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2.
Med J Aust ; 213(9): 417-423, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33037644

RESUMO

OBJECTIVES: To evaluate whether educating junior doctors and hospital pharmacists about analgesic prescribing improved discharge prescribing of opioids for opioid-naïve patients after surgical admissions. DESIGN: Cluster randomised controlled trial, undertaken during the first half of 2019. SETTING: The Alfred Hospital, a major Melbourne teaching hospital with 13 surgical units. PARTICIPANTS: Opioid-naïve patients discharged from surgical units after a stay of at least 24 hours. INTERVENTION: Surgical units were randomised to the intervention or control arms. Interns, residents, and clinical pharmacists assigned to intervention arm units attended education sessions, presented by the hospital analgesic stewardship pharmacist, about appropriate analgesic prescribing for patients in hospital surgical units. MAIN OUTCOME MEASURES: The patients prescribed slow release opioids on discharge from hospital during the baseline (1 February - 30 April 2018) and post-intervention periods (17 February - 30 April 2019). RESULTS: During the baseline period, 1369 intervention unit and 1014 control unit admissions were included in our analysis; during the evaluation period, 973 intervention unit and 706 control unit episodes were included. After adjusting for age, length of stay, pain score, acute pain service involvement, and use of immediate release opioids prior to admission, patients in the intervention group were prescribed slow release opioids at discharge less frequently than patients in the control group (adjusted odds ratio [aOR], 0.52; 95% CI, 0.35-0.77) and were more frequently discharged without any prescribed opioids following the intervention (aOR, 1.69; 95% CI, 1.24-2.30). Providing de-escalation plans was more frequent for intervention than control group patients prescribed slow release opioids on discharge post-intervention (OR, 2.36; 95% CI, 1.25-4.45). CONCLUSIONS: Specific education for clinicians and pharmacists about appropriate analgesic prescribing for surgical patients is effective in reducing prescribing of opioids at discharge. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12618000876291 (prospective).


Assuntos
Analgésicos Opioides/uso terapêutico , Educação em Farmácia/métodos , Prescrição Inadequada/prevenção & controle , Corpo Clínico Hospitalar/educação , Farmacêuticos/estatística & dados numéricos , Adulto , Austrália , Análise por Conglomerados , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Hospitais de Ensino , Humanos , Masculino , Dor Pós-Operatória/tratamento farmacológico , Alta do Paciente/estatística & dados numéricos , Serviço de Farmácia Hospitalar , Padrões de Prática Médica/estatística & dados numéricos , Estudos Prospectivos
3.
Drugs Aging ; 37(12): 917-924, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33047252

RESUMO

BACKGROUND: The STOPPFrail criteria were developed to assist physicians in deprescribing medications among frail patients approaching end of life. We aimed to measure the prevalence of potentially inappropriate medications (PIMs) and to describe changes over time, using STOPPFrail, in frail nursing home residents (NHRs) with limited life expectancy included in a medication review trial. METHODS: We conducted a post-hoc analysis of the COME-ON study, a cluster-controlled trial that evaluated the effect of a complex intervention on appropriateness of prescribing in Belgian nursing homes. We identified NHRs eligible for the application of STOPPFrail based on functional status, comorbidities, level of care and survival. PIM use was measured at baseline and at 8 months. Changes over time were compared in the control group (CG) and intervention group (IG). RESULTS: At baseline, 308 NHRs met the STOPPFrail eligibility criteria, of whom 196 (64.1%) had one or more PIM. At 8 months, among the 218 NHRs who were alive, there was an absolute reduction in the prevalence of PIMs of 9.1% in the CG (p < 0.05) and 10.2% in the IG (p < 0.05). We found large reductions for some medications (e.g. proton pump inhibitors) but no reduction for others (e.g. calcium). The percentage of NHRs with one or more PIM discontinued without a new PIM initiated was higher in the IG than the CG but the difference was not significant (35.1% vs 23.6%, p = 0.127). CONCLUSION: Among frail NHRs with poor survival prognosis, a significant and encouraging decrease in PIM prevalence over time was observed, probably facilitated by medication reviews. The overall prevalence of PIMs remained high, however.


