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2.
Expert Opin Drug Metab Toxicol ; 16(2): 125-141, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31976778

RESUMO

Introduction: Opioids continue to be used widely for pain management. Widespread availability of prescription opioids has led to opioid abuse and addiction. Besides steps to reduce inappropriate prescribing, exploiting opioid pharmacology to make their use safer is important.Areas covered: This article discusses the pathology and factors underlying opioid abuse. Pharmacokinetic and pharmacodynamic properties affecting abuse liability of commonly abused opioids have been highlighted. These properties inform the development of ideal abuse deterrent products. Mechanisms and cost-effectiveness of available abuse deterrent products have been reviewed in addition to the pharmacology of medications used to treat addiction.Expert opinion: The opioid crisis presents unique challenges to managing pain effectively given the limited repertoire of strong analgesics. The 5-point strategy to combat the opioid crisis calls for better preventive, treatment, and recovery services, better data, better pain management, better availability of overdose-reversing drugs and better research. There is an urgent need to decrease the cost of abuse deterrent opioids which deters their cost-effectiveness. In addition, discovery of novel analgesics, further insight into central and peripheral pain mechanisms, understanding genomic risk profiles for efficient targeted efforts, and education will be key to winning this fight against the opioid crisis.


Assuntos
Analgésicos Opioides/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Formulações de Dissuasão de Abuso , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/economia , Animais , Análise Custo-Benefício , Overdose de Drogas/tratamento farmacológico , Humanos , Prescrição Inadequada/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Dor/tratamento farmacológico
3.
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.
Expert Rev Clin Pharmacol ; 13(1): 15-22, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31790317

RESUMO

Introduction: STOPP (Screening Tool of Older Persons' Prescriptions) and START (Screening Tool to Alert to Right Treatment) are explicit criteria that facilitate medication review in multi-morbid older people in most clinical settings. This review examines the clinical trial evidence pertaining to STOPP/START criteria as an intervention.Areas covered: The literature was searched for registered clinical trials that used STOPP/START criteria as an intervention. In single-center trials, applying STOPP/START criteria improved medication appropriateness, reduced polypharmacy, reduced adverse drug reactions (ADRs), led to fewer falls, and lower medication costs. Two large-scale multi-center trials (SENATOR and OPERAM) examined the impact of computer-generated STOPP/START criteria on incident ADRs (SENATOR) and drug-related hospitalizations (OPERAM) in multi-morbid older people. Results of these trials will be publicized in 2020.Expert opinion: Applying STOPP/START criteria improves clinical outcomes in multi-morbid older people. Electronic deployment of STOPP/START criteria is a substantial technical challenge; however, recent clinical trials of software prototypes demonstrate feasibility. Even with well-functioning software for the application of STOPP/START criteria, the need remains for face-to-face interaction between attending clinicians and appropriately trained personnel (likely pharmacists) to explain and qualify specific STOPP/START recommendations in individual multi-morbid older patients. Such interaction is essential for the implementation of relevant STOPP/START recommendations.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Prescrição Inadequada/prevenção & controle , Lista de Medicamentos Potencialmente Inapropriados , Idoso , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Hospitalização/estatística & dados numéricos , Humanos , Polimedicação , Padrões de Prática Médica/normas
6.
Rev Chilena Infectol ; 36(4): 403-413, 2019 Aug.
Artigo em Espanhol | MEDLINE | ID: mdl-31859762

RESUMO

Invasive fungal disease (IFD) is a condition affecting immunosuppressed and critically ill patients. Recently there has been an increase in the amount of patients at risk for IFD, which implies an increase in the prescription of antifungal agents as prophylactic, pre-emptive or empiric therapy. Some studies evaluating appropriateness of antifungal prescription have shown that inappropriate formulations reach 72%, exposing patients to side effects, pharmacological interactions and rising costs. Some groups have recommended many interventions to control and make a rational use of antimicrobials, into strategies known as "antimicrobial stewardship", these interventions are useful also for antifungal agents and it has been named "antifungal stewardship". Here we present a narrative review of the scientific literature showing published articles about appropriate use of antifungal agents and the experience of some centers after implementing antifungal stewardship programs.


