Rural-urban differences in use of health services before and after dementia diagnosis: a retrospective cohort study.

BACKGROUND: Rural-urban differences in health service use among persons with prevalent dementia are known. However, the extent of geographic differences in health service use over a long observation period, and prior to diagnosis, have not been sufficiently examined. The purpose of this study was to examine yearly rural-urban differences in the proportion of patients using health services, and the mean number of services, in the 5-year period before and 5-year period after a first diagnosis of dementia. METHODS: This population-based retrospective cohort study used linked administrative health data from the Canadian province of Saskatchewan to investigate the use of five health services [family physician (FP), specialist physician, hospital admission, all-type prescription drug dispensations, and short-term institutional care admission] each year from April 2008 to March 2019. Persons with dementia included 2,024 adults aged 65 years and older diagnosed from 1 April 2013 to 31 March 2014 (617 rural; 1,407 urban). Matching was performed 1:1 to persons without dementia on age group, sex, rural versus urban residence, geographic region, and comorbidity. Differences between rural and urban persons within the dementia and control cohorts were separately identified using the Z-score test for proportions (p < 0.05) and independent samples t-test for means (p < 0.05). RESULTS: Rural compared to urban persons with dementia had a lower average number of FP visits during 1-year and 2-year preindex and between 2-year and 4-year postindex (p < 0.05), a lower likelihood of at least one specialist visit and a lower average number of specialist visits during each year (p < 0.05), and a lower average number of all-type prescription drug dispensations for most of the 10-year study period (p < 0.05). Rural-urban differences were not observed in admission to hospital or short-term institutional care (p > 0.05 each year). CONCLUSIONS: This study identified important geographic differences in physician services and all-type prescription drugs before and after dementia diagnosis. Health system planners and educators must determine how to use existing resources and technological advances to support care for rural persons living with dementia.

Regular Medications in the Emergency Department Short Stay Unit (ReMedIES): Can Prescribing be Improved Without Increasing Resources?

Background: Hospital medication errors are frequent and may result in adverse events. Data on non-prescription of regular medications to emergency department short stay unit patients is lacking. In response to local reports of regular medication omissions, a multi-disciplinary team was tasked to introduce corrective emergency department (ED) process changes, but with no additional financing or resources. Aim: To reduce the rate of non-prescription of regular medications for patients admitted to the ED Short Stay Unit (SSU), through process change within existing resource constraints. Methods: A pre- and post-intervention observational study compared regular medication omission rates for patients admitted to the ED SSU. Included patients were those who usually took regular home medications at 08:00 or 20:00. Omissions were classified as clinically significant medications (CSMs) or non-clinically significant medications (non-CSMs). The intervention included reinforcement that the initially treating acute ED doctor was responsible for prescription completion, formal checking of prescription presence at SSU handover rounds, double-checking of prescription completeness by the overnight SSU lead nurse and junior doctor, and ED pharmacist medication reconciliation for those still identified as having regular medication non-prescription at 07:30. Results: For the 110 and 106 patients in the pre- and post-intervention periods, there was a non-significant reduction in the CSM omission rate of -11% (95% CI: -23 to 2), from 41% (95% CI: 32-50) to 30% (95% CI: 21-39). Conclusion: Non-prescription of regular CSMs for SSU patients was not significantly reduced by institution of work practice changes within existing resource constraints.

Do patients with prediabetes managed with metformin achieve better glycaemic control? A national study using primary care medical records.

