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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.
Ann Otol Rhinol Laryngol ; 129(2): 142-148, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31559860

RESUMO

BACKGROUND: The prevalence of opioid abuse has become epidemic in the United States. Microdirect laryngoscopy (MDL) is a common otolaryngological procedure, yet prescribing practices for opioids following this operation are not well characterized. OBJECTIVE: To characterize current opioid-prescribing patterns among otolaryngologists performing MDL. METHODS: A cross-sectional survey of otolaryngologists at a national laryngology meeting. RESULTS: Fifty-eight of 205 physician registrants (response rate 28%) completed the survey. Fifty-nine percent of respondents were fellowship-trained in laryngology. Respondents performed an average of 13.3 MDLs per month. Thirty-four percent of surgeons prescribe opioids for over two-thirds of their MDLs, while only 7% of surgeons never prescribe opioids. Eighty-eight percent of surgeons prescribed a combination opioid and acetaminophen compound, hydrocodone being the most common opioid component. Many surgeons prescribe non-opioid analgesics as well, with 70% and 84% of surgeons recommending acetaminophen and ibuprofen after MDL respectively. When opioids were prescribed, patient preference, difficult exposure and history of opioid use were the most influential patient factors. Concerns of opioid abuse, the physician role in the opioid crisis, and literature about postoperative non-opioid analgesia were also underlying themes in influencing opioid prescription patterns after MDL. CONCLUSIONS: In this study, over 90% of practicing physicians surveyed are prescribing opioids after MDL, though many are also prescribing non-opioid analgesia as well. Further studies should be completed to investigate the needs of patients following MDL in order to allow physicians to selectively and appropriately prescribe opioid analgesia postoperatively.


Assuntos
Analgésicos Opioides , Prescrições de Medicamentos/estatística & dados numéricos , Laringoscopia , Otolaringologia , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica , Analgésicos , Estudos Transversais , Pesquisas sobre Serviços de Saúde , Humanos , Laringoscopia/métodos
5.
Int J Cancer ; 146(3): 829-838, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30989639

RESUMO

Advances in multimodality cancer treatments have increased the risk of long-term complications in early-onset cancer survivors. For female cancer survivors, these include diminished reproductive function, often resulting in a narrowed fertile window. The aim of our study was to evaluate the use of fertility treatments in cancer survivors (aged 0-39 years at diagnosis) compared to siblings. Data from Finnish registers on cancer, birth and prescribed medications were merged to identify 8,929 survivors and 9,495 siblings without previous deliveries. Fertility drug purchases from 1993 to 2012 at the age of 16-41 years were included. A Poisson regression model was used to estimate incidence rate ratios (IRRs) for the use of fertility drugs, adjusting for age and calendar time at fertility drug purchase. Fertility treatments were more common in survivors compared to siblings, as 6.1% of survivors compared to 3.8% of siblings had bought fertility drugs (IRR 1.43, 95% confidence interval [CI] 1.25-1.65). A subclassification of fertility treatments into ovulation inductions and assisted reproductive technology (ART), showed increased use of ART (IRR 2.41, 95% CI 1.97-2.96), whereas the use of ovulation induction was similar in survivors and siblings. Analyses by calendar time periods showed the use of ART to be significantly higher in the most recent decade, from 2003 onwards. We conclude that cancer survivors have an increased risk for subfertility, which is why fertility counseling is important. However, our results mirror a more active approach among clinicians towards fertility treatments in cancer survivors during the most recent years.


Assuntos
Sobreviventes de Câncer/estatística & dados numéricos , Fármacos para a Fertilidade/uso terapêutico , Infertilidade Feminina/terapia , Neoplasias/complicações , Adolescente , Adulto , Antineoplásicos/efeitos adversos , Estudos de Casos e Controles , Criança , Pré-Escolar , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Fertilidade/efeitos dos fármacos , Fertilidade/efeitos da radiação , Finlândia , Humanos , Lactente , Recém-Nascido , Infertilidade Feminina/etiologia , Masculino , Neoplasias/mortalidade , Neoplasias/terapia , Gravidez , Radioterapia/efeitos adversos , Sistema de Registros/estatística & dados numéricos , Técnicas de Reprodução Assistida/estatística & dados numéricos , Irmãos , Adulto Jovem
6.
Int J Cancer ; 146(3): 610-616, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30861115