Assuntos
Antifúngicos/administração & dosagem , Antifúngicos/efeitos adversos , Gestão de Antimicrobianos/métodos , Prescrição Inadequada/prevenção & controle , Infecções Fúngicas Invasivas/tratamento farmacológico , Monitoramento de Medicamentos , Humanos , Hospedeiro Imunocomprometido , Prescrição Inadequada/estatística & dados numéricos , Infecções Fúngicas Invasivas/diagnóstico
7.
Yakugaku Zasshi ; 139(11): 1449-1456, 2019.
Artigo em Japonês | MEDLINE | ID: mdl-31685741

RESUMO

Benzodiazepine receptor agonists (BZDs) should be appropriately used owing to the associated risks of delirium and falls. Since January 2018, the liaison team pharmacist at Iizuka Hospital has been applying digital labels with recommendations for the reduction of use and changes in the medication orders and prescriptions of BZDs on electronic medical records of patients in the surgical ward. This study aimed to verify the effectiveness of reducing the use of BZDs via the implementation of digital labels. Patients in the surgical ward were retrospectively assessed for changes in medication orders and prescription ratios of BZDs before and after the implementation of digital labels. The ratio of the number of digital labels implemented to the number of confirmations of medication orders and prescriptions of BZDs was 15.0% at the start of implementation; however, the ratio gradually and significantly decreased to 3.6%. The medication order ratio of BZDs was 52.2% before the implementation of digital labels; however, this ratio decreased to 2.7% and 5.6% immediately and 4 months after the implementation of digital labels, respectively. The present study showed that medication orders for BZDs were reduced after the implementation of digital labels and that the reduction effect was maintained for a certain period of time. Thus, the liaison team pharmacist-led approach can contribute to the proper use of BZDs.


Assuntos
Uso de Medicamentos/estatística & dados numéricos , Registros Eletrônicos de Saúde , Agonistas de Receptores de GABA-A , Prescrição Inadequada/prevenção & controle , Acidentes por Quedas , Idoso , Idoso de 80 Anos ou mais , Delírio/induzido quimicamente , Feminino , Agonistas de Receptores de GABA-A/administração & dosagem , Agonistas de Receptores de GABA-A/efeitos adversos , Humanos , Prescrição Inadequada/estatística & dados numéricos , Masculino , Prescrições/estatística & dados numéricos
9.
Rev. clín. esp. (Ed. impr.) ; 219(7): 375-385, oct. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-ET1-4054

RESUMO

Introducción y objetivos: La prescripción potencialmente inapropiada (PPI) es frecuente en ancianos. Se ha convertido en un problema de salud pública mundial por su relación con efectos adversos a medicamentos (EAM), aumento de la morbimortalidad, visitas a urgencias y consumo de recursos. El objetivo principal de este estudio fue determinar si el uso de un programa de notificación de PPI en pacientes ancianos hospitalizados condujo a una reducción en su prescripción. Método: Se realizó un estudio quasi-experimental pre-post. La identificación de las PPI se llevó a cabo según los criterios de Beers (actualización 2012) y STOPP-START (versión 2008). Se elaboró un informe individualizado sobre PPI y se evaluó el efecto de esta intervención. Resultados: Se incluyeron 174 pacientes con 284 PPI. Se aceptaron el 54% (153) de las recomendaciones. La única variable que demostró contribuir a la presencia de modificaciones en la PPI fue el índice de Barthel. Los pacientes a los que se les modificó la PPI se caracterizaron por ser significativamente más dependientes (p=0,005), presentar deterioro cognitivo (p=0,001) y encontrarse más institucionalizados (p=0,039) que aquellos a los que no se les realizó ninguna modificación. Se produjeron menos reingresos, visitas a urgencias y menor mortalidad al comparar los pacientes con y sin modificaciones de PPI, pero sin diferencias significativas. Se identificaron 32 EAM, 29 relacionados con fármacos inapropiados. Los EAM se asociaron con PPI respecto a otros fármacos de manera significativa (p<0,001), odds ratio 242,5 (IC 95%: 56,9-1.023,6). Conclusiones: La revisión de la medicación en pacientes de edad avanzada, junto con el uso de herramientas que ayudan en la identificación de fármacos inapropiados, conlleva una reducción de la PPI y contribuye de manera significativa a la mejora continua de la medicación crónica en los ancianos