AIMS: To estimate the effectiveness of metformin on glycaemic parameters among participants with incident prediabetes attending Australian general practices. METHODS: This retrospective cohort study used electronic health records of regular participants (3+ visits in two consecutive years) attending 383 Australian general practices (MedicineInsight). Participants with 'incident' prediabetes (newly recorded diagnosis between 2012 and 2017) and their glycaemic parameters (haemoglobin A1c [HbA1c] or fasting blood glucose [FBG]) at 6-, 12-, and 18-24 months post diagnosis (unexposed) or post-management with metformin (treatment) were identified from the database. We estimated the average treatment effect (ATE) of metformin management on glycaemic parameters using both linear regression and augmented inverse probability weighting. RESULTS: Of the 4770 investigated participants with 'incident' prediabetes, 10.2% were managed with metformin. Participants on metformin had higher HbA1c levels at the baseline than those unexposed (mean 45 mmol/mol [6.2%] and 41 mmol/mol [5.9%], respectively), but no differences were observed at 6-12 months (mmol/mol ATE 0.0, 95% CI -0.4; 0.7) or 12-18 months (ATE -0.3, 95% CI -1.2; 0.3). However, participants on metformin had lower mean HbA1c mmol/mol at 18-24 months (ATE -1.1, 95% CI -2.0; 0.1) than those unexposed. Consistent results were observed for FBG (ATE at 6-12 months -0.14 [95% CI -0.25; -0.04], 12-18 months 0.02 [95% CI -0.08; 0.13] and 18-24 months -0.07 [95% CI -0.25; 0.12]). CONCLUSION: The higher HbA1c and FBG baseline levels among participants with 'incident' prediabetes managed with metformin improved after 6-12 months of starting pharmacological management, and the effect persisted for up to 24 months. Management with metformin could prevent further deterioration of glycaemic levels.

Personal Continuity and Appropriate Prescribing in Primary Care.

PURPOSE: Personal continuity between patient and physician is a core value of primary care. Although previous studies suggest that personal continuity is associated with fewer potentially inappropriate prescriptions, evidence on continuity and prescribing in primary care is scarce. We aimed to determine the association between personal continuity and potentially inappropriate prescriptions, which encompasses potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), by family physicians among older patients. METHODS: We conducted an observational cohort study using routine care data from patients enlisted in 48 Dutch family practices from 2013 to 2018. All 25,854 patients aged 65 years and older having at least 5 contacts with their practice in 6 years were included. We calculated personal continuity using 3 established measures: the usual provider of care measure, the Bice-Boxerman Index, and the Herfindahl Index. We used the Screening Tool of Older Person's Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START) specific to the Netherlands version 2 criteria to calculate the prevalence of potentially inappropriate prescriptions. To assess associations, we conducted multilevel negative binomial regression analyses, with and without adjustment for number of chronic conditions, age, and sex. RESULTS: The patients' mean (SD) values for the usual provider of care measure, the Bice-Boxerman Continuity of Care Index, and the Herfindahl Index were 0.70 (0.19), 0.55 (0.24), and 0.59 (0.22), respectively. In our population, 72.2% and 74.3% of patients had at least 1 PIM and PPO, respectively; 30.9% and 34.2% had at least 3 PIMs and PPOs, respectively. All 3 measures of personal continuity were positively and significantly associated with fewer potentially inappropriate prescriptions. CONCLUSIONS: A higher level of personal continuity is associated with more appropriate prescribing. Increasing personal continuity may improve the quality of prescriptions and reduce harmful consequences.

Role of private prescriptions in the long-term use of benzodiazepines and Z-drugs: A patient-related follow-up study.

PURPOSE: To analyse (1) how often patients insured under the statutory health insurance (SHI) scheme received repeated prescriptions for benzodiazepines or Z-drugs as private prescriptions and (2) how often doctors switched from SHI prescriptions to private prescriptions and vice versa when issuing repeat prescriptions. METHODS: On basis of anonymized prescriptions from 874 ambulatory practices in Germany, we analysed the percentage of private prescriptions for Z-drugs, benzodiazepines/anxiolytics, and benzodiazepines/hypnotics and sedatives over 6 years (2014 to 2020). RESULTS: Of 2 200 446 prescriptions for a benzodiazepine or Z-drug, 38% were private prescriptions. In case of Z-drugs, the rate of private prescriptions was 44.1% for single prescriptions and 48.9% for refills. The difference was smaller for anxiolytics (23.3% vs. 26.0%) and, for benzodiazepine/hypnotics and sedatives, the proportion of private prescriptions for refills was even lower than for single prescriptions. In case of Z-drugs, the proportion of private prescriptions was, on average, 42.7% for the first prescription of a series of repeat prescriptions and 49.6% for the tenth prescription. The increase was smaller for anxiolytics and negligible for benzodiazepine/hypnotics and sedatives. Doctors stayed with their initial decision in more than three quarters of repeat prescriptions, be it a SHI or private prescription. CONCLUSION: While we observed a large number of private prescriptions for benzodiazepines and Z-drugs, the proportion was only slightly higher for refills than for single prescriptions. Doctors do not seem to issue private prescriptions as a strategy to mask especially long-term use of these substances.