RESUMO

Statins (HMG-CoA reductase inhibitors) have antiinflammatory and possibly anticancer properties. We hypothesized that statin use is associated with lower risk of pancreatic cancer in patients with chronic pancreatitis. This nationwide population-based cohort study included all Danish patients diagnosed with incident chronic pancreatitis from 1 January 1996 to 31 December 2012. We used the Danish National Prescription Registry to ascertain information on statin prescriptions for members of the study population before and after their pancreatitis diagnosis. We computed crude incidence rates, incidence rate ratios (IRRs) and adjusted hazard ratios (HRs) with associated 95% confidence intervals (CIs) for pancreatic cancer, comparing statin users with nonusers. We computed HRs using Cox proportional hazards regression with statins treated as a time-varying exposure lagged by 1 year, adjusting for age, sex, socioeconomic status and individual comorbidities. The study included 8,311 chronic pancreatitis patients with a median age of 54 years. We observed 153 pancreatic cancers during 60,365 person-years of follow-up. The unadjusted IRR comparing statin users with nonusers was 1.00 (95% CI: 0.60-1.60). Adjustment for potential confounders only had a small impact on the estimate (adjusted HR: 0.90; 95% CI: 0.56-1.44). Our findings suggest that statin use is not associated with pancreatic cancer risk in patients with chronic pancreatitis.


Assuntos
Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Neoplasias Pancreáticas/epidemiologia , Pancreatite Crônica/complicações , Adulto , Idoso , Comorbidade , Dinamarca , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/etiologia , Neoplasias Pancreáticas/prevenção & controle , Pancreatite Crônica/epidemiologia , Sistema de Registros/estatística & dados numéricos , Fatores de Risco
7.
J Opioid Manag ; 15(6): 499-506, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31850512

RESUMO

BACKGROUND: As determinants of the opioid epidemic are several, describing patterns of opioid prescription over time is of importance. OBJECTIVE: To characterize the prescribing patterns of opioids per US region and physician specialty from 2012 to 2015. METHODS: Truven Health Analytics MarketScan® Databases were used to obtain data on opioid prescription rates per US region and physician specialty for the years 2012-2015. Opioids included in the study are tramadol, hydrocodone, codeine, oxycodone, oxymorphone, methadone, and fentanyl. RESULTS: Starting sample consisted of 5,860,096 individuals. An increase in prescriptions was seen for codeine (22.3 percent), oxycodone (22.4 percent), and tramadol (22.4 percent), while other opioids had decreases between 6.5 and 20.2 percent during this period. Family medicine physicians were the most frequent prescriber for all opioids except for oxycodone; nonphysician prescribers' share of prescriptions nearly doubled for all opioids. The share of oxycodone and of tramadol among all opioids increased in all regions, while the opposite was seen for hydrocodone. Codeine prescription share increased substantially in the South but not in other regions. When comparing the period of 2012-2015, differences were significant for all regions (p < 0.0001 for all regions). In 2015, the rate of prescription of oxycodone was nearly twofold higher in the Northeast vs North Central (38 percent vs 18.5 percent, p < 0.0001), while tramadol was substantially more frequently prescribed in the South, where it responded to nearly 20 percent of all opioid prescriptions (p < 0.0001). CONCLUSION: Patterns of prescription per opioid vary considerably per physician specialty and per US region. Although an overall decrease in prescriptions was seen, certain opioids were more frequently prescribed in 2015 than in 2012.


Assuntos
Analgésicos Opioides , Prescrições de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Humanos , Hidrocodona , Oxicodona , Padrões de Prática Médica/estatística & dados numéricos , Tramadol , Estados Unidos
8.
Tidsskr Nor Laegeforen ; 139(16)2019 11 05.
Artigo em Norueguês | MEDLINE | ID: mdl-31686488

RESUMO

BACKGROUND: It is generally agreed that prescribing of antipsychotic drugs to older patients should be reduced, but figures for the prescribing of these drugs to older patients living at home in Norway are not available. The study aimed to investigate developments in prescribing of antipsychotic drugs among older patients living at home from 2006 to 2018, and whether there were differences in prescribing rates between the age groups 65-74 years, 75-84 years and 85 years or older. MATERIAL AND METHOD: Data were retrieved from the Norwegian Prescription Database. All persons aged 65 years or older who were dispensed at least one antipsychotic drug in 2006, 2010, 2014 and 2018 were included, and gender-specific prevalence for the ten most widely used antipsychotic drugs was calculated. RESULTS: The proportion of patients aged 65 or older who were prescribed antipsychotic drugs in the period decreased for both sexes. For the age group 65-74 years, an increase was found from 2014 to 2018. There was a clear decrease in the prescribing rate for prochlorperazine and levomepromazine, whereas prescriptions for quetiapine increased. INTERPRETATION: Attention should be paid to the increase in prescribing of antipsychotic drugs for the youngest age group of older patients (65-74 years) in the last four years, along with the increase in prescribing of quetiapine for older patients.