Introduction and objectives: Potentially inappropriate prescription (PIP) is common in elderly people. It has become a global public health problem due to its association with adverse drug effects (ADE), increased morbidity and mortality, emergency care visits and resource use. The main aim of this study was to determine whether the use of a notification program of PIP in elderly patients admitted in the hospital led to a reduction of their prescription. Method: A quasi-experimental before-after study was conducted. PIP were identified by using Beers (2012 update) and STOPP-START criteria (2008 version). An individualized report on PPI was prepared and the effect of this intervention was evaluated. Results: 174 patients were included who presented 284 PIP. 54% (153) of the recommendations were accepted. Barthel index was the only variable that proved to contribute to the presence of PIP modifications. The patients whose PIP drugs were modified were significantly more dependent (p=0.005), presented cognitive impairment (p=0.001) and were more institutionalized (p=0.039) than those without any modifications. There were fewer readmissions, emergency care visits and mortality within six months after intervention comparing patients with and without PIP modifications, but without significant differences. 32 ADE were detected, 29 related with PIP drugs. Adverse events were significantly associated with PIP drugs, versus other medications (p<0.001), odds ratio 242.5 (CI95%: 56.9-1023.6). Conclusions: Review of medication in elderly patients, along with the use of tools that help in the identification of dangerous drugs, entail a reduction of inadequate prescription and significantly contribute to the continuous improvement of chronic medication in elders


Assuntos
Humanos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Prescrição Inadequada/prevenção & controle , Hospitalização/estatística & dados numéricos , Reconciliação de Medicamentos/organização & administração , Conduta do Tratamento Medicamentoso/organização & administração , Avaliação de Eficácia-Efetividade de Intervenções , Melhoria de Qualidade/tendências , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Segurança do Paciente , Estudos Prospectivos
10.
Expert Opin Drug Saf ; 18(11): 1091-1098, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31524003

RESUMO

Objectives: Inappropriate prescription is a problem related to aging and deprescription could be a possible strategy. The aim of this study was to adapt the available evidence on deprescribing to the medication management of older people living in long-term care facilities. Methods: The authors carried out a bibliographic search based on the most prevalent drugs in our context to develop a specific deprescribing intervention. A committee of experts reviewed this intervention which was later validated through an interobserver variability study. Finally, the authors evaluated it in a sample of patients through a controlled before-after study. Results: The authors included 119 subjects living in a public elderly long-term care center and 122 controls living in a center with similar clinical characteristics. The authors evaluated 852 medications, identifying a total of 175 (20.5%) potentially inappropriate medications and 162 (92.5%) drugs were deprescribed (1.4 per patient). The application of the intervention meant an annual saving of 9.525.25 €. Conclusion: The implementation of a deprescribing intervention aimed at the most prevalent drugs prescribed in a particular setting improves the appropriateness of pharmacotherapy in the patients.


Assuntos
Desprescrições , Prescrição Inadequada/prevenção & controle , Conduta do Tratamento Medicamentoso/organização & administração , Lista de Medicamentos Potencialmente Inapropriados , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Custos de Medicamentos , Feminino , Instituição de Longa Permanência para Idosos , Humanos , Prescrição Inadequada/economia , Assistência de Longa Duração/normas , Masculino , Casas de Saúde , Padrões de Prática Médica/normas
11.
Int J Pediatr Otorhinolaryngol ; 127: 109677, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31526937

RESUMO

INTRODUCTION: Exercise-induced laryngeal obstruction (EILO) affects 2-3% of the general population and 5.1% of elite athletes. Symptoms arise during high-intensity exercise and resolve at rest. EILO is often misdiagnosed as exercise-induced asthma as both conditions can present with dyspnea, chest tightness and cough. The purpose of this quality initiative was to identify patient characteristics that predict a higher likelihood of EILO, streamline referrals for exercise-endoscopy testing and avoid unnecessary medications. METHODS: A retrospective chart review included patients referred to a pediatric tertiary center between 2013 and 2018 for suspected EILO requesting exercise endoscopy. Data was collected from the patient chart and referral letters included age, sex, physical activity, medications, symptoms, and results of pulmonary and cardiac function tests. RESULTS: Between 2013 and 2018, 35 patients (9 males and 26 females, aged 5-18 years) were referred. Only 18 patients developed symptoms during an exercise endoscopy test. The majority were female (15/18), older than 10 years (18/18) and were involved in competitive sports (16/18). Stridor was the most common complaint among all patients referred (24/35) and many reported anxiety and high stress (15/35). The majority (63%) were previously treated with asthma medication. Pulmonary and cardiac function testing was not predictive of EILO. CONCLUSION: EILO is typically present in adolescent females involved in competitive sports. Anxiety and high stress was commonly noted. The majority were treated with asthma medication even though pulmonary function testing was normal. Recognition of this patient profile should improve timely access to appropriate diagnostic assessments, avoid unnecessary medical treatment, and promote a return to optimal athletic performance.