Managing opioid waste, cost, and opportunity for drug diversion in the emergency department.

INTRODUCTION: Management of pain is a component of 80% of all emergency department (ED) visits, and intravenous (IV) opioids are most commonly used to treat moderate to severe pain. Since the dose of stock vials is rarely purchased based on provider ordering patterns, there is often a discrepancy between ordered doses and the dose of the stock vial, leading to waste. Here, waste is defined as the difference between the dose of the stock vials used to fill an order and the ordered dose. Drug waste is problematic as it increases the chance of administering the incorrect dose, it is a source of lost revenue, and in the context of opioids, it increases the opportunity for drug diversion. In this study, we sought to utilize real-world data to describe the magnitude of morphine and hydromorphone waste in the studied EDs. We also applied scenario analyses based on provider ordering patterns to simulate the effects of cost versus opioid waste minimization when making purchasing decisions for the dose of stock vial of each opioid. METHODS: This was an observational analysis of IV morphine and hydromorphone orders across three EDs within a health care system between December 1, 2014 and November 30, 2015. In the primary analysis we measured total waste and cost of all ordered hydromorphone and morphine, and we created logistic regression models for each opioid to estimate the odds that a given ordered dose would create waste. In the secondary scenario analysis we determined the total waste created and total cost to satisfy all written orders for both opioids with respect to prioritizing minimizing waste versus cost. RESULTS: Among a total of 34,465 IV opioid orders, 7866 (35%) of morphine orders created 21,767 mg of waste, and 10,015 (85%) of hydromorphone orders created 11,689 mg of waste. Larger dose orders were associated with a smaller likelihood of waste in both morphine and hydromorphone due to the doses of stock vials available. In the waste optimization scenario, relative to the base scenario, total waste, which included waste from both morphine and hydromorphone, was reduced by 97% and cost was reduced by 11%. In the cost optimization scenario, cost was reduced by 28% but waste increased by 22%. CONCLUSION: As hospitals continue to seek strategies to reduce costs and mitigate the harms of opioid diversion amidst the opioid epidemic, this study shows that optimizing the dose of the stock vial to minimize waste using provider ordering patterns, could mitigate risk while also reducing cost. Limitations included the use of data from EDs within a single health system, drug shortages that affected stock vial availability, and finally, the actual cost of stock vials, used for cost calculations, can differ based on a variety of factors.

Psychotropic consumption before and during COVID-19 in Asturias, Spain.

BACKGROUND: Spain as multiple other countries has been experiencing an increasing and sustained trend in the use of psychotropic medications since the mid 90s. Recent studies show public health measures implemented to control SARS-Cov2, such as mobility restrictions and the shutdown of nonessential activities increased mental suffering, even contributing to a higher number of anxiety, depression and insomnia disorders that could lead to an increase in the consumption of psychotropics. The aims were: 1) Evaluate the temporal trend in psychotropic consumption by pharmacological subgroup, sex, and age group 2) Estimate the effect of the COVID-19 pandemic in the use of psychotropic drugs. METHODS: We conducted a retrospective observational study, retrieving all prescriptions of anxiolytics, hypnotics and sedatives, and antidepressants dispensed in pharmacies of Asturias (Northern Spain) for Primary Care patients for the period 2018-2021. We presented the data expressed in Daily Defined Doses (DDDs) for 1000 persons/day (DHD). To estimate changes in DHDs by year and age group we conducted two multiple linear regressions (one for males and one for females) for every pharmacological subgroup studied. Changes were considered statistically significant when the regression coefficient was p < 0.05. We used the Software R 4.1.0. RESULTS: For the studied period, the highest DHDs are for antidepressants, although all of the subgroups experienced an increase in consumption rates. Women consumed more psychotropic drugs than men. In 2021, 372 out of every 1000 women were taking daily 1 DDD of these drugs versus 184 out of every 1000 men. Consumption rates for all psychotropic drugs progressively increases with age. Conversely, the biggest increases in consumption were among the youngest age groups (0-14 and 15-29 years) for women, while for men there is more variability. The regression models suggest an upward trend in psychotropic consumption during all the period, especially remarkable from 2020, for both genders and all age groups. CONCLUSIONS: - The consumption of psychotropic drugs has gradually increased over the last 4 years, with a significant boost starting in 2020 for both sexes, matching the start of the SARS-COV2 pandemic and the implementation of strict Public Health measures to contain it. - The increase observed on children and adolescents is a matter of concern.