Assuntos
Antipsicóticos/administração & dosagem , Prescrições de Medicamentos/estatística & dados numéricos , Uso de Medicamentos , Vida Independente , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Noruega , Prevalência , Sistema de Registros
9.
BMJ ; 367: l6015, 2019 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-31690553

RESUMO

OBJECTIVE: To evaluate the association between gifts from pharmaceutical companies to French general practitioners (GPs) and their drug prescribing patterns. DESIGN: Retrospective study using data from two French databases (National Health Data System, managed by the French National Health Insurance system, and Transparency in Healthcare). SETTING: Primary care, France. PARTICIPANTS: 41 257 GPs who in 2016 worked exclusively in the private sector and had at least five registered patients. The GPs were divided into six groups according to the monetary value of the received gifts reported by pharmaceutical, medical device, and other health related companies in the Transparency in Healthcare database. MAIN OUTCOME MEASURES: The main outcome measures were the amount reimbursed by the French National Health Insurance for drug prescriptions per visit (to the practice or at home) and 11 drug prescription efficiency indicators used by the National Health Insurance to calculate the performance related financial incentives of the doctors. Doctor and patient characteristics were used as adjustment variables. The significance threshold was 0.001 for statistical analyses. RESULTS: The amount reimbursed by the National Health Insurance for drug prescriptions per visit was lower in the GP group with no gifts reported in the Transparency in Healthcare database in 2016 and since its launch in 2013 (no gift group) compared with the GP groups with at least one gift in 2016 (-€5.33 (99.9% confidence interval -€6.99 to -€3.66) compared with the GP group with gifts valued at €1000 or more reported in 2016) (P<0.001). The no gift group also more frequently prescribed generic antibiotics (2.17%, 1.47% to 2.88% compared with the ≥€1000 group), antihypertensives (4.24%, 3.72% to 4.77% compared with the ≥€1000 group), and statins (12.14%, 11.03% to 13.26% compared with the ≥€1000 group) than GPs with at least one gift between 2013 and 2016 (P<0.001). The no gift group also prescribed fewer benzodiazepines for more than 12 weeks (-0.68%, -1.13% to -0.23% compared with the €240-€999 group) and vasodilators (-0.15%, -0.28% to -0.03% compared with the ≥€1000 group) than GPs with gifts valued at €240 or more reported in 2016, and more angiotensin converting enzyme (ACE) inhibitors compared with all ACE and sartan prescriptions (1.67%, 0.62% to 2.71%) compared with GPs with gifts valued at €1000 or more reported in 2016 (P<0.001). Differences were not significant for the prescription of aspirin and generic antidepressants and generic proton pump inhibitors. CONCLUSION: The findings suggest that French GPs who do not receive gifts from pharmaceutical companies have better drug prescription efficiency indicators and less costly drug prescriptions than GPs who receive gifts. This observational study is susceptible to residual confounding and therefore no causal relation can be concluded. TRIAL REGISTRATION: OSF register OSF.IO/8M3QR.


Assuntos
Indústria Farmacêutica/economia , Prescrições de Medicamentos/estatística & dados numéricos , Clínicos Gerais/estatística & dados numéricos , Doações , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Adulto , Idoso , Bases de Dados Factuais/estatística & dados numéricos , Indústria Farmacêutica/estatística & dados numéricos , Prescrições de Medicamentos/economia , Medicamentos Genéricos/economia , Feminino , França , Clínicos Gerais/economia , Humanos , Reembolso de Seguro de Saúde/economia , Reembolso de Seguro de Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde/economia , Programas Nacionais de Saúde/estatística & dados numéricos , Padrões de Prática Médica/economia , Medicamentos sob Prescrição/economia , Estudos Retrospectivos , Adulto Jovem
10.
J Opioid Manag ; 15(4): 307-322, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637683

