesis that opioid prescriptions had decreased after legislative changes. Results: Of a total of 80 participants, the mean (SD) age in the before (15 women [37.5%]) and after (16 women [40.0%]) groups were 41.4 years and 40.6 years, respectively. There was a statistically significant decrease in the number of pills prescribed to the after group (17.5 to 9.7; P < .001) as well as a decrease in the morphine milligram equivalents that were prescribed (130.9 to 73.2; P < .001). There was no statistical difference in the number of postoperative telephone calls for pain, second prescriptions, or increased complaints of pain at the postoperative visit. Conclusions and Relevance: Recent laws in Vermont regarding opioid prescribing were implemented in 2017 to curb the ongoing opioid epidemic. Our observations of patients undergoing septoplasties and rhinoplasties found a significant reduction in opioid prescriptions. This was not associated with an increase in patient complaints about postoperative pain or the need for a second prescription after surgery. This shows that we may safely be able to decrease the number of narcotic medications that we prescribe. Level of Evidence: 3.


Assuntos
Analgésicos Opioides/uso terapêutico , Controle de Medicamentos e Entorpecentes/legislação & jurisprudência , Septo Nasal/cirurgia , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica/legislação & jurisprudência , Rinoplastia , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Medição da Dor , Vermont
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