Physicians' assessment of the Bavarian drug-expenditure control system: a qualitative study.

BACKGROUND: In 2014 a new system for drug expenditures, the Wirkstoffvereinbarung (WSV, English: Active substance agreement) was implemented in Bavaria. In pre-defined indication groups, economic prescription of medications shall be enabled based on the selection, quantity, and proportion of an individual drug. Ambulatory care physicians receive quarterly trend reports on their prescribing behavior. This study examines physicians' perceptions of the WSV. METHODS: Qualitative interviews (n = 20) and seven focus groups (n = 36) were conducted with ambulatory care physicians (e.g. general practitioners, cardiologists, pulmonologists). The methodology followed Qualitative Content Analysis. RESULTS: Physicians generally accepted the necessity of prescribing economically. The majority of them rated the WSV positively and better than the previous system. As an improvement, they especially named timely feedback in form of easily understandable trend reports, encouraging self-reflection as well as allowing early control options. Problems perceived were drug discount contracts that were strongly criticized as leading to patients mixing up medications. Some perceived constraints of therapeutic freedom. CONCLUSIONS: The implementation of the WSV is mostly viewed positively by physicians. The restrictions of therapeutic freedom partially perceived might be met by improved information on the reasons why some drugs are rated as less economical than others. TRIAL REGISTRATION NUMBER: Main ID: DRKS00019820 (German Register of Clinical Studies and World Health Organization).

Smoking in early adulthood is prospectively associated with prescriptions of antipsychotics, mood stabilizers, antidepressants and anxiolytics.

BACKGROUND: Whether smoking should be regarded as a risk factor for mental disorders remains unresolved. Prescribed psychotropic drugs can be used as indications for mental disorders. We investigated how smoking was prospectively related to prescription of antipsychotics, mood stabilizers, antidepressants, and anxiolytics. METHODS: Information about smoking, including the Fagerström Test for Nicotine Dependence, and relevant confounders, were obtained from the population-based Young in Norway Study (N = 2602), with four data collection waves between 1992 and 2006. These survey data were linked with information on prescriptions for psychotropic drugs from the comprehensive, nationwide Norwegian Prescription Database from 2007 to 2015. RESULTS: Daily smoking with high dependence in 2006 at age 28.5 (s.d. = 2.0) was associated with filling prescriptions of antipsychotics (OR, 6.57, 95% CI 2.19-19.70, p = 0.001), mood stabilizers (OR, 7.11, 95% CI 2.51-20.15, p < 0.001) and antidepressants (OR, 1.91, 95% CI 1.13-3.23, p = 0.016) 1-9 years later. Associations remained significant after adjustment for a variety of potential confounders measured before the assessment of smoking, including sociodemographic background, conduct problems, cannabis use, mental distress, and previous prescriptions for psychotropic medications. The association between smoking and prescription of anxiolytics was weaker and more unstable. CONCLUSIONS: In this study of young adults, daily smoking with high dependence was associated with later prescriptions of antipsychotics, mood stabilizers and antidepressants, indicating smoking as a risk factor for mental disorders treated with these drugs.

Family burden of hospital-managed pediatric atopic dermatitis: A nationwide registry-based study.