RESUMO

BACKGROUND: Increasing opioid-related deaths have heightened focus on combating the opioid epidemic. The impact of surgical trainees on opioid-related deaths is unclear, and there is little data examining the association between trainee pain management education and opioid prescribing practices. METHODS: An anonymous, online survey was distributed to members of the Resident and Associate Society of the American College of Surgeons. The survey covered five themes: education and knowledge, prescribing practices, clinical case scenarios, policy, and beliefs and attitudes. Linear mixed models were used to evaluate the influence of respondent characteristics on reported morphine milligram equivalents (MME) prescribed for common general surgery clinical scenarios. RESULTS: Of 427 respondents, 54 percent indicated receiving training in postoperative pain management during medical school and 66 percent during residency. Only 35 percent agreed that they had received adequate training in prescribing opioids. There was a significant association between undergoing formal pain management training in medical school and prescribing fewer MME for common outpatient general surgery scenarios (94 ± 15.2 vs 108 ± 15.0; p = 0.003). Similarly, formal pain management training in residency was associated with prescribing fewer MME in the survey scenarios (92.6 ± 15.2 vs 109 ± 15.2; p = 0.002). CONCLUSION: In this survey, nearly two-thirds of surgical residents felt that they were inadequately trained in opioid pre-scribing. Our findings additionally suggest that improving education may result in increased resident comfort with man-aging surgical pain, potentially leading to more responsible opioid prescribing. Further work will facilitate residency pro-grams' development of educational curricula for opioid prescribing best practices.


Assuntos
Analgésicos Opioides , Prescrições de Medicamentos , Cuidados Pós-Operatórios/métodos , Padrões de Prática Médica , Analgésicos Opioides/administração & dosagem , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Masculino , Inquéritos e Questionários
11.
J Opioid Manag ; 15(4): 333-341, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637685

RESUMO

BACKGROUND: The use of opioid analgesics in the United States has increased nearly fourfold since 1999 resulting in a similar increase in opioid-related overdose deaths. Although the Centers for Disease Control published guidelines for prescribing chronic opioids, there is a lack of guidance for prescribing postoperative opioids. OBJECTIVE: To offer an evidence-based approach to prescribing opioids for post-operative pain management in the orthopedic setting. METHODS: A narrative review was performed of studies evaluating and quantifying opioid use in orthopedic patients in the postoperative setting, as well as studies analyzing patient satisfaction and perception with regards to opioid use. RESULTS: Studies show that postoperative pain may not be the largest contributing factor to developing an opioid use disorder, but rather patient factors such as tobacco and substance use disorder, mental health disorders, anxiety, mood disorders, pre-existing chronic pain, and recent opioid use may play a role. The review also found that most patients do not utilize significant portions of prescribed opioids and most do not require a refill. This trend leaves patients with thousands of unused pills, which are either retained, shared, or diverted. Although there is no guideline for prescribing opioids postoperatively, data suggest that clinicians can prescribe smaller dosages and fewer quantities of opioids initially. There are also non-opioid strategies that can be employed to reduce opioid consumption. CONCLUSION: There is a need for more high quality research to be conducted to standardize postoperative opioid prescribing patterns and create best practice guidelines to guide clinicians. Orthopedic practices should consider creating institutional guidelines to reduce the amount of opioids prescribed.


Assuntos
Analgésicos Opioides , Prescrições de Medicamentos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides , Padrões de Prática Médica , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Humanos , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Procedimentos Ortopédicos , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Estados Unidos
12.
Rev Saude Publica ; 53: 92, 2019.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31644723

RESUMO

OBJECTIVE: To estimate the use of the first dose of antibiotics in the health care unit in children from the 2015 Pelotas Birth Cohort at 24 months. METHODS: A total of 4,014 children were monitored. We used descriptive statistics and Poisson regression to analyze the association between socioeconomic and demographic variables, participation in daycare units, in the activities of the Pastoral da Criança and in the Primeira Infância Melhor program, low birth weight, hospitalization between 12 and 24 months, place of medical appointment, prevalence of medical appointment in the last 30 days, prescription of antibiotics, and administration of the first dose in the health care unit. RESULTS: A total of 1,044 children had medical appointments in the last 30 days, of which 45% were prescribed antibiotics and only 10.5% were administered the first dose of this medication in the health care unit. Children with brown, yellow or indigenous skin color were administered 2.5 times more antibiotics than white children. Children whose mothers had 12 years or more of education were administered 83.0% fewer antibiotics than those whose mothers had up to 4 years of education. Among those who were hospitalized for 12 to 24 months, the use of antibiotics was almost four times higher than among those who were not. Among the children served by the Brazilian Unified Health System (SUS), only 15.3% were administered the first dose of antibiotic in the health care unit. When compared with children served by private health care or health plan, administration of the first dose in the SUS was 76.0% higher. CONCLUSIONS: Despite the efforts related to the Pastoral da Criança campaign "Antibiotic: first dose immediately," adherence to the provision of antibiotics in the health care unit is still low. Strategies are necessary and urgent so children have access to the first dose of antibiotics in the health care unit.