Assuntos
Desprescrições , Idoso Fragilizado , Prescrição Inadequada/prevenção & controle , Casas de Saúde , Lista de Medicamentos Potencialmente Inapropriados , Idoso , Idoso de 80 Anos ou mais , Bélgica , Comorbidade , Feminino , Humanos , Prescrição Inadequada/estatística & dados numéricos , Expectativa de Vida , Masculino , Prevalência
5.
J Eval Clin Pract ; 26(6): 1579-1582, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32955801

RESUMO

INTRODUCTION: There was no evidence concerning the prophylaxis with hydroxychloroquine, and only low-grade evidence regarding the use of hydroxychloroquine as a treatment for COVID-19 patients. We performed a survey among Romanian physicians in order to see how many of them would administer prophylactically hydroxychloroquine to themselves or to people close to them, and if they would participate to a randomized controlled trial. METHODS: Between March 30 and April 02, 2020, a 16-item questionnaire was shared in a Romanian Facebook group of 2645 physicians dedicated to COVID-19 information, asking to be completed by physicians who could be directly involved in the care of these patients. RESULTS: A total of 785 answers were collected. Nine physicians (1.1%) thought that there was clear evidence on prescribing hydroxychloroquine prophylaxis, 375 (48%) considered the evidence acceptable, 348 (44.3%) considered it weak, whereas 53 (6.8%) answered there was no evidence. 59 (7.5%) respondents were determined to take it (of which 31 = 4% already took), 192 (24.5%) were inclined to take, 271 (34.5%) were not decided yet. 175 (22.3%) of respondents declared they (would) give the treatment to their close ones, and this decision was associated with a higher age (P = 0.003), and the opinion that there was evidence (P < 0.001). When asked about the source of the treatment regimen, 286 (36.4%) indicated a scientific paper, while no scientific paper about the prophylaxis with hydroxychloroquine existed at that time. 718 (91.5%) considered a randomized clinical trial necessary (RCT), but only 333 (42.4%) answered they would enrol in such a trial. There was only a very weak correlation (Kendall's tau _b = 0.255, P < 0.001) between the belief that an RCT is necessary and the willingness to enrol in such an RCT. CONCLUSIONS: Despite the lack of evidence, many physicians considered the evidence as existing, and were ready to take or to give hydroxychloroquine prophylactically to family. They considered an RCT necessary, but they were not willing to participate.


Assuntos
Antivirais/uso terapêutico , Medicina de Família e Comunidade/estatística & dados numéricos , Hidroxicloroquina/uso terapêutico , Padrões de Prática Médica/estatística & dados numéricos , Profilaxia Pré-Exposição/estatística & dados numéricos , Atitude do Pessoal de Saúde , Competência Clínica , Humanos , Prescrição Inadequada/prevenção & controle , Romênia
6.
Pharm. pract. (Granada, Internet) ; 18(3): 0-0, jul.-sept. 2020. tab
Artigo em Inglês | IBECS | ID: ibc-194198

RESUMO

BACKGROUND: Potentially inappropriate prescribing is clearly associated with adverse health consequences among older people. Nevertheless, scarce evidence exists regarding the prevalence of potentially inappropriate prescriptions (PIP) in Albania, a Western Balkans country. OBJECTIVE: The aim of this study was to assess the prevalence of PIP among older Albanian patients in primary care and to determine the associated sociodemographic and medical factors, including the presence of mild cognitive impairment (MCI). METHODS: Cross-sectional study in two primary healthcare centers located in two different cities of Albania, a middle-income country in the Western Balkans. The Montreal Cognitive Assessment (MoCA) tool was applied to evaluate MCI. PIPs were assessed by two trained pharmacists using the Beers criteria 2019 update. Multivariate logistic regression analysis was conducted for possible risk factors predicting PIP in the study population. RESULTS: At least one PIP was identified among 40.23 % of the participants (174 older patients) and 10.35 % had more than one PIP. MCI was detected among 79.31 % of the patients. The most commonly represented drug groups in PIP were diuretics (24.71 %), benzodiazepines in the presence of MCI and antidepressants (both 8.62 %). The lack of electrolytes monitoring was the most common reason for PIP. According to the multivariate analysis, the only statistically significant association observed was between PIP and number of drugs prescribed [three to four drugs (OR 3.34; 95% CI 1.65:6.76), five or more than five drugs (OR 4.08; 95% CI 1.42:11.69)]. CONCLUSIONS: About four out of 10 older Albanian patients experience PIP in primary care. Further studies are needed for a comprehensive estimation of the prevalence and factors associated with PIP, particularly among elderly with mild cognitive impairment