BACKGROUND: Parents of children with atopic dermatitis (AD) report reduced quality of life and higher stress level, which could increase risk of psychiatric and pain disorders, and medication use. METHODS: By use of Danish national registries, we identified family members of all first-born Danish children born between 1 January 1995 and 31 December 2013 with a hospital diagnosis of AD, matched them 1:10 with family members of children without AD, and followed the cohorts over time. RESULTS: Mothers of children with hospital-managed AD had higher risk of filling a prescription for medications for depression, anxiety, pain and sleep problems, and of consulting a psychologist, but most associations disappeared after full adjustment. Siblings had higher risk of receiving a diagnosis for adjustment disorder, and fathers showed increased risk of filling a prescription for pain medication and of divorce, in crude but not adjusted models. CONCLUSIONS: The increased risk of study endpoints seen in mothers of children with hospital-managed AD was not explained by pediatric AD alone. Rather, the total burden in these families including parent and child morbidity and socioeconomic resources seems to explain these observations. The burden in families of children with AD may potentially affect the overall management of their child's AD.

Coping with COVID: Preparing prescribers during the pandemic.

In response to the COVID-19 pandemic, Health Education England (HEE) and the University of Birmingham provided National Health Service (NHS) staff free access to SCRIPT, a national eLearning programme for safer prescribing and therapeutics. The eLearning was particularly for those returning to work or being redeployed. In the year March 2020-21, 3412 users registered to access portfolios and opened an aggregate of 17 198 modules. Each user completed a median of 2 (range 1-50, interquartile range [IQR] 1-7) assessed learning modules. Marks improved from pre-test to post-test by a median of 2 (IQR 0-3) marks out of 10. The most frequently selected modules were Adherence and Concordance (1109 users), Fluids (981 users) and Diabetic Emergencies (818 users). A total of 878 users accessed the unassessed COVID-19 module. The SCRIPT modules provided standardised education in core principles relating to prescribing and therapeutics, and were used by professionals from many healthcare disciplines.

Decreased survival in children inpatients with COVID-19 and antibiotic prescription.

BACKGROUND: The empirical prescription of antibiotics to inpatients with Coronavirus Disease 2019 (COVID-19) is frequent despite uncommon bacterial coinfections. Current knowledge of the effect of antibiotics on the survival of hospitalized children with COVID-19 is limited. OBJECTIVE: To characterize the survival experience of children with laboratory-positive COVID-19 in whom antibiotics were prescribed at hospital admission. METHODS: A retrospective cohort study was conducted in Mexico, with children hospitalized due to COVID-19 from March 2020 to December 2021. Data from 1601 patients were analyzed using the Kaplan-Meier method and the log-rank test. We computed hazard ratios (HR) and 95% confidence intervals (CI) to evaluate the effect of the analyzed exposures on disease outcomes. RESULTS: Antibiotics were prescribed to 13.2% ([Formula: see text] = 211) of enrolled children and a higher mortality rate [14.9 (95% CI 10.1-19.8) vs. 8.3 (95% CI 6.8-9.8)] per 1000 person-days, [Formula: see text] < 0.001) was found among them. At any given cut-off, survival functions were lower in antibiotic-positive inpatients ([Formula: see text] < 0.001). In the multiple model, antibiotic prescription was associated with a 50% increase in the risk of fatal outcome (HR = 1.50, 95% CI 1.01-2.22). A longer interval between illness onset and healthcare-seeking and pneumonia at hospital admission was associated with a poorer prognosis. CONCLUSIONS: Our results suggest that antibiotic prescription in children hospitalized due to COVID-19 is associated with decreased survival. If later replicated, these findings highlight the need for rational antibiotics in these patients.

Racial disparities in opioid prescriptions for fractures in the pediatric population.