Assuntos
Antibacterianos/administração & dosagem , Pesquisas sobre Serviços de Saúde/estatística & dados numéricos , Adulto , Agendamento de Consultas , Brasil/epidemiologia , Saúde da Criança/estatística & dados numéricos , Pré-Escolar , Estudos de Coortes , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Lactente , Masculino , Mães , Programas Nacionais de Saúde , Prevalência , Fatores Socioeconômicos , Fatores de Tempo , Adulto Jovem
13.
Forensic Sci Int ; 305: 109970, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31629200

RESUMO

Our aim was to investigate the reason for relatively low detection rates for opioids and fentanyl in particular in post-mortem cases in the State of Hamburg. We re-analysed 822 blood samples from two different time periods, 2011/12 and 2016. These samples had been previously analysed in accordance with post-mortem routine by a case selected strategy. All samples were re-analysed with an LC-MS/MS method specific for prescription opioids. The main point in the evaluation was to determine whether the previous analysis strategy had led to underreporting of drug-related deaths (DRD), especially with regard to fentanyl. Another aim was to evaluate changes in prescribing prevalence of opiates and opioids. We compared pharmacy claims data in Hamburg with Germany. The analyses showed that the number of DRD remained unaffected by the new analytical strategy. Detection rates in DRD, however, increased for fentanyl 3.4-fold from 1.2% to 4.1%, buprenorphine from 5.9% to 7.6%, oxycodone from 0% to 1.8%, tilidine from 1.8% to 2.4%. The most frequently detected opioids in DRD cases were methadone (39.4%) and heroin (20%). Prescription rates between 2011-2017 decreased in Hamburg for nearly all opioids, morphine by - 43.5%, buprenorphine - 43%, codeine - 57%, fentanyl - 25%, tilidine -17%, tramadol - 31%, and hydromorphone -6%. Oxycodone, tapentadol, and piritramide prescription rates increased. For Germany, a decrease in the prescription rates for fentanyl was also found during this period (-12.9 %), although not as pronounced as in Hamburg. Prescription rates for methadone were three to greater than five times higher in Hamburg as compared to the German average due to the higher number of substituted persons per inhabitant. Conclusion: Despite the global problem of opioid abuse, there are significant regional differences in the nature and extent of opioid abuse. It is necessary to collect data at the national level to develop appropriate prevention strategies.


Assuntos
Analgésicos Opioides/análise , Fentanila/análise , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Adulto , Idoso de 80 Anos ou mais , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/envenenamento , Cromatografia Líquida , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Fentanila/efeitos adversos , Fentanila/envenenamento , Toxicologia Forense , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Mudanças Depois da Morte , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Espectrometria de Massas em Tandem , Adulto Jovem
14.
Einstein (Sao Paulo) ; 18: eAO4871, 2019.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31664324

RESUMO

OBJECTIVE: To analyze, from the pharmacotherapy perspective, the factors associated to visits of older adults to the emergency department within 30 days after discharge. METHODS: A cross-sectional study carried out in a general public hospital with older adults. Emergency department visit was defined as the stay of the older adult in this service for up to 24 hours. The complexity of drug therapy was determined using the Medication Regimen Complexity Index. Potentially inappropriate drugs for use in older adults were classified according to the American Geriatric Society/Beers criteria of 2015. The outcome investigated was the frequency of visits to the emergency department within 30 days of discharge. Multivariate logistic regression was performed to identify the factors associated with the emergency department visit. RESULTS: A total of 255 elderly in the study, and 67 (26.3%) visited emergency department within 30 days of discharge. Polypharmacy and potentially inappropriate medications for older adults did not present a statistically significant association. The diagnosis of heart failure and Medication Regimen Complexity Index >16.5 were positively associated with emergency department visits (OR=2.3; 95%CI: 1.04-4.94; p=0.048; and OR=2.1; 95%CI: 1.11-4.02; p=0.011), respectively. Furthermore, the diagnosis of diabetes mellitus and chronic kidney disease were protection factors for the outcome (OR=0.4; 95%CI: 0.20-0.73; p=0.004; and OR=0.3; 95%CI: 0.13-0.86; p=0.023). CONCLUSION: The diagnosis of heart failure and Medication Regimen Complexity Index >16.5 were positively associated with the occurrence of an emergency department visit within 30 days of discharge.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Tratamento Farmacológico/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Insuficiência Cardíaca/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Polimedicação , Fatores de Tempo
15.
J Drugs Dermatol ; 18(10): 987-990, 2019 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-31584776