No disponible


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Atenção Primária à Saúde/métodos , Prescrição Inadequada/prevenção & controle , Disfunção Cognitiva/tratamento farmacológico , Disfunção Cognitiva/epidemiologia , Antidepressivos , Benzodiazepinas , Fatores de Risco , Farmacêuticos/normas , Estudos Transversais , Análise Multivariada
7.
West J Emerg Med ; 21(5): 1283-1286, 2020 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-32970587

RESUMO

While current research efforts focus primarily on identifying patient level interventions that mitigate the direct impact of COVID-19, it is important to consider the collateral effects of COVID-19 on antimicrobial resistance. Early reports suggest high rates of antibiotic utilization in COVID-19 patients despite their lack of direct activity against viral pathogens. The ongoing pandemic is exacerbating known barriers to optimal antibiotic stewardship in the ED, representing an additional direct threat to patient safety and public health. There is an urgent need for research analyzing overall and COVID-19 specific antibiotic prescribing trends in the ED. Optimizing ED stewardship during COVID-19 will likely require a combination of traditional stewardship approaches (e.g. academic detailing, provider education, care pathways) and effective implementation of host response biomarkers and rapid COVID-19 diagnostics. Antibiotic stewardship interventions with demonstrated efficacy in mitigating the impact of COVID-19 on ED prescribing should be widely disseminated and inform the ongoing pandemic response.


Assuntos
Antibacterianos/uso terapêutico , Gestão de Antimicrobianos/métodos , Betacoronavirus , Infecções por Coronavirus/tratamento farmacológico , Serviço Hospitalar de Emergência , Prescrição Inadequada/prevenção & controle , Pneumonia Viral/tratamento farmacológico , Padrões de Prática Médica , Gestão de Antimicrobianos/organização & administração , Gestão de Antimicrobianos/estatística & dados numéricos , Betacoronavirus/isolamento & purificação , Técnicas de Laboratório Clínico , Infecções por Coronavirus/diagnóstico , Diagnóstico Diferencial , Serviço Hospitalar de Emergência/organização & administração , Humanos , Prescrição Inadequada/estatística & dados numéricos , Pandemias , Pneumonia Viral/diagnóstico , Padrões de Prática Médica/estatística & dados numéricos
8.
BMC Infect Dis ; 20(1): 586, 2020 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-32767968

RESUMO

BACKGROUND: Inappropriate and excessive antimicrobial prescribing can lead to antimicrobial resistance. Antimicrobial Stewardship (AMS) principles are not well established in general practice in Australia despite the relatively high rate of community antimicrobial prescribing. Few interventions have been implemented that have resulted in a significant reduction or improvement in antimicrobial prescribing by General Practitioners (GPs). This study was therefore conducted to assess the impact of a novel GP educational intervention on the appropriateness of antimicrobial prescriptions as well as GP compliance with antimicrobial prescription guidelines. METHODS: In 2018, a simple GP educational intervention was rolled out in a large clinic with the aim of improving antimicrobial prescribing. It included face-to-face education sessions with GPs on AMS principles, antimicrobial resistance, current prescribing guidelines and microbiological testing. An antibiotic appropriateness audit on prescribing practice before and after the educational intervention was conducted. Data were summarised using percentages and compared across time points using Chi-squared tests and Poisson regression (results reported as risk ratios (RR) with 95% confidence intervals (CI)). RESULTS: Data from 376 and 369 prescriptions in July 2016 and July 2018, respectively, were extracted. There were significant improvements in appropriate antimicrobial selection (73.9% vs 92.8%, RR = 1.26; 95% CI = 1.18-1.34), appropriate duration (53.1% vs 87.7%, RR = 1.65; 95% CI = 1.49-1.83) and compliance with guidelines (42.2% vs 58.5%, RR = 1.39, 95% CI = 1.19-1.61) post- intervention. Documentation of antimicrobial duration directions, patient follow-up as well as patient weight significantly increased after the intervention (p < 0.001). There was significant reduction in; prescriptions without a listed indication for antimicrobial therapy, prescriptions without appropriate accompanying microbiological tests and the provision of unnecessary repeat prescriptions (p < 0.001). Inappropriate antimicrobial prescriptions observed pre-intervention for medical termination of pregnancy ceased post-intervention. CONCLUSIONS: Auditing GP antimicrobial prescriptions identified prescribing practices inconsistent with Australian guidelines. However, implementation of a simple education program led to significantly improved antimicrobial prescribing by GPs. These findings indicate the important role of AMS and continued antimicrobial education within general practice.