BACKGROUND AND OBJECTIVES: Racial disparities have been well documented in literature regarding pain management. However, few studies have focused on its effect in the pediatric population. This study seeks to examine the relationship between race and opioid prescription patterns for children with fractures. METHODS: A retrospective study was conducted by reviewing all analgesic prescriptions of discharged pediatric patients (ages 0-21, median 10 years) from a large children's hospital over a five-year period. Multiple logistic regression analysis was applied to examine racial differences in opioid prescriptions for patients with long bone fractures after adjusting for sex, age, length of stay, and payer type. RESULTS: 58,402 analgesic prescriptions were reviewed in this study; 5061 were given for the primary discharge diagnosis of "fracture" of any bone. Overall, 52% of analgesics prescribed for this diagnosis were opioid medications. The relative frequency of opioid prescriptions was 48.7% in Hispanic White patients and 63.1% in non-Hispanic White patients. The odds ratio for non-Hispanic White patients to be prescribed an opioid medication was 1.44 (CI 1.20-1.73) compared to Black patients and to Hispanic White patients after adjustment for sex, age, length of hospital stay, and payer type. The same racial disparity pattern was observed in patients regardless of long bone fracture location. CONCLUSIONS: Racial bias is suggested in opioid prescription patterns, even in the pediatric population, which may have untoward negative downstream effects. This study delineates the need for improved and standardized methods to adequately treat pain and reduce variations in prescriber habits.

Sociodemographic characterisation of antibiotic heavy users in the Danish elderly population.

AIMS: The development of effective interventions to reduce inappropriate use of antibiotics in the elderly population requires knowledge on who can benefit from such interventions. Thus, we aimed to identify and characterise antibiotic heavy users among elderly patients in general practice with respect to sociodemographic variables. METHODS: We conducted a retrospective nationwide register-based study on all Danish elderly citizens (⩾65 years) who redeemed an antibiotic prescription in 2017. Heavy users were defined as the 10% with the highest excess use, that is, their recorded use minus the average use for their sex, age group and comorbidity level as estimated from a linear regression model. Comparative analyses of sociodemographic characteristics (civil status, employment status, urbanity, educational level and country of origin) of heavy users and non-heavy users were performed using logistic regression models. RESULTS: The study population consisted of 251,733 elderly individuals, who in total redeemed 573,265 prescriptions of antibiotics. Heavy users accounted for 68% of all excess use of antibiotics. In multivariable analyses, individuals with an educational level above basic schooling, non-retired, residing in an urban municipality and being born in a country outside Scandinavia all had lower odds of being a heavy user. Widowed, divorced or single individuals had higher odds of being a heavy user compared with married individuals. Relative importance analyses showed that civil status and educational level contributed considerably to the explained variance. CONCLUSIONS: This study found an association between sociodemographic characteristics and risk of being a heavy user, indicating that sociodemographic variation exists with regard to antibiotic prescribing.

OntoPharma: ontology based clinical decision support system to reduce medication prescribing errors.

BACKGROUND: Clinical decision support systems (CDSS) have been shown to reduce medication errors. However, they are underused because of different challenges. One approach to improve CDSS is to use ontologies instead of relational databases. The primary aim was to design and develop OntoPharma, an ontology based CDSS to reduce medication prescribing errors. Secondary aim was to implement OntoPharma in a hospital setting. METHODS: A four-step process was proposed. (1) Defining the ontology domain. The ontology scope was the medication domain. An advisory board selected four use cases: maximum dosage alert, drug-drug interaction checker, renal failure adjustment, and drug allergy checker. (2) Implementing the ontology in a formal representation. The implementation was conducted by Medical Informatics specialists and Clinical Pharmacists using Protégé-OWL. (3) Developing an ontology-driven alert module. Computerised Physician Order Entry (CPOE) integration was performed through a REST API. SPARQL was used to query ontologies. (4) Implementing OntoPharma in a hospital setting. Alerts generated between July 2020/ November 2021 were analysed. RESULTS: The three ontologies developed included 34,938 classes, 16,672 individuals and 82 properties. The domains addressed by ontologies were identification data of medicinal products, appropriateness drug data, and local concepts from CPOE. When a medication prescribing error is identified an alert is shown. OntoPharma generated 823 alerts in 1046 patients. 401 (48.7%) of them were accepted. CONCLUSIONS: OntoPharma is an ontology based CDSS implemented in clinical practice which generates alerts when a prescribing medication error is identified. To gain user acceptance OntoPharma has been designed and developed by a multidisciplinary team. Compared to CDSS based on relational databases, OntoPharma represents medication knowledge in a more intuitive, extensible and maintainable manner.