Assuntos
Obstrução das Vias Respiratórias/diagnóstico , Asma Induzida por Exercício/diagnóstico , Exercício , Doenças da Laringe/diagnóstico , Adolescente , Obstrução das Vias Respiratórias/etiologia , Antiasmáticos/uso terapêutico , Asma Induzida por Exercício/tratamento farmacológico , Criança , Pré-Escolar , Diagnóstico Diferencial , Dispneia/etiologia , Teste de Esforço , Feminino , Humanos , Prescrição Inadequada/prevenção & controle , Doenças da Laringe/etiologia , Laringoscopia , Masculino , Testes de Função Respiratória , Sons Respiratórios/etiologia , Estudos Retrospectivos , Fatores de Risco
12.
Infez Med ; 27(3): 251-257, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31545768

RESUMO

The emergence of antibiotic resistance as a consequence of inappropriate use results in higher mortality rates and has become a major public health challenge worldwide. Antimicrobial stewardship programs (ASPs) aim to ensure proper use of antimicrobials and reduce health care costs. We assessed the impact of using a behavioral approach during a persuasive ASP on antibiotic appropriateness, consumption and costs. We conducted a prospective interventional cohort before-and-after study in the intensive care unit (ICU) of a 554-bed, university teaching hospital in Terni, Italy, 14 of which are located in the ICU. We describe a 10-month persuasive ASP intervention model used in a referral ICU with daily rounds. The aim of the study was to improve medication appropriateness through educational action and reduce the consumption of carbapenems and echinocandins by conducting post-prescription reviews, prescribing reviews and holding daily discussions with the ICU team. We analyzed the prescribing appropriateness of the ICU team in accordance with the decisions made by the Antimicrobial Stewardship (AMS) team to improve the quality of antibiotic prescribing during the first five months and the last five months of the surveillance period. The results were expressed as the defined daily dose (DDD) per 100 occupied bed-days and costs. The data were compared with those previously obtained during the pre-educational period (the year before ASP implementation). Comparisons were made between the decisions taken to improve antimicrobial treatments administered during the first half of the surveillance period (March-July) and those administered during the second half (August-December). In all, 116 decisions were made from March to July while only 65 were made from August to December (p-value 0.00001). A significant reduction was observed in the consumption of carbapenems and echinocandins (11.15% and 25.62%, respectively). Total antibiotic cost savings amounted to 57,541.16 euros. The persuasive ASP strategy positively influenced the prescribing behavior of physicians, thus improving the appropriateness of antibiotic therapy and reducing antimicrobial consumption.


Assuntos
Gestão de Antimicrobianos , Carbapenêmicos/uso terapêutico , Farmacorresistência Bacteriana , Equinocandinas/uso terapêutico , Prescrição Inadequada/prevenção & controle , Unidades de Terapia Intensiva , Carbapenêmicos/economia , Estudos Controlados Antes e Depois , Equinocandinas/economia , Hospitais de Ensino , Humanos , Itália , Modelos Organizacionais , Estudos Prospectivos , Fatores de Tempo
13.
Australas J Ageing ; 38 Suppl 2: 9-25, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31496065

RESUMO

OBJECTIVE: To systematically review literature reporting processes, impact and outcomes of medication review and reconciliation in Australian residential aged care facilities (RACFs). METHODS: PubMed/MEDLINE, EMBASE, CINAHL, Informit Health and grey literature were searched from 1995 to July 2018. Studies reporting outcomes of a stand-alone medication review or reconciliation interventions in Australian RACFs were included. RESULTS: Thirteen studies investigated medication review, eight of which studied Residential Medication Management Reviews (RMMRs). Five studies reported that medication reviews identified an average of 2.7-3.9 medication-related problems (MRPs) per resident. One study reported medication reviews had no impact on quality of life, hospitalisation or mortality, but was not powered to assess these. Three studies reported general practitioners' acceptance of pharmacists' recommendations to resolve MRPs, ranging between 45 and 84%. CONCLUSIONS: Medication review may be a useful strategy to identify and prompt resolution of MRPs. However, the impact on clinical and resident-centred outcomes remains unclear.