RESUMO

Introduction: Introduction: Although future atopic dermatitis (AD) clinical research is intended to improve standard-of-care treatment, how patients are currently treated is not well characterized. The purpose of this study was to determine the most frequent medications prescribed in all ages of AD. Methods: The National Ambulatory Medical Care Survey (NAMCS) is a nationally representative survey of United States office-based ambulatory visits and records demographics, diagnoses, and treatments. This is a cross-sectional study using the NAMCS of all AD outpatient office visits from 2006 to 2015. Patient visits with an ICD-9-CM code for AD (691.8) were collected and analyzed. Frequency tables were created for age, race, providers managing AD, and treatment. Results: Patient demographics of AD visits included 51% male (95% Confidence Interval [CI]: 44-58%), 71% white (65-77%), 19% African American (14-25%), and 10% Asian (6-14%). About 31% (24-37%) of visits were to pediatricians and 27% (22-33%) to dermatologists whereas per physician, dermatologists managed more AD visits than pediatricians. Topical corticosteroids (59%; 52-66%) were the most common class of medications prescribed followed by antibiotics (11%; 6-16%) and second generation antihistamines (6%; 3-10%). The most common topical corticosteroid prescribed in AD was triamcinolone (25% of office visits; 18-31%). Hydrocortisone was the most common topical corticosteroid prescribed to children <1 year of age and children aged 8 to 18, whereas triamcinolone was more common in children 2 to 7 years and adults >18 years. Discussion: Topical corticosteroids were the most frequent prescriptions provided at office-based ambulatory visits whereas antibiotics and second-generation antihistamines were the second and third most common prescribed medications, respectively. Although pediatricians manage more AD visits than dermatologists in total visits, dermatologists manage more AD visits than pediatricians per physician. Characterizing how AD patients are currently treated may build a reference for future clinical research investigating novel standard-of-care treatment in AD. J Drugs Dermatol. 2019;18(10):987-990.


Assuntos
Dermatite Atópica/tratamento farmacológico , Fármacos Dermatológicos/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Padrão de Cuidado/estatística & dados numéricos , Administração Cutânea , Adolescente , Adulto , Antibacterianos/uso terapêutico , Criança , Pré-Escolar , Estudos Transversais , Dermatologistas/estatística & dados numéricos , Feminino , Glucocorticoides/uso terapêutico , Pesquisas sobre Serviços de Saúde/estatística & dados numéricos , Antagonistas dos Receptores Histamínicos/uso terapêutico , Humanos , Lactente , Recém-Nascido , Masculino , Visita a Consultório Médico/estatística & dados numéricos , Estados Unidos , Adulto Jovem
16.
BMJ ; 367: l5205, 2019 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-31578187

RESUMO

OBJECTIVES: To determine how clinicians vary in their response to new guidance on existing or new interventions, by measuring the timing and magnitude of change at healthcare institutions. DESIGN: Automated change detection in longitudinal prescribing data. SETTING: Prescribing data in English primary care. PARTICIPANTS: English general practices. MAIN OUTCOME MEASURES: In each practice the following were measured: the timing of the largest changes, steepness of the change slope (change in proportion per month), and magnitude of the change for two example time series (expiry of the Cerazette patent in 2012, leading to cheaper generic desogestrel alternatives becoming available; and a change in antibiotic prescribing guidelines after 2014, favouring nitrofurantoin over trimethoprim for uncomplicated urinary tract infection (UTI)). RESULTS: Substantial heterogeneity was found between institutions in both timing and steepness of change. The range of time delay before a change was implemented was large (interquartile range 2-14 months (median 8) for Cerazette, and 5-29 months (18) for UTI). Substantial heterogeneity was also seen in slope following a detected change (interquartile range 2-28% absolute reduction per month (median 9%) for Cerazette, and 1-8% (2%) for UTI). When changes were implemented, the magnitude of change showed substantially less heterogeneity (interquartile range 44-85% (median 66%) for Cerazette and 28-47% (38%) for UTI). CONCLUSIONS: Substantial variation was observed in the speed with which individual NHS general practices responded to warranted changes in clinical practice. Changes in prescribing behaviour were detected automatically and robustly. Detection of structural breaks using indicator saturation methods opens up new opportunities to improve patient care through audit and feedback by moving away from cross sectional analyses, and automatically identifying institutions that respond rapidly, or slowly, to warranted changes in clinical practice.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Medicina Estatal/estatística & dados numéricos , Anti-Infecciosos/uso terapêutico , Conjuntos de Dados como Assunto , Substituição de Medicamentos/estatística & dados numéricos , Medicamentos Genéricos/uso terapêutico , Inglaterra , Medicina Geral/organização & administração , Medicina Geral/normas , Medicina Geral/estatística & dados numéricos , Humanos , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Medicina Estatal/normas , Fatores de Tempo , Infecções Urinárias/tratamento farmacológico
17.
Tidsskr Nor Laegeforen ; 139(13)2019 Sep 24.
Artigo em Norueguês, Inglês | MEDLINE | ID: mdl-31556524