Assuntos
Anti-Infecciosos/uso terapêutico , Gestão de Antimicrobianos , Medicina Geral/educação , Clínicos Gerais/psicologia , Austrália , Humanos , Prescrição Inadequada/prevenção & controle , Projetos Piloto , Guias de Prática Clínica como Assunto , Prescrições
9.
Med Clin North Am ; 104(5): 751-765, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32773043

RESUMO

Polypharmacy, the use of five or more medications, is common in older adults. It can lead to the use of potentially inappropriate medications and severe adverse outcomes. Deprescribing is an essential step of the thoughtful prescribing process and it can decrease the use of potentially inappropriate medications. Studies have demonstrated that deprescribing is feasible in the clinical setting, especially when it incorporates patient preferences, shared decision making, and an interdisciplinary team. Medication-specific algorithms can facilitate deprescribing in the clinical setting.


Assuntos
Desprescrições , Prescrição Inadequada/prevenção & controle , Múltiplas Afecções Crônicas/tratamento farmacológico , Idoso , Humanos , Lista de Medicamentos Potencialmente Inapropriados
10.
PLoS One ; 15(8): e0237186, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32785232

RESUMO

BACKGROUND: Multimorbidity is a global health challenge that is associated with polypharmacy, increasing the risk of potentially inappropriate prescribing (PIP). There are tools to improve prescription, such as implicit and explicit criteria. OBJECTIVE: To estimate the prevalence of PIP in a population aged 65 to 74 years with multimorbidity and polypharmacy, according to American Geriatrics Society Beers Criteria® (2015, 2019), the Screening Tool of Older Person's Prescription -STOPP- criteria (2008, 2014), and the Medication Appropriateness Index -MAI- criteria in primary care. METHODS: This was an observational, descriptive, cross-sectional study. The sample included 593 community-dwelling elderly aged 65 to 74 years, with multimorbidity and polypharmacy, who participated in the MULTIPAP trial. Socio-demographic, clinical, professional, and pharmacological-treatment variables were recorded. Potentially inappropriate prescribing was detected by computerized prescription assistance system, and family doctors evaluated the MAI. The MAI-associated factors were analysed using a logistic regression model. RESULTS: A total of 4,386 prescriptions were evaluated. The mean number of drugs was 7.4 (2.4 SD). A total of 94.1% of the patients in the study had at least one criterion for drug inappropriateness according to the MAI. Potentially inappropriate prescribing was detected in 57.7%, 43.6%, 68.8% and 71% of 50 patients according to the explicit criteria STOPP 2014, STOPP 2008, Beers 2019 and Beers 2015 respectively. For every new drug taken by a patient, the MAI score increased by 2.41 (95% CI 1.46; 3.35) points. Diabetes, ischaemic heart disease and asthma were independently associated with lower summated MAI scores. CONCLUSIONS: The prevalence of potentially inappropriate prescribing detected in the sample was high and in agreement with previous literature for populations with multimorbidity and polypharmacy. The MAI criteria detected greater inappropriateness than did the explicit criteria, but their application was more complex and difficult to automate.


Assuntos
Prescrição Inadequada/prevenção & controle , Multimorbidade , Polimedicação , Lista de Medicamentos Potencialmente Inapropriados , Idoso , Estudos Transversais , Feminino , Geriatria/métodos , Humanos , Vida Independente , Masculino , Prevalência , Atenção Primária à Saúde , Risco , Espanha
11.
Pediatrics ; 146(3)2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32747473