Assuntos
Instituição de Longa Permanência para Idosos , Conduta do Tratamento Medicamentoso , Casas de Saúde , Idoso , Idoso de 80 Anos ou mais , Austrália , Interações de Medicamentos , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Feminino , Humanos , Prescrição Inadequada/prevenção & controle , Masculino , Erros de Medicação/prevenção & controle , Polimedicação , Medição de Risco , Fatores de Risco
16.
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
17.
Int J Pediatr Otorhinolaryngol ; 126: 109616, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31376791

RESUMO

BACKGROUND: The rate of antibiotic prescribing for acute otitis media (AOM) remains high despite efforts to decrease inappropriate use. Studies have aimed to understand the prescribing patterns of providers to increase antibiotic stewardship. Watch and wait (WAW) prescriptions are effective at decreasing the number of antibiotic prescriptions being filled by patients. Additionally, poor continuity of care has been associated with higher cost and lower quality health care. OBJECTIVE: To understand the antibiotic prescribing habits for AOM in a largely Hispanic population. METHODS: A retrospective review was performed from 2016 to 2018 of all patients under 25 years old with a diagnosis of AOM seen at multiple outpatient primary care clinics of a single institution. Charts were reviewed for factors including race, ethnicity, gender, insurance status, presence of fever, primary care physician visit, and treatment choice. Data were collected and analyzed using STATA software with t-tests, ANOVA, and Pearson chi squared analysis. RESULTS: Antibiotics were prescribed 95.6% of the time with 3.8% being WAW prescriptions. There was no significant difference in antibiotic prescribing by race (p = 0.66), ethnicity (p = 0.38), gender (p = 0.34) or insurance status (p = 0.24). There was a difference between physicians, nurse practitioners, and physician's assistants and antibiotic prescribing rate (p < 0.01). Additionally, seen by their primary care provider were less likely to be prescribed antibiotics (85.8% vs 94.4%, p = 0.01). CONCLUSION: While a patient's race, ethnicity, gender, and insurance status did not influence the prescribing rate of physicians, continuity of care may play an important role in decreasing inappropriate antibiotic prescribing.


Assuntos
Antibacterianos/uso terapêutico , Continuidade da Assistência ao Paciente , Prescrição Inadequada/estatística & dados numéricos , Otite Média/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Doença Aguda , Adolescente , Análise de Variância , Criança , Feminino , Hispano-Americanos , Humanos , Prescrição Inadequada/prevenção & controle , Seguro Saúde , Masculino , Otite Média/etnologia , Estudos Retrospectivos , Texas
18.
Am J Health Syst Pharm ; 76(Supplement_3): S85-S90, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31418771

RESUMO

PURPOSE: A novel automatic discontinuation policy implemented within an antimicrobial stewardship program (ASP) is described, and results of an evaluation of the policy's effects on antibiotic usage are reported. METHODS: A retrospective, before-and-after study was conducted at an 800-bed, tertiary care, academic teaching hospital to evaluate selected antibiotic usage outcomes in both intensive care unit (ICU) and non-ICU adult patients targeted for ASP interventions before and after implementation of an automatic discontinuation of antibiotics policy (ADAP) authorizing the ASP team to automatically halt antibiotic therapy in cases involving inappropriate duplicate antimicrobial coverage or excess duration of therapy. The primary outcome was total days of antibiotic therapy. Secondary outcomes included excess days of therapy and rates of 30-day readmission, Clostridioides difficile infection, and multidrug-resistant infection. RESULTS: There were no statistically significant differences in group demographics or clinical characteristics. The most common indication for antibiotics was hospital-acquired pneumonia, and the most common reason for ASP intervention was excess duration of therapy. The mean total number of antibiotic days per patient was reduced from 7.6 days in the pre-ADAP group to 6.6 days in the post-ADAP group (p < 0.05). The mean number of excess days of antibiotics was similarly reduced, from 2.3 days to 1.5 days, after implementation of the ADAP (p < 0.05). CONCLUSION: Adoption of an ADAP-a more active approach to ASP interventions-was effective in reducing overall antibiotic usage and improving the efficiency of the ASP.


Assuntos
Antibacterianos/uso terapêutico , Gestão de Antimicrobianos/organização & administração , Infecções por Clostridium/epidemiologia , Guias de Prática Clínica como Assunto , Antibacterianos/farmacologia , Gestão de Antimicrobianos/normas , Gestão de Antimicrobianos/estatística & dados numéricos , Infecções por Clostridium/microbiologia , Infecções por Clostridium/prevenção & controle , Clostridium difficile/efeitos dos fármacos , Clostridium difficile/isolamento & purificação , Farmacorresistência Bacteriana Múltipla , Feminino , Humanos , Prescrição Inadequada/prevenção & controle , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Políticas , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Centros de Atenção Terciária/organização & administração , Centros de Atenção Terciária/estatística & dados numéricos
19.
Drugs Aging ; 36(10): 969-978, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31435913