RESUMO

BACKGROUND: Norwegian national guidelines recommend that clozapine be offered to patients with schizophrenia after two failed attempts with other antipsychotic drugs. One of the main objectives for the introduction of clinical pathways in mental health care is to provide an equal service to patients irrespective of where in the country they live. We wished to investigate the prescribing level of clozapine in various Norwegian counties. MATERIAL AND METHOD: We retrieved aggregated data from the Norwegian Prescription Database, the Norwegian Patient Registry and Statistics Norway on prescribing of clozapine, number of patients in contact with the specialist health service with the diagnosis schizophrenia, and population figures for 2016. RESULTS: Nationwide in 2016, there were 50 users of clozapine per 100 000 inhabitants (95 % confidence interval (CI) 48-52). The number of users was highest in Troms county (76 (95 % CI 63-89) per 100 000 inhabitants) and lowest in Akershus county (38 (95 % CI 33-43) per 100 000 inhabitants). We found no significant correlation between the prescribing rate for clozapine and the proportion of the population in the county who were undergoing treatment for schizophrenia in the specialist health service. INTERPRETATION: Prescribing of clozapine varies among Norwegian counties and is not correlated with the proportion of the population who are undergoing treatment for schizophrenia in the specialist health service. Different levels of implementation of the national guidelines constitute a possible explanation for the geographic differences.


Assuntos
Antipsicóticos/administração & dosagem , Clozapina/administração & dosagem , Prescrições de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos , Esquizofrenia/tratamento farmacológico , Adulto , Idoso , Antipsicóticos/uso terapêutico , Clozapina/uso terapêutico , Bases de Dados Factuais , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Pessoa de Meia-Idade , Noruega , Guias de Prática Clínica como Assunto , Sistema de Registros , Adulto Jovem
18.
MMWR Morb Mortal Wkly Rep ; 68(38): 819-824, 2019 Sep 27.
Artigo em Inglês | MEDLINE | ID: mdl-31557148

RESUMO

Rheumatic diseases are a leading cause of chronic, noncancer pain. Systemic lupus erythematosus (SLE) is a chronic autoimmune rheumatic disease characterized by periodic flares that can result in irreversible target organ damage, including end-stage renal disease. Both intermittent and chronic musculoskeletal pain, as well as fibromyalgia (considered a centralized pain disorder due to dysregulation of pain processing in the central nervous system), are common in SLE. Opioids are generally not indicated for long-term management of musculoskeletal pain or centralized pain (fibromyalgia) because of lack of efficacy, safety issues ranging from adverse medical effects to overdose, and risk for addiction (1,2). In this study of 462 patients with SLE from the population-based Michigan Lupus Epidemiology and Surveillance (MILES) Cohort and 192 frequency-matched persons without SLE, nearly one third (31%) of SLE patients were using prescription opioids during the study period (2014-2015), compared with 8% of persons without SLE (p<0.001). Among the SLE patients using opioids, 97 (68%) were using them for >1 year, and 31 (22%) were concomitantly on two or more opioid medications. Among SLE patients, those using the emergency department (ED) were approximately twice as likely to use prescription opioids (odds ratio [OR] = 2.1; 95% confidence interval [CI] = 1.3-3.6; p = 0.004). In SLE, the combined contributions of underlying disease and adverse effects of immunosuppressive and glucocorticoid therapies already put patients at higher risk for some known adverse effects attributed to long-term opioid use. Addressing the widespread and long-term use of opioid therapy in SLE will require strategies aimed at preventing opioid initiation, tapering and discontinuation of opioids among patients who are not achieving treatment goals of reduced pain and increased function, and consideration of nonopioid pain management strategies.


Assuntos
Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Vigilância da População , Adulto , Idoso , Estudos de Coortes , Serviço Hospitalar de Emergência , Feminino , Humanos , Lúpus Eritematoso Sistêmico/epidemiologia , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Manejo da Dor/métodos , Risco
19.
Br J Anaesth ; 123(5): 655-663, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31558315

RESUMO

BACKGROUND: The Korean National Health Insurance Service (NHIS) was developed to provide population data for medical research. The aim of this study was to estimate trends in prescription opioid use in South Korea, and to determine the association between chronic opioid use and 5-yr mortality in cancer and non-cancer patients. METHODS: A population-based cohort study was conducted amongst the South Korean adult population using data from the NHIS. Those prescribed a continuous supply of opioids for ≥90 days were defined as chronic opioid users. Multivariable Cox regression analysis was used to assess the association between chronic opioid use and 5-yr mortality. RESULTS: The proportion of chronic weak opioid users increased from 1.03% in 2002 to 9.62% in 2015. The proportion of chronic strong opioid users increased from 0.04% in 2002 to 0.24% in 2015. In the 2010 cohort (n=822 214), compared with non-users, chronic weak opioid users had a significantly lower 5-yr mortality (hazard ratio [HR]: 0.93; 95% confidence interval [CI]: 0.89-0.96; P<0.001), and chronic strong opioid users had a significantly higher 5-yr mortality (HR: 1.45; 95% CI: 1.28-1.63; P<0.001). Similar results were observed in non-cancer patients, but chronic weak opioid users were not significantly associated with 5-yr mortality in cancer patients (P=0.063). CONCLUSIONS: In South Korea, chronic opioid use has increased since 2002. Chronic strong opioid use was associated with a higher 5-yr mortality, and chronic weak opioid use was associated with a slightly lower 5-yr mortality. However, the findings regarding chronic weak opioid users should be interpreted carefully because there might be residual confounders in this study. Further study is needed to confirm these retrospective findings.


Assuntos
Analgésicos Opioides/administração & dosagem , Dor Crônica/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor Crônica/mortalidade , Estudos de Coortes , Relação Dose-Resposta a Droga , Esquema de Medicação , Prescrições de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/tratamento farmacológico , Neoplasias/mortalidade , Modelos de Riscos Proporcionais , República da Coreia/epidemiologia , Estudos Retrospectivos , Fatores Socioeconômicos
20.
Georgian Med News ; (292-293): 72-75, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31560667

RESUMO

The aims of our study were to determine antibiotic prescribing rates for prevention and treatment of infections in pediatric units, to evaluate the number and type of antimicrobial agents and administration route, reveal commonly used antibiotic subgroups and identify targets for improving the quality of antimicrobial prescribing. A 1-day PPS (Point Prevalence Study) on antibiotic use in hospitalized children was performed in Georgia from 2015 to 2019. 18 clinics in different regions of Georgia were included in the survey. Antimicrobial prevalence rates increased over the years from 60.1% in 2015 to 92.6% in 2018. The most commonly, antibiotics were prescribed for lower respiratory tract infections (LRTI). In 2015 25.1% of LRTI were treated by ampicillin-sulbactam but the next year it replaced with ceftriaxone (37.1% in 2017 and 38.2% in 2018). In pediatric surgical ward, the antibiotics were commonly prescribed for surgical prevention (54.1% in 2015, 32.3% in 2018). The most common conditions treated with antibiotics in neonates were sepsis (30.1%) and LRTI (45.3%). The most used antibiotic was ceftriaxone (33.3% in 2015). Ampicilin-sulbactam was prescribed in 28.1% of pneumonia case in neonates in 2018. In 2015 antibiotics were mainly prescribed empirically (98.0%). In 2018 resistance of MRSA was 8.1%, and resistance to the third-generation cephalosporin 17.3%. Prevalence rate of antibiotics for prevention and treatment of infection disease in pediatric units increased in 2018. Main feasible targets for optimization of antibiotic prescribing have been identified: high use of broad-spectrum antibiotics in hospitals, high frequency of empirical treatment, rarely performed culture tests, prolonged antibiotic prophylaxis in surgery patients and an alarming raise of resistant strains. The implementation of disease-specific clinical pathways associated with annual PPSs could be a good way to monitor and improve antibiotic prescription patterns in neonatal and pediatric inpatients over time.


Assuntos
Antibacterianos/uso terapêutico , Anti-Infecciosos/uso terapêutico , Infecções Bacterianas/tratamento farmacológico , Prescrições de Medicamentos/estatística & dados numéricos , Farmacorresistência Bacteriana , Uso de Medicamentos/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Infecções Bacterianas/epidemiologia , Criança , Pré-Escolar , Feminino , República da Geórgia/epidemiologia , Pesquisas sobre Serviços de Saúde , Humanos , Recém-Nascido , Masculino , Pediatria , Prevalência , Inquéritos e Questionários
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