RESUMO

BACKGROUND: One-third of outpatient antibiotic prescriptions for pediatric acute respiratory tract infections (ARTIs) are inappropriate. We evaluated a distance learning program's effectiveness for reducing outpatient antibiotic prescribing for ARTI visits. METHODS: In this stepped-wedge clinical trial run from November 2015 to June 2018, we randomly assigned 19 pediatric practices belonging to the Pediatric Research in Office Settings Network or the NorthShore University HealthSystem to 4 wedges. Visits for acute otitis media, bronchitis, pharyngitis, sinusitis, and upper respiratory infection for children 6 months to <11 years old without recent antibiotic use were included. Clinicians received the intervention as 3 program modules containing online tutorials and webinars on evidence-based communication strategies and antibioti c prescribing, booster video vignettes, and individualized antibiotic prescribing feedback reports over 11 months. The primary outcome was overall antibiotic prescribing rates for all ARTI visits. Mixed-effects logistic regression compared prescribing rates during each program module and a postintervention period to a baseline control period. Odds ratios were converted to adjusted rate ratios (aRRs) for interpretability. RESULTS: Among 72 723 ARTI visits by 29 762 patients, intention-to-treat analyses revealed a 7% decrease in the probability of antibiotic prescribing for ARTI overall between the baseline and postintervention periods (aRR 0.93; 95% confidence interval [CI], 0.90-0.96). Second-line antibiotic prescribing decreased for streptococcal pharyngitis (aRR 0.66; 95% CI, 0.50-0.87) and sinusitis (aRR 0.59; 95% CI, 0.44-0.77) but not for acute otitis media (aRR 0.93; 95% CI, 0.83-1.03). Any antibiotic prescribing decreased for viral ARTIs (aRR 0.60; 95% CI, 0.51-0.70). CONCLUSIONS: This program reduced antibiotic prescribing during outpatient ARTI visits; broader dissemination may be beneficial.


Assuntos
Antibacterianos/uso terapêutico , Educação a Distância/organização & administração , Prescrição Inadequada/prevenção & controle , Atenção Primária à Saúde , Infecções Respiratórias/tratamento farmacológico , Doença Aguda , Bronquite/tratamento farmacológico , Bronquite/virologia , Chicago , Criança , Pré-Escolar , Comunicação , Intervalos de Confiança , Educação a Distância/métodos , Feminino , Humanos , Lactente , Análise de Intenção de Tratamento , Modelos Logísticos , Masculino , Razão de Chances , Otite Média/tratamento farmacológico , Pacientes Ambulatoriais , Enfermagem Pediátrica/educação , Enfermagem Pediátrica/estatística & dados numéricos , Pediatras/educação , Pediatras/estatística & dados numéricos , Faringite/tratamento farmacológico , Faringite/microbiologia , Faringite/virologia , Desenvolvimento de Programas , Melhoria de Qualidade , Infecções Respiratórias/epidemiologia , Infecções Respiratórias/virologia , Sinusite/tratamento farmacológico , Infecções Estreptocócicas/tratamento farmacológico
12.
Am Surg ; 86(8): 950-954, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32762466

RESUMO

BACKGROUND: There is an opioid epidemic in the United States. With the increased concern of over-prescribing opioids, physicians are seeking alternative pain management strategies. The purpose of this study is to review the impact of instituting a multimodal analgesia (MMA) guideline on decreasing opioid use in trauma patients at a Level 1 trauma center. METHODS: In 2017, an MMA guideline was developed and included anti-inflammatories, muscle relaxants, neuropathic agents, and local analgesics in addition to opioids. Staff were educated and the guideline was implemented. A retrospective review of medications prescribed to patients admitted from 2016 through 2018 was performed. Patients admitted in 2016 served as the control group (before MMA). In 2018, all patients received multimodal pain therapy as standard practice, and served as the comparison group. RESULTS: A total of 10 340 patients were admitted to the trauma service from 2016 through 2018. There were 3013 and 3249 patients for review in 2016 and 2018, respectively. Total morphine milligram equivalents were 2 402 329 and 1 975 935 in 2016 and 2018, respectively, a 17.7% decrease (P < .001). Concurrently, there was a statistically significant increase in the use of multimodal pain medications. A secondary endpoint was studied to evaluate for changes in acute kidney injury; there was not a statistically significant increase (0.56% versus 0.68%, P = .55). DISCUSSION: Implementation of an MMA guideline significantly reduced opioid use in trauma patients. The use of nonopioid MMA medications increased without an increased incidence of acute kidney injury.


Assuntos
Analgesia/métodos , Analgésicos não Entorpecentes/uso terapêutico , Analgésicos Opioides/uso terapêutico , Uso de Medicamentos/tendências , Prescrição Inadequada/prevenção & controle , Padrões de Prática Médica/tendências , Ferimentos e Lesões/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgesia/normas , Feminino , Humanos , Prescrição Inadequada/tendências , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos
13.
BMC Med ; 18(1): 265, 2020 08 21.
Artigo em Inglês | MEDLINE | ID: mdl-32825816

RESUMO

BACKGROUND: New emerging infections have no known treatment. Assessing potential drugs for safety and efficacy enables clinicians to make evidence-based treatment decisions and contributes to overall outbreak control. However, it is difficult to launch clinical trials in the unpredictable environment of an outbreak. We conducted a bibliometric systematic review for the 2009 influenza pandemic to determine the speed and quality of evidence generation for treatments. This informs approaches to high-quality evidence generation in this and future pandemics. METHODS: We searched PubMed for all clinical data (including clinical trial, observational and case series) describing treatment for patients with influenza A(H1N1)pdm09 and ClinicalTrials.gov for research that aimed to enrol patients with the disease. RESULTS: Thirty-three thousand eight hundred sixty-nine treatment courses for patients hospitalised with A(H1N1)pdm09 were detailed in 160 publications. Most were retrospective observational studies or case series. Five hundred ninety-two patients received treatment (or placebo) as participants in a registered interventional clinical trial with results publicly available. None of these registered trial results was available during the timeframe of the pandemic, and the median date of publication was 213 days after the Public Health Emergency of International Concern ended. CONCLUSION: Patients were frequently treated for pandemic influenza with drugs not registered for this indication, but rarely under circumstances of high-quality data capture. The result was a reliance on use under compassionate circumstances, resulting in continued uncertainty regarding the potential benefits and harms of anti-viral treatment. Rapid scaling of clinical trials is critical for generating a quality evidence base during pandemics.


Assuntos
Antivirais/uso terapêutico , Ensaios de Uso Compassivo , Prescrição Inadequada/prevenção & controle , Vírus da Influenza A Subtipo H1N1 , Influenza Humana/tratamento farmacológico , Uso Off-Label , Betacoronavirus , Bibliometria , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/epidemiologia , Análise Custo-Benefício , Saúde Global , Humanos , Influenza Humana/epidemiologia , Pandemias , Pneumonia Viral/tratamento farmacológico , Pneumonia Viral/epidemiologia , Projetos de Pesquisa , Resultado do Tratamento
14.
Am Surg ; 86(8): 965-970, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32779472

RESUMO

BACKGROUND: Recent data on opioid consumption indicate that patients typically require far less than is prescribed. Prisma Health Upstate Hernia Center adopted standardized postoperative prescribing after hernia repair and began tracking patient-reported opioid utilization. The aim of this study is to evaluate patient opioid use after hernia repair in order to guide future prescribing. METHODS: All patients who underwent primary ventral (umbilical and epigastric), incisional, and inguinal hernia repair between February and May 2019 were reviewed. Patients reported the number of opioid pills taken at their first postoperative visit and documented either in the progress note or in the Americas Hernia Society Quality Collaborative (AHSQC) patient-reported outcomes (PRO) questionnaire. All demographic, operative, and outcomes data were captured prospectively in the AHSQC. Opioid use reported as milligram morphine equivalents (MME). RESULTS: A total of 162 surgeries were performed during the study period, and 107 had patient-reported opioid use for analysis. Inguinal hernia repair was performed in 36 patients, 10 primary ventral hernia repairs, and 61 incisional hernia repairs. No opioid use was reported in 63.9% of inguinal hernias, 60% of primary ventral hernias, and 20% of incisional hernias. Inguinal hernia patients consumed a mean of 10.5 MME, primary ventral patients 11 MME, and incisional hernia patients 78.5 MME. CONCLUSION: Patients require little to no opioid after primary ventral or inguinal hernia repair and opioid-free surgery is feasible. Incisional hernia is more heterogenous, but the majority of patients still required less opioid than previously thought.


Assuntos
Analgésicos Opioides/uso terapêutico , Uso de Medicamentos/estatística & dados numéricos , Hérnia Inguinal/cirurgia , Hérnia Ventral/cirurgia , Herniorrafia , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica/tendências , Protocolos Clínicos , Humanos , Prescrição Inadequada/prevenção & controle , Prescrição Inadequada/tendências , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Autorrelato , Estados Unidos
15.
PLoS One ; 15(8): e0237868, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32818951

RESUMO

BACKGROUND: Older adults with chronic kidney disease (CKD) are at heightened risk for polypharmacy. We examined potentially inappropriate prescribing in this population and whether introducing pharmacists into the ambulatory kidney care model was associated with improved prescribing practices. METHODS: Retrospective cohort study using linked administrative databases. We included patients with an eGFR ≤30 mL/min/1.73 m2 ≥66 years of age followed in multidisciplinary kidney clinics in Ontario, Canada (n = 25,016 from 28 centres). The primary outcome was the absence of a statin prescription or the receipt of a potentially inappropriate prescription defined by the American Geriatric Society Beers Criteria® and a modified Delphi panel that identified key drugs of concern in CKD. We calculated the crude cumulative incidence and incidence rate for the primary outcome and used change-point regression to determine if a change occurred following pharmacist introduction. RESULTS: There were 6,007 (24%) and 16,497 patients (66%) not prescribed a statin and with ≥1 potentially inappropriate prescription, respectively. The rate of potentially inappropriate prescribing was 125.6 per 100 person-years and was higher in more recent years. The change-point regression analysis included 2,275 patients from two centres. No immediate change was detected at pharmacist introduction, but potentially inappropriate prescribing was increasing pre-pharmacist introduction, and this rising trend was reversed post-pharmacist introduction. The incidence of potentially inappropriate prescribing still remained high post-pharmacist introduction. CONCLUSIONS: Potentially inappropriate prescribing practices were common. Incorporating pharmacists into the kidney care model may improve prescribing practices. The role of pharmacists in the ambulatory kidney care team warrants further investigation in a randomized controlled trial.


Assuntos
Prescrições de Medicamentos/normas , Prescrição Inadequada/prevenção & controle , Polimedicação , Insuficiência Renal Crônica/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial , Canadá/epidemiologia , Gerenciamento de Dados , Feminino , Humanos , Masculino , Farmacêuticos , Lista de Medicamentos Potencialmente Inapropriados , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/patologia , Estudos Retrospectivos
16.
Z Evid Fortbild Qual Gesundhwes ; 155: 29-33, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32826187

RESUMO

INTRODUCTION: Potentially inappropriate prescribing (PIP, including potentially inappropriate medication, PIM) is frequent. In research and practice, the use of PIP lists could optimize a patient's medication. However, they are barely used, possibly because of their limited user-friendliness. This study aimed at evaluating the opinions of pharmacists and physicians caring for nursing home residents on user-friendliness as well as knowledge and current use of PIP lists. METHODS: Semi-structured telephone interviews and paper-based surveys were conducted with physicians and pharmacists who care for nursing home residents. Descriptive analysis and Fisher's exact test were performed. RESULTS: A total of 30 practitioners participated in the survey, eight of whom were interviewed by phone. 43 % (13/30) of the participants had already heard of PIP lists, and 46 % (6/13) of them made use of a PIP list. Less experienced professionals had more often heard of PIP lists than more experienced ones. The most important aspects of user-friendliness were: time required to use the list, electronic availability, clear structure and provision of reasons why a medication is potentially inappropriate. Physicians preferred a PIP list adapted to the Swiss drug market more often than pharmacists. DISCUSSION: Knowledge and current use of PIP lists are limited, which is partially consistent with the results of other studies. Participants with less professional experience have heard of PIP lists more frequently, opinions on user-friendliness differ between professions, and preferences seem to be, overall, highly individual. CONCLUSION: In order for PIP lists to be used more frequently, the aspects of user-friendliness should be taken into account. Personalizable PIP lists could be an interesting development.


Assuntos
Prescrição Inadequada , Farmacêuticos , Alemanha , Humanos , Prescrição Inadequada/prevenção & controle , Casas de Saúde , Inquéritos e Questionários
17.
Pediatrics ; 146(2)2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32611807

RESUMO

BACKGROUND AND OBJECTIVES: Vancomycin remains one of the most commonly prescribed antibiotics in NICUs despite recommendations to limit its use for known resistant infections. Baseline data revealing substantially higher vancomycin use in our NICU compared to peer institutions informed our quality improvement initiative. Our aim was to reduce the vancomycin prescribing rate in neonates hospitalized in our NICU by 50% within 1 year and sustain for 1 year. METHODS: In the 60-bed level IV NICU of an academic referral center, we used a quality improvement framework to develop key drivers and interventions including (1) physician education with benchmarking antibiotic prescribing rates; (2) pharmacy-initiated 48-hour antibiotic time-outs on rounds; (3) development of clinical pathways to standardize empirical antibiotic choices for early-onset sepsis, late-onset sepsis, and necrotizing enterocolitis; coupled with (4) daily prospective audit with feedback from the antimicrobial stewardship program. RESULTS: We used statistical process u-charts to show vancomycin use declined from 112 to 38 days of therapy per 1000 patient-days. After education, pharmacy-initiated 48-hour time-outs, and development of clinical pathways, vancomycin use declined by 29%, and by an additional 52% after implementation of prospective audit with feedback. Vancomycin-associated acute kidney injury also declined from 1.4 to 0.1 events per 1000 patient-days. CONCLUSIONS: Through a sequential implementation approach of education, standardization of care with clinical pathways, pharmacist-initiated 48-hour time-outs, and prospective audit with feedback, vancomycin days of therapy declined by 66% over a 1-year period and has been sustained for 1 year.


Assuntos
Gestão de Antimicrobianos/estatística & dados numéricos , Prescrição Inadequada/prevenção & controle , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Vancomicina/uso terapêutico , Antibacterianos/uso terapêutico , Gestão de Antimicrobianos/organização & administração , Brasil , Procedimentos Clínicos , Enterocolite Necrosante/tratamento farmacológico , Hospitais Pediátricos/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Prescrição Inadequada/estatística & dados numéricos , Recém-Nascido , Doenças do Recém-Nascido/tratamento farmacológico , Serviço de Farmácia Hospitalar/organização & administração , Estudos Prospectivos , Melhoria de Qualidade , Sepse/tratamento farmacológico
18.
Am J Surg ; 220(5): 1284-1289, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32650975

RESUMO

BACKGROUND: Six percent of opioid-naïve patients develop opioid dependence post-operatively. We implemented a protocol in our renal transplant recipients that eliminated opioid patient-controlled analgesia (PCA) and included a multi-modal non-opioid regimen. The purpose of this study was to examine the impact of PCA elimination on opioid requirements at discharge in renal transplant recipients. METHODS: We reviewed adult renal transplant recipients for the three months prior to, and following, the protocol's implementation. Patients with an intra-abdominal transplant, pancreas-renal transplant, or chronic pain were excluded. The number of opioid pills prescribed on the day prior to discharge were categorized as A) 0, B) 1-3, and C) ≥4. Discharge opioid prescriptions were then evaluated based on a recent recommendation that group A receive 0 pills, group B 15 pills, and group C 30 pills, to satisfy the outpatient pain needs of 85% of patients. Pre- and post-intervention metrics were compared using independent t-tests and Chi squared tests. RESULTS: 150 recipients were included (79 pre-intervention, 71 post; 51% male). PCA use decreased significantly (81% vs. 4.2%, p < 0.001). Post-intervention, gabapentin, topical lidocaine, and acetaminophen increased significantly (6.3%-69%, p < 0.001, 5.1%-66.2%, p < 0.001, 73.4%-93% respectively, p = 0.003.) PCA use did not impact the amount of opioids prescribed at discharge (median 75 OMEs in both groups). Of patients requiring no opioids on the day prior to discharge regardless of PCA use, 51.5% of pre- and 35.5% of post- were prescribed excess opioids at discharge. Of patients prescribed 1-3 pills on the day prior to discharge regardless of PCA use, 24.2% of pre- and 25.8% of post patients were prescribed excessive opioids at discharge. CONCLUSIONS: A multidisciplinary approach to developing an opioid-reducing protocol significantly decreased the use of PCAs and increased the use of non-opioid adjunct medications in renal transplant recipients. Patients continued to be prescribed excess opioids at discharge compared to inpatient opioid use the day prior to discharge. Ongoing communication with all providers caring for renal transplant recipients and protocolization of the different stages of a patient's post-operative hospitalization are crucial.


Assuntos
Analgésicos Opioides/administração & dosagem , Prescrição Inadequada/prevenção & controle , Transplante de Rim , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Cuidados Pós-Operatórios/métodos , Padrões de Prática Médica/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/uso terapêutico , Protocolos Clínicos , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Prescrição Inadequada/tendências , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/etiologia , Alta do Paciente , Cuidados Pós-Operatórios/normas , Cuidados Pós-Operatórios/tendências , Estudos Retrospectivos
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