RESUMO

BACKGROUND: To improve drug treatment in older people, who often present with multimorbidity and related polypharmacy, the FORTA (Fit fOR The Aged) List was developed via a Delphi consensus procedure. As a patient-in-focus listing approach (PILA), it has been clinically validated (VALFORTA trial). Unlike drug-oriented listing approaches (DOLAs), its application requires knowledge of patients' characteristics, including diagnoses and other details. As a drug list with discrete labels, application of FORTA seems particularly amenable to electronic support. METHODS: An information technology (IT) algorithm was developed to analyze bulk data on International Classification of Diseases (ICD)-coded diseases and Anatomical Therapeutic Chemical (ATC)-coded drugs. FORTA-labeled diagnoses and drugs were used to compute the FORTA score, an automatically generated score that describes medication quality by adding up points assigned for errors related to over- and under-treatment. The algorithm detects mismatches between diagnoses and drugs, suboptimal drugs, omitted drugs, and deficient medication escalation schemes. The read-out produces explanations for each error point. RESULTS: A total of 5603 and 7954 patients ≥ 65 years were included from two claims datasets (> 30,000 patients each, public health insurance). The FORTA scores were comparable (mean ± standard deviation 4.29 ± 3.37 vs. 4.17 ± 3.16), and similar to that determined in VALFORTA (pre-intervention 3.5 ± 2.7). Under-treatment was two times more prevalent than over-treatment. The main areas of under-treatment were pain, type 2 diabetes mellitus, and depression, and the main areas of over-treatment were gastrointestinal (proton pump inhibitors), pain (non-steroidal anti-inflammatory drugs), and arterial hypertension (ß-blockers). The FORTA score is positively correlated with higher age, a higher Charlson Comorbidity Index, and more frequent hospitalizations. Patients in disease management programs run by public health insurers had higher scores than comparators. CONCLUSIONS: The algorithm produces plausible analyses of medication errors in older people, pointing to established areas of therapeutic deficiencies. Though individual recommendations exist, the algorithm cannot employ the full potential of FORTA as important details (e.g., blood pressure values, pain intensity) are not (yet) included. However, it seems capable of detecting medication problems in large cohorts-FORTA-EPI (Epidemiological) is designed to support epidemiological analyses, e.g., on comparisons of large cohorts, interventional impact, or longitudinal trends.


Assuntos
Algoritmos , Tratamento Farmacológico/normas , Erros de Medicação/estatística & dados numéricos , Polimedicação , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Consenso , Técnica Delfos , Métodos Epidemiológicos , Feminino , Humanos , Prescrição Inadequada/prevenção & controle , Masculino , Erros de Medicação/prevenção & controle
20.
Yakugaku Zasshi ; 139(8): 1073-1079, 2019.
Artigo em Japonês | MEDLINE | ID: mdl-31366841

RESUMO

"Academic detailing" is used to clearly explain scientific issues. In the field of clinical practice, "academic detailing" is a form of interactive educational outreach to physicians in order to provide unbiased, non-commercial, evidence-based information about medications and other therapeutic modalities, with the goal of improving patient care. It is necessary to provide proper information about prescription drugs for their appropriate use in clinical practice. However, this requires of physicians significant time and labor to comprehensively collect and summarize all necessary information for the proper clinical application of pharmaceutical products, a task which may be both difficult and prohibitive to a busy physician. However, if clinical experience and other pharmaceutical or treatment information is derived solely from the commercial entities, this may lead to improper prescription practices. In western countries, public funds are used to support universities and other research institution programs. In Canada, clinical pharmacists act as "detailers". Their mission and role is to listen to the needs of the physician or health care professional, to provide objective, evidence-based drug information on selected drug therapy topics, to educate physicians on the optimal use of medications, to provide practical alternatives, and to extend the physician's usable knowledge base. The importance of this "academic detailing" activity is also recognized in Japan, and pharmacists can be expected to act as detailers in the future. We hope that this will lead to improvement in the quality of medical care.


Assuntos
Serviços de Informação sobre Medicamentos , Tratamento Farmacológico , Assistência ao Paciente , Farmacêuticos , Médicos , Medicamentos sob Prescrição , Melhoria de Qualidade , Qualidade da Assistência à Saúde , Análise Custo-Benefício , Tratamento Farmacológico/economia , Educação Médica Continuada , Humanos , Prescrição Inadequada/prevenção & controle , Medicamentos sob Prescrição/economia , Papel Profissional
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