[Antibiotic consumption in primary care in the adult population of Asturias during 2014-2020 period]. / Consumo de antibióticos en atención primaria en población adulta de Asturias durante el periodo 2014-2020.

Trend study of the consumption of systemic antibiotics in the adult population in of Primary Care of the Health Service of the Principality of Asturias (SESPA) during the period 2014̶2020. Retrospective observational study. SESPA, Primary Care. Population from the Individual Health Card database. Data were collected on the prescription of antibiotics, carried out in the family medicine consultations, dispensed in the pharmacy offices with charge of SESPA. Antibiotic use and consumption variables were analyzed using linear regression models. Prevalence of antibiotic use (population percentage); consumption rate of systemic antibiotics (DTD), relative consumption of narrow-spectrum antibiotics (percentage DDD). The average prevalence of the use of antibiotics for the 2014̶2019 period was 32.2% and 23.9% in 2020. The rate of consumption of systemic antibiotics decreased from 21.4 DTD in 2014 to 12.7 DTD in 2020. The consumption of narrow-spectrum antibiotics remained stable (19.4% DDD in 2014 and 19.3% DDD in 2020) (CI95: -0.10, 0.26). In the period from March to December 2020, the consumption of antibiotics decreased by 28.6% compared to the same period in 2019. In 2014̶2020, the consumption of antibiotics decreased, especially since the COVID-19 pandemic, with stabilization of the consumption of narrow-spectrum antibiotics compared to the total. There is variability in consumption by therapeutic subgroups.

Challenges and Potential Improvements to Patient Access to Pharmaceuticals: Examples From Cardiology.

Patient access to a drug after US regulatory approval is controlled by complex interactions between governmental and third-party payers, pharmacy benefit managers, distributers, manufacturers, health systems, and pharmacies that together mediate the receipt of goods by patients after prescription by clinicians. Recent medication approvals highlight why and how the distribution of clinically beneficial novel therapies is controlled. Although imposed limitations on availability may be rational considering the fiduciary responsibilities of payers and escalating spending on health care and pharmaceuticals, transparency and communication are lacking, and some utilization management may disproportionately affect vulnerable populations. Analysis of the current health insurance landscape suggests mechanisms by which patient access to appropriate medications can be improved and patient and clinician frustration reduced while acknowledging the financial realities of the pharmaceutical marketplace. We propose creation of a shared, standardized, and transparent process for coverage decisions that minimizes administrative barriers and is defensible on the basis of clinical and cost-effectiveness evidence. These reforms would benefit patients and improve the efficiency of the pharmaceutical system.

Trends in oral corticosteroids use in severe asthma: a 14-year population-based study.

BACKGROUND: Oral corticosteroids are important components of pharmacotherapy in severe asthma. Our objective was to describe the extent, trends, and factors associated with exposure to oral corticosteroids (OCS) in a severe asthma cohort. METHODS: We used administrative health databases of British Columbia, Canada (2000-2014) and validated algorithms to retrospectively create a cohort of severe asthma patients. Exposure to OCS within each year of follow-up was measured in two ways: maintenance use as receiving on average ≥ 2.5 mg/day (prednisone-equivalent) OCS, and episodic use as the number of distinct episodes of OCS exposure for up to 14 days. Trends and factors associated with exposure on three time axes (calendar year, age, and time since diagnosis) were evaluated using Poisson regression. RESULTS: 21,144 patients (55.4% female; mean entry age 28.7) contributed 40,803 follow-up years, in 8.2% of which OCS was used as maintenance therapy. Maintenance OCS use declined by 3.8%/calendar year (p < 0.001). The average number of episodes of OCS use was 0.89/year, which increased by 1.1%/calendar year (p < 0.001). Trends remained significant for both exposure types in adjusted analyses. Both maintenance and episodic use increased by age and time since diagnosis. CONCLUSIONS: This population-based study documented a secular downward trend in maintenance OCS use in a period before widespread use of biologics. This might have been responsible for a higher rate of exacerbations that required episodic OCS therapy. Such trends in OCS use might be due to changes in the epidemiology of severe asthma, or changes in patient and provider preferences over time.

Assuming one dose per day yields a similar estimate of medication adherence in patients with stroke: An exploratory analysis using linked registry data.

PURPOSE: Prescribed daily dose (PDD), the number of doses prescribed to be taken per day, is used to calculate medication adherence using pharmacy claims data. PDD can be substituted by (i) one dose per day (1DD), (ii) an estimate based on the 75th percentile of days taken by patients to refill a script (PDD75 ) or (iii) the World Health Organization's defined daily dose (DDD). We aimed to compare these approaches for estimating the duration covered by medications and whether this affects calculated 1-year adherence to antihypertensive medications post-stroke. METHODS: We conducted a retrospective review of prospective cohort data from the ongoing Australian Stroke Clinical Registry linked with pharmacy claims data. Adherence was calculated as the proportion of days covered (PDC) for 1DD, PDD75 and DDD. Differences were assessed using Wilcoxon rank-sum tests. RESULTS: Among 12 628 eligible patients with stroke, 10 057 (80%) were prescribed antihypertensive medications in the year after hospital discharge (78.2% aged ≥65 years, 45.2% female). Overall, the 75th percentile of patient time until next medication refill was 39 days. The greatest variations in dose regimens, estimated using person- and dose-level refill times, were for beta blockers (11.4% taking two tablets/day). There were comparable levels of adherence between 1DD and the PDD75 (median PDC 91.0% vs 91.2%; P = 0.70), but adherence was slightly higher using DDD (92.3%; both P < 0.001). However, this would represent a clinically nonsignificant difference. CONCLUSION: Adherence to antihypertensive medications shows similar estimates across standard measures of dosage in patients during the first year after an acute stroke.

Prescribing practices of migraine-specific pharmacotherapy associated with emergency department use for migraine.

OBJECTIVE: This study compared migraine medication prescribing between patients with a migraine diagnosis who used versus did not use the emergency department (ED) for migraine. BACKGROUND: Headache is the fifth most common chief complaint for ED visits nationwide and the third most common potentially avoidable ED diagnosis in the University of Colorado Health system. The reasons some patients use the ED for migraine management while others do not and whether some ED admissions might be preventable remain unclear. METHODS: This retrospective cohort study identified adults with migraine-related diagnoses within 1 year before the index date of July 1, 2018 and compared patient characteristics and migraine medication prescribing patterns between those who did or did not have a subsequent migraine-related ED encounter the following year. ED admission notes were manually reviewed to identify potentially preventable circumstances that led to the ED visit. The primary outcome was the proportion of patients with an active triptan prescription at the index date. RESULTS: Of the 3843 patients identified, 35 patients (0.9%) had a migraine-related ED encounter. Of these, 17/35 (49%) had an active triptan prescription compared to 1360/3808 (36%) of non-ED utilizers (p = 0.114), OR 1.22 (95% CI 0.61-2.45). More ED utilizers had an active prescription for opioids (11/35 [31%] vs. 663/3808 [17%], p = 0.030) and migraine preventive therapy (19/35 [54%] vs. 1149/3808 [30%], p = 0.002), and neurology referrals (20/35 [57%] vs. 654/3808 [17%], p < 0.001) compared to non-ED utilizers. The most common circumstance for migraine-related ED visits was nonresponse to migraine abortive medications administered at home. CONCLUSIONS: Triptan prescribing did not differ between ED utilizers and non-ED utilizers for migraine. Overall, less than half of the total patient population had a triptan prescribed. More ED utilizers had neurology referrals, prescriptions for opioids and preventive therapies, and a history of previous ED visit for any reason, which may be markers for higher disease severity or behavior patterns. Future research and interventions to reduce migraine-related ED use could target high-risk patients such as those with previous ED visits for any indication and neurology